What are the indications, operative technique, and postoperative management for a lower‑segment caesarean section (LSCS)?

Lower Segment Caesarean Section (LSCS): Indications, Operative Technique, and Postoperative Management

Regional anesthesia is the preferred anesthetic method for LSCS, with prophylactic antibiotics administered within 60 minutes before skin incision, followed by a transverse lower uterine segment incision with blunt expansion, two-layer uterine closure, and subcuticular skin closure. 1

Preoperative Preparation and Indications

Antimicrobial Prophylaxis

• Administer intravenous first-generation cephalosporin within 60 minutes before skin incision (not after cord clamping) 1
• Add azithromycin for women in labor or with ruptured membranes to further reduce postoperative infections 1
• For patients with obesity (BMI >40 kg/m²), consider 48 hours of postoperative oral cephalexin plus metronidazole in addition to standard preoperative prophylaxis 2

Skin Preparation

• Use chlorhexidine-alcohol for abdominal skin cleansing (preferred over aqueous povidone-iodine) 1
• Perform vaginal preparation with povidone-iodine solution to reduce postcesarean infections 1

Anesthetic Management

• Regional anesthesia (spinal or combined spinal-epidural) is strongly preferred over general anesthesia as part of enhanced recovery protocols 1, 3
• Spinal anesthesia provides the most reliable neuraxial block with fastest onset 3
• Counsel patients preoperatively that they will feel pressure and "pulling/tugging" sensations during surgery, not complete absence of sensation 3
• Risk factors for intraoperative pain include: opioid use disorder, previous cesarean pain, low BMI, urgent/emergent delivery, repeat cesarean, and epidural (versus spinal) anesthesia 3

Patient Positioning and Fasting

• Allow clear liquids up to 2 hours before surgery and small meals within 6 hours 4
• Consider dorsal lithotomy positioning for optimal pelvic visualization and vaginal/bladder access 5

Intraoperative Technique

Prevention of Hypothermia

• Apply forced air warming devices, warm intravenous fluids, and increase operating room temperature to prevent maternal hypothermia 1
• Monitor patient temperature appropriately throughout the procedure 1

Surgical Approach

• Modified Cohen's incision is preferred for skin entry 6
• For patients with portal hypertension and abdominal wall varices, consider median low abdominal incision over low transverse incision 7
• Inspect the uterus after peritoneal entry to determine placental location and level of invasion 5

Uterine Incision and Delivery

• Create transverse lower uterine segment incision, avoiding the placenta when possible 5, 6
• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 1
• For placenta accreta spectrum, avoid forced placental removal as this causes profuse hemorrhage 5

Uterine Closure

• Close the hysterotomy in 2 layers as this may be associated with lower rates of uterine rupture in subsequent pregnancies 1
• Single-layer closure appears acceptable when technically possible 6

Peritoneal and Subcutaneous Management

• Do not close the peritoneum (visceral or parietal layers) as closure is not associated with improved outcomes and increases operative time 1
• In women with ≥2 cm of subcutaneous tissue, reapproximate this layer to reduce wound disruption 1

Skin Closure

• Close skin with subcuticular suture in most cases due to evidence of reduced wound separation compared to staples 1

Neonatal Care

• Delay cord clamping for at least 1 minute at term delivery 1, 8
• Delay cord clamping for at least 30 seconds at preterm delivery 1
• Maintain neonatal body temperature between 36.5°C and 37.5°C 1
• Avoid routine airway suctioning or gastric aspiration unless obstructive symptoms present 1

Fluid Management

• Maintain perioperative and intraoperative euvolemia as this leads to improved maternal and neonatal outcomes 1

Postoperative Management

Pain Control

• Use multimodal opioid-sparing analgesia with acetaminophen and NSAIDs taken together 3
• Intrathecal morphine provides superior postoperative analgesia but increases side effects (nausea, vomiting, pruritus) 1
• Consider transversus abdominis plane (TAP) blocks when intrathecal morphine cannot be used 1

Early Recovery Measures

• Remove urinary catheter immediately postoperatively 4
• Resume regular diet within 2 hours after surgery 9, 4
• Encourage early ambulation 4
• Use pneumatic compression stockings for venous thromboembolism prophylaxis 4

Antiemetic Management

• Manage fluid balance to prevent nausea and vomiting 4
• Use antiemetics as needed 4

Glucose Control

• Maintain tight capillary glucose control in the postoperative period 4

Common Pitfalls to Avoid

• Never give antibiotics after cord clamping - this outdated practice increases wound infection rates 1
• Never attempt forced placental removal in suspected accreta - observe for spontaneous separation with preparations for hysterectomy ready 5
• Do not routinely close peritoneum - this wastes time without benefit 1
• Avoid general anesthesia when possible - reserve for inadequate neuraxial block or patient refusal of regional anesthesia 3