.

1. LOWER SEGMENT CAESAREAN
SECTION
BIMAL POKHAREL
MBBS 4TH BATCH

2. It is an operative procedure whereby the fetuses after
the end of 28th week are delivered through an incision
on the abdominal and uterine walls.
Incidence: steadily rising.
Factors for rising cesarean section rate:
1) Identification of at risk fetuses before term (IUGR).
2) Identification of at risk mothers.
3) Wider use of repeat CS in cases with previous cesarean
delivery.
4) Rising rates of IOL and failure of induction.
5) Decrease in vaginal breech delivery.
6) Increased no. of women with age more than 30 yrs at
conception and associated medical complications.
7) Wider use of electronic fetal monitoring and increased
diagnosis of fetal distress.
8) Cesarean delivery on demand.

3. Indications
Absolute Indications
1) Central placenta previa
2) Contracted pelvis or cephalopelvic disproportion
3) Pelvic mass causing obstruction ( cervical or broad ligament fibroid)
4) Advanced carcinoma cervix
5) Vaginal obstructions (atresia, stenosis)
Relative indications
1) Previous cesarean delivery
2) Non- reassuring FHR ( fetal distress)
3) Dystocia
4) Antepartum haemorrhage ( placenta previa & abruptio placenta)
5) Malpresentation
6) Failed surgical induction of labor, failure to progress in labor

4. 7) Bad obstetric history- with recurrent fetal
wastage
8) Hypertensive disorders of pregnancy ( severe pre
eclampsia , eclampsia - uncontrolled fits even with
anti-seizure therapy.
9) Medical- gynecological disorders
a) Uncontrolled diabetes
b) Heart disease
c) Mechanical obstruction due to benign or
malignant pelvic tumors ( carcinoma cervix ) or
following repair of VVF

5. Time of operation
Elective: operation done at pre arranged time during
pregnancy to ensure the best quality of obstetrics,
anaesthesia, neonatal resuscitation and nursing
services.
Timing:
a) Maturity certain: operation done about 1 week prior
to the expected date of delivery
b) Maturity uncertain: Amniocentesis is done for L/S
ratio to ensure the fetal lung maturity, otherwise
spontaneous onset of labor is awaited , then CS is
done
Emergency LSCS: Operation is done due to
acute obstetric emergencies

6. Types of operation:
a) Lower segment caesarean section
b) Classical caesarean section
Peculiarities of lower uterine segment:
• Peritoneum is more loosely attached to the uterus
• Contraction is less than in upper part of uterus
• Lower segment is less vascular
• Thin muscle layer
• Healing is more efficient
• Sutures are intact (less problem with suture loosening)

7. Merits and demerits of LSCS over
classical CS
LOWER SEGMENT CLASSICAL
Technique 1. Technically slightly difficult
2. Blood loss is less
3. The wall is thin and so
apposition is perfect
4. Perfect peritonization is
possible
5. Technically difficult in
placenta previa or transverse
lie
1. Technically easier
2. Blood loss is more
3. The wall is thick and apposition
of the margins is not perfect
4. Not possible
5. Comparatively safer in such
circumstances
Post-
operative
1. Haemorrhage and shock- less
2. Chance of peritonitis is less in
presence of uterine sepsis
3. Peritoneal adhesions and
intestinal obstruction are less
4. Recovery is better
5. Less incidence of morbidity
and mortality
1. More
2. Chance of peritonitis is more in
presence of uterine sepsis
3. More because of imperfect
peritonization
4. Relatively poor
5. Morbidity and mortality are high

8. LOWER SEGMENT CLASSICAL
Wound healing The scar is better healed
because of:
1) Perfect muscle
apposition due to thin
margins
2) Minimal wound
hematoma
3) The wound remains
quiescent during healing
process
4) Chance of gutter
formation is unlikely
The scar is weak because
of:
1) Imperfect muscle
apposition due to thick
margins
2) More wound
hematoma formation
3) Wound remains in a
state of tension due to
contraction and
relaxation of the upper
segment
4) Chance of gutter
formation on the inner
aspect is more
During future pregnancy Scar rupture- less More risk of scar rupture

9. • INSTRUMENTS REQUIRED FOR CAESAREAN
SECTION:
1) Towel clips 12) Mayo scissors
2) Sponge holding forceps 13) Kidney tray
3) Allis tissue holding forceps 14) Electric cautery
4) Green armytage haemostatic forceps 15) Clamps
5)Artery forceps
6)Toothed forceps
7)Dissecting forceps ( toothed and non- toothed)
8) Needle holder
9) Suction
10) BP handle and blade
11) Doyen’ retractor

10. PRE- OPERATIVE PREPARATIONS
• Informed written high risk consent for the procedure,
anesthesia and arrangement of properly cross matched
blood.
• Antacid ( sodium citrate 30ml) given orally before
transferring the patient to the OT.
• Ranitidine 150mg orally night before and is repeated by
50mg iv 1 hr before surgery.
• Metoclopramide( 10mg iv) is given to increase the tone of
the lower esophageal sphincter.
• Bladder is emptied by a Foleys catheter.
• FHS should be checked once more at this stage.
• Neonatologist should be made available.

11. • ANAESTHESIA:
May be spinal , epidural or general.
POSITION OF THE PATIENT
Patient is kept in dorsal position. In susceptible cases, to minimize any
adverse effects of venacaval compression, a 15 degree tilt to her left
using a wedge till delivery of the baby is benificial.
ANTISEPTIC PAINTING
Abdomen is painted with 7.5% povidine iodine solution.
INCISION ON THE ABDOMEN
Either a vertical or transverse skin incision
Vertical incision: infraumbilical midline or paramedian
Transverse incision: modified pfannensteil incision is made 3 cm above
the pubic symphisis.

12. Advantages of transverse i.e.
pfannensteil incision
• Post-operative comfort is more.
• Fundus of the uterus can be better palpated
during immediate post- operative period.
• Less chance of wound dehiscence.
• Less chance of incisional hernia.
• Cosmetic value.

13. Steps
• Assessment of the presenting part
Identifying the incision line
Pfannensteil incision

15. Incision to the rectus sheath
Open the rectus muscle and retract
laterally
Opening the peritoneal cavity

18. Parietoperitoneum of the bladder and uterus
is separated by fingers
Doyen’s retractor is introduced and
bladder is pushed downwards
Recognition of the lower uterine segment is
made by the presence of loose peritoneum over
it

19. The loose peritoneum is incised transversely
Lower uterine segment incision is made in the
middle, deepened till the membranes are reached and
then extended laterally
Amniotic sac is ruptured and the Doyen’s
retractor is removed
The presenting part is hooked by the surgeon and
delivered while the assistant applies fundal pressure
Green armytage hemostatic forceps are applied to
the angles and margins of uterine incision to control
bleeding

20. Umbilical cord is clamped at two places and
cut.
Doyen’s retractor is reintroduced and the
placenta and membranes are delivered.
Uterus is exteriorized and the inside of the
uterus is inspected for any abnormalities and
completeness of removal of contents

21. Suture of the uterine wound in 3 layers
1) suture is placed on the far side in the lateral angle of uterine incision.
• suture material is no. 0 chromic catgut suture.
• continuous running suture taking deeper muscles
2) second layer: a similar continuous suture is placed taking the superficial
muscles and adjacent fascia overlapping the first layer of suture
3) peritoneal flaps are oppposed by continuous inverting suture but it is not
necessary to close the visceral and parietal peritoneal layers.

22. The mops placed inside are removed and numbers are
verified
Peritoneal toileting is done and the blood clots are removed
Bilateral tubes and ovaries are examined
Doyen’s retractor is removed
After being satisfied that the uterus is well contracted, the
abdomen is closed in layers.
Vaginal toileting is done
Sterile vulval pad is applied

23. Post-operative care
First 24 hours
• NPO and observation for the first 6-8 hours.
• Periodic checkup of pulse, BP, PV bleeding, abdominal distension,
input/ output charting, behavior of the uterus
• Administration of iv fluids 2 pints each of RL NS AND D5
• Inj oxytocin 10 units in 1 pint RL
• Blood transfusion is required if there is more than expected blood
loss.
• Prophylactic antibiotics ( cephalosporins and metronidazole) for all
cesarean delivery for 2-3 days. Therapeutic antibiotic is given when
indicated.
• Analgesics in the form of pethidine and ketorolac is given.
• Baby is put to breastfeeding after 3 to 4 hours when mother is
stable and relieved of pain.

24. • 1st post-operative day: oral feeding in the form of
sips is given. Ambulation is done and patient
shifted to ward and oral antibiotics is given.
• 2nd post-operative day: soft diet and ambulation.
• 3rd post-operative: observation of wound for any
soakage and bleeding. Soft to normal diet.
• 5th postoperative day: suture out is done and the
patient is discharged and contraceptive advice is
given.

25. complications
Intraoperative complications:
1) Extension of the uterine incision: may lead to
bleeding from the uterine vessels and formation of
broad ligament hematoma.
2) Uterine lacerations at lower uterine segment- may
extend laterally and inferiorly into the vagina.
3) Bladder injury
4) Ureteral injury
5) GI tract injury
6) Excessive hemorrhage

26. Post-operative complications
• Immediate complications
1) post-partum haemorrhage- Due to uterine atony.
2) Shock
3) Anaesthetic hazards: Aspiration of gastric contents , may result in
aspiration atelectasis and aspiration pneumonitis.
others: hypotension and spinal headache.
4) Infections: endomyometritis, UTI, wound infections, peritonitis
5) Intestinal obstruction: due to formation of adhesions and bands or
paralytic ileus following peritonitis.
6) DVT and thromboembolic disorders
7) Wound complications: wound sepsis, haematoma, dehiscence,burst
abdomen (involving the peritoneal coat)
8) Secondary PPH

27. Remote complications
• Gynaecological: Menstrual excess or
irregularities, chronic pelvic pain or bachache
• General surgical: Incisional hernia, intestinal
obstructions due to adhesions or bands
• Future pregnancy: risk of scar rupture
FETAL COMPLICATIONS
• Iatrogenic prematurity and development of
RDS

28. References
• DC Dutta’s textbook of obstretics 8th edition.