What are the step‑by‑step procedures for performing a lower‑segment caesarean section (LSCS)?

Steps for Performing Lower Segment Caesarean Section (LSCS)

The optimal LSCS technique involves a Joel-Cohen incision, blunt uterine expansion, two-layer hysterotomy closure without peritoneal closure, and subcuticular skin suturing, combined with a comprehensive multimodal analgesia protocol starting pre-operatively. 1

Pre-operative Preparation (30-60 minutes before incision)

Antibiotic Prophylaxis

• Administer intravenous first-generation cephalosporin within 60 minutes before skin incision 2, 1
• Add azithromycin if the woman is in labor or has ruptured membranes for additional infection reduction 2, 1
• Critical pitfall: Never delay antibiotics until after cord clamping—this outdated practice increases infection risk 1

Skin Preparation

• Cleanse the abdomen with chlorhexidine-alcohol solution (preferred over aqueous povidone-iodine) 2, 1
• Perform vaginal preparation with povidone-iodine solution to reduce postcesarean infections 2, 1

Anesthesia and Analgesia

• Use regional anesthesia (spinal or epidural) as the preferred method 2, 1
• Add intrathecal morphine 50-100 μg (or diamorphine up to 300 μg) to the spinal anesthetic for optimal postoperative pain control 2, 1
• Administer oral paracetamol pre-operatively 2, 1

Patient Positioning

• Position women after 20 weeks gestation with left uterine displacement to prevent aortocaval compression 1
• Apply 10-15° left lateral table tilt, verified with an inclinometer rather than visual estimation 3

Temperature Management

• Prepare forced air warming devices 2, 1
• Warm intravenous fluids 2, 1
• Increase operating room temperature to prevent hypothermia 2, 1

Surgical Steps

Abdominal Incision

• Perform a Joel-Cohen (modified Misgav-Ladach) incision rather than Pfannenstiel incision—this reduces postoperative pain and improves outcomes 2, 1
• Make the transverse incision in the lower abdomen 1
• Use blunt dissection to open the fascia, which results in less postoperative pain 2

Uterine Entry

• Create a transverse incision in the lower uterine segment 1
• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 4, 1
• Avoid making a bladder flap when possible, as its absence improves postoperative pain scores 2

Delivery

• Deliver the infant through the hysterotomy 1
• Delay cord clamping for at least 1 minute at term (at least 30 seconds for preterm deliveries) 1

Intra-operative Medications (After Delivery)

• Administer intravenous paracetamol if not given pre-operatively 2, 1
• Give intravenous non-steroidal anti-inflammatory drugs (NSAIDs) 2, 1
• Administer intravenous dexamethasone for pain control and anti-emetic prophylaxis (use caution in patients with glucose intolerance) 2, 1

Uterine Closure

• Close the hysterotomy in 2 layers using continuous suture—this technique is associated with lower rates of uterine rupture in subsequent pregnancies 4, 1
• Perform in situ closure of the uterus rather than exteriorization, as exteriorization causes more postoperative pain 2

Abdominal Closure

• Do not close the peritoneum—this increases operative time without providing benefit and is associated with reduced pain 2, 1
• Do not re-approximate the rectus muscle, as this reduces postoperative pain 2
• Reapproximate subcutaneous tissue if thickness is ≥2 cm 4, 1
• Close skin with subcuticular suture rather than staples—this reduces wound complications 4, 1

Regional Analgesia Considerations

When Intrathecal Morphine Was Used

• TAP blocks or quadratus lumborum blocks provide minimal additional benefit when combined with intrathecal morphine 2
• These blocks may be omitted in this scenario 2

When Intrathecal Morphine Was NOT Used

• Consider single-shot local anesthetic wound infiltration or continuous wound infusion 2, 1
• Consider fascial plane blocks (TAP blocks or quadratus lumborum blocks) 2, 1

Postoperative Care

Analgesia

• Continue oral or intravenous paracetamol regularly 2, 1
• Continue oral or intravenous NSAIDs regularly 2, 1
• Use opioids for rescue only when other strategies fail or are contraindicated 2, 1
• Do not omit basic analgesics (paracetamol and NSAIDs) even when using intrathecal morphine—they work synergistically 1

Adjunctive Measures

• Apply abdominal binders (Grade A recommendation) 2, 1
• Consider transcutaneous electrical nerve stimulation (TENS) as an analgesic adjunct 2, 1

Special Considerations and Modifications

When Standard Lower Segment Approach is Contraindicated

• Consider a low vertical uterine incision (rather than classical fundal incision) when access to the lower segment is limited by prematurity, obstructing lesion, transverse lie, or high presenting part 5
• In confirmed placenta accreta spectrum disorder, avoid the Joel-Cohen incision—use a vertical midline incision instead for better exposure and vascular control 6

Interventions to Avoid

• Avoid gabapentinoids, intravenous ketamine, and neuraxial clonidine/dexmedetomidine—these have limited evidence and concerning side effects 2, 1
• Do not use staples for skin closure if they will be removed at 4 days—subcuticular sutures reduce wound complications 1
• Never attempt manual placental removal if placenta accreta is confirmed—this dramatically increases hemorrhage risk 6

Key Technical Points for Optimal Outcomes

The Joel-Cohen incision combined with blunt dissection techniques reduces operative time, blood loss, and postoperative pain compared to traditional Pfannenstiel approach 2. The two-layer uterine closure is critical for reducing rupture risk in subsequent pregnancies 4, 1. Non-closure of the peritoneum is supported by high-quality evidence showing no benefit to closure and potential harm 2, 1. The multimodal analgesia approach—combining intrathecal morphine, paracetamol, NSAIDs, and dexamethasone—provides superior pain control while minimizing opioid requirements 2.