1. A TO Z OF
DIFFICULT LSCS

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

4. INTRODUCTION
• Caesarean section is the MOST
COMMON obstetrics operative
procedure performed
• However, a obstetrician can face many
difficulties throughout the procedure.

5. TYPES OF LSCS
Traditional Caesarean section: The classic Caesarean
section involves a long, vertical incision being made
in the midline of the abdomen.
Lower Uterine Segment Caesarean section (LUCS):
The risk of bleeding and other complications such as
hernia are minimal and the surgical wound repairs
more easily than the wound that is left after a
traditional C-section.

6. INDICATIONS FOR PLANNED LSCS
Indication for Planned LSCS:
1. Breech presentation and Transverse Lie At
38wks
2. In twin pregnancies where the first twin is not
cephalic
3. Placenta Praevia
4. Morbidly Adherent Placenta
5. HIV who: are not receiving any anti-retroviral
therapy or are receiving any anti-retroviral
therapy and have a viral load of 400 copies per
ml or more
6. Previous Classical Caesarean

7. INDICATIONS FOR EMERGENCY LSCS
Absolute Indication
• Contracted Pelvis or
cephalopelvic
disproportion
• Pelvic mass causing
obstruction for E.g. cervical
or broad ligament fibroid
• Advanced Carcinoma
Cervix
• Vaginal obstruction
Relative Indication
• Non-Assuring foetal heart rate
• Cord prolapse
• Relative Cephalopelvic Disproportion
• Ante partum haemorrhage
• Previous 2 CS
• Previous Classical CS
• Features of Scar dehiscence
• Dystocia leading to Non-progress of labour
• Failed instrumental delivery
• Failed induction

9. DIFFICULT ABDOMINAL ACCESS

11. TYPES OF INCISIONS
• Compared with Pfannenstiel caesarean section,
the Joel-Cohen-based methods were
associated with less blood loss, shorter
operating time, less fever and shorter time
from skin incision to birth of the baby.
• Vertical incision : emergent access.
• Maylard incision can be used if the access is
restricted due to dense adhesions, however
surgeons should be extremely cautious with
the integrity of inferior epigastric artery.

12. • Previous scar should be excised with an elliptical incision.
• If the sides of this incision is difficult to join up accurately, make some scratch
marks across it and align them later.
• Special care must be taken while entering the peritoneum to prevent bladder or
bowel injury so peritoneum should be opened as high as possible.
• Adhesions could have been prevented by if omentum had been placed between
uterus and abdominal wall, at the last operation.

13. ADHESIOLYSIS BETWEEN RECTUS SHEATH

14. DIFFICULT UTERINE INCISION

16. A . CLASSICAL INCISION
B . LOWER SEGMENT TRANSVERSE INCISION
C . LOWER SEGMENT VERTICAL INCISION
Difficulties in taking a uterine incision can be
attributed to following factors:
• Dense intraperitoneal adhesions
• Bladder adhered to the lower uterine segment
• Previous classical caesarean section scar
• Uterine anomaly
• Fibroid in lower segment or cervical cancer
INTRODUCTION

17. DENSE INTRAPERITONEAL ADHESIONS
• Adhesions are formed if the patient has a history of previous laparotomy.
• Parietal peritoneum should be opened high up.
• Adhesions should always be divided with the points of scissors directed towards
uterus.
• Important pointers while tackling adhesions are: to stay close to uterus to avoid
bladder and open uterus between stay sutures.

18. ADHESIOLYSIS

19. BLADDER ADHERED TO THE LOWER
UTERINE SEGMENT
• The incidence of bladder injury during caesarean section ranges from 0.08 to
0.94%.
• Most commonly bladder injury occurs in cases of previous LSCS.
• A very common problem encountered in cases of previous operation is that the
bladder gets adhered to lower segment.
• If such is the case, peritoneum should be incised on uterus about 2 cm above the
bladder so that UV fold could be mobilize with a finger or a swab.

20. BLADDER ADHERED TO THE LOWER
UTERINE SEGMENT
• Lifting the lower edge of the UV
fold in forceps to stretches the
adhesions between bladder and
uterus.
• If bladder adhesiolysis is difficult,
an incision should be made
about 3 cm above where bladder
and uterus have stuck together.
Bladder separated from lower uterine segment

21. BLADDER ADHESIOLYSIS

22. PREVIOUS CLASSICAL CAESAREAN
SECTION SCAR
In cases of previous classical caesarean
section, it is wiser to do a lower segment
operation.

23. UTERINE ANOMALY
• In cases of bicornuate uterus or
didelphys uterus, it is important to
recognize both the horns. Lateral
extensions of the uterine incision
should be watched for.
•
• A mop curettage of the uterine cavity
should be done, especially in cases of
septate uterus, so that any adhered
membranes and placental bits are not
left behind.

24. LEIOMYOMA IN LOWER SEGMENT
OR CERVICAL CANCER
• The incidence of uterine leiomyomas varies from
0.3 to 7.2% during pregnancy.
• A classical caesarean section might be required
if a large leiomyoma in lower segment, prevents
adequate exposure.
• Caesarean myomectomy can be done if the
fibroid is subserous, at the incision site and can
easily be removed.
• Classical section is also advised in cases of
cervical cancer.
Anterior wall leiomyoma size 5x5 cms at
the level of uterine incision

25. DIFFICULT BABY DELIVERIES

27. FLOATING HEAD
• Head might not be engaged during caesarean section with a poorly formed
and highly vascular lower uterine segment.
• A pre-assessment and placental localisation is necessary as complete
placenta praevia might be the cause of the floating head.
• After amniotomy, the liquor should be allowed to drain completely as this
facilitates the descent of head especially in cases of polyhydramnios.

28. FLOATING HEAD
Delivery of floating, non-
engaged head can be facilitated
by:
1. Vacuum, Vectis or forceps
extraction
2. Internal Podalic version

29. VECTIS IN DELIVERY OF FLOATING HEAD

30. DEEPLY ENGAGED HEAD
• Deeply engaged foetal heads that are difficult to deliver complicate about 1.5
percent of caesarean deliveries.
• These cases often follow a prolonged second stage and failed attempts at
operative vaginal delivery.
• The impacted head places the infant at increased risk of intracranial
haemorrhage, skull fractures, neck fractures, and asphyxia injuries, while
simultaneously increasing the risk of maternal complications, such as severe
uterine lacerations, damage to the uterine vessels, and injury to the lower
urinary tract.

31. DEEPLY ENGAGED HEAD
The best methods to dislodging the
deeply engaged foetal head include:
• Abdominovaginal delivery
• Patwardhan’s shoulders first
technique
• Modified Patwardhan’s technique
• Use of a head elevators
• Reverse breech extraction
technique
• Forceps delivery
Reverse breech extraction

32. PATWARDHAN’S MANOEUVRE
• 1. BOTH SHOULDERS
• 2. BACK & TRUNK
• 3. BUTTOCKS
• 4. LOWER LIMBS

33. BREECH PRESENTATION
Breech may present as
• Frank Breech
• Complete Breech
• Footling presentation

34. BREECH DELIVERY IN LSCS

35. TRANSVERSE LIE• The dorsosuperior (back up) transverse lie may be
delivered as a footling breech through a low
transverse incision in a well-developed lower uterine
segment. At the Ankle you hold the lower limb like
anCigarette held between the Index and middle
finger.
• Dorsoinferior (or back down) may requires a vertical
incision on the uterus.
• If the foetal membranes are intact at the time the
caesarean delivery is performed, intra-abdominal
version of the foetus can convert the transverse lie to
a cephalic or breech presentation allowing delivery
through a low-segment transverse incision.

36. TRANSVERSE LIE

37. CONJOINT TWINS

38. PLACENTA PRAEVIA
Placenta praevia carries a risk of massive obstetric haemorrhage and hysterectomy.
The six elements considered to be reflective of good care were:
● Consultant obstetrician planned and directly supervising delivery.
● Consultant anaesthetist planned and directly supervising anaesthetic at delivery.
● Blood and blood products available.
● Multidisciplinary involvement in pre-op planning.
● Discussion and consent includes possible interventions (such as hysterectomy, leaving
the placenta in place, cell salvage and intervention radiology).
● Local availability of a level 2 critical care bed.

39. PLACENTA PRAEVIA
De Lee incision is preferred (lower vertical
incision) if
• Poorly developed lower segment, which would
not allow a transverse incision of adequate
length.
• A very vascular lower segment with large veins
on it.
• The presenting part is high, and baby is lying
transversely, indicating that the placenta
praevia is probably central.

40. BABY DELIVERY IN PLACENTA PREVIA

41. PLACENTA PRAEVIA
• If the placenta fails to separate with the
usual measures, closing the uterus and
proceeding to a hysterectomy are both
associated with less blood loss.
• If the placenta separates, sutures can be
taken on the placental bed.

42. PLACENTAL BED HAEMOSTASIS IN PLACENTA PREVIA

43. DIFFICULT HAEMOSTASIS

46. COLPORRHEXIS
• Colporrhexis is a laceration causing
separation of the cervix from the vaginal
fornix.
• It can be primary or secondary.
• Primary colporrhexis is a vaginal vault tear
which is not associated with cervical or
uterine extension
• Secondary colporrhexis cannot be
differentiated from a rupture originating in
the uterus and then extending to involve the
vagina.

47. UTERINE INCISION EXTENSION LEADING
TO UTERINE ARTERY AVULSION
After a prolonged labour or in case of
deeply impacted, standard uterine
incision frequently get extended
laterally, leading avulsion of uterine
artery.
Extension might be in to the broad
ligament or to the vagina and bladder.
uterine artery ligation in uterine lacerations

48. COMPRESSION SUTURES
• A woman meets the criteria of
compression sutures if bimanual
compression of uterus controls
bleeding by abdominal and
vaginal inspection.

49. SYSTEMATIC DEVASCULARISATION
OF UTERUS
• Step wise devascularisation was
1st reported from Egypt. It is
effective in controlling PPH in
80% of cases.
• Bilateral uterine artery ligation,
initially in upper part of the lower
uterine segment.
• It is followed by ligation of lower
uterine vessels and ovarian
vessels.

50. INTERNAL ILIAC LIGATION
• Experiments in the 1960’s by Burchell,
ascertained that ligating the hypogastric
artery turned the pelvic circulation like a
venous system, thereby aiding clotting and
controlling PPH.
• It is effective in
• Uterine atony,
• Midline perforation,
• Large broad ligament or lateral pelvic wall
haematoma,
• Multiple cervical tears and
• Lower segment bleeding.

51. SYSTEMATIC PELVIC DEVASCULARISATION

52. OBSTETRIC HYSTERECTOMY
Most common indications are:
• Placenta accrete
• Uterine atony
• Severe Couvelaire uterus
• Uterine rupture
• Cornual or cervical pregnancy
• Refractory uterine scar infection
• Chronic recurrent uterine inversion

53. BLADDER INJURY
• The incidence of bladder injury during
caesarean section ranges from 0.08 to 0.94%.
• Most commonly bladder injury occurs in cases
of previous LSCS.
• Ninety-five (95) % of bladder injuries during
caesarean section occur at the dome of the
bladder with the remaining occurring at the
trigone.

54. BLADDER INJURY
• The average length of bladder injury is 4.2 cm (1–10 cm).
• The most likely time bladder injury occurs is during the
• 1. Creation of a bladder flap (43%)
• 2. Time of entry into the peritoneal cavity (33%).
• 3. During uterine incision or delivery.

55. BLADDER INJURY
• A simple rent is normally repaired in two layers, with the
first layer consisting of a simple running closure of the
mucosa with a 3–0 absorbable suture.
• The second layer may be closed continuous interlocking
stitch using either 2–0 or 3–0 absorbable suture to include
the submucosa and muscularis.
• Foley catheter for at least 7–10 days postoperatively.

56. CONCLUSION
• With the increasing rate of caesarean sections, there are higher chances to
encounter adhesions during LSCS.
• Difficulties can be encountered during opening the abdomen, uterine
incision, baby delivery and haemostasis.
• So every obstetricians should be equipped with these surgical techniques to
overcome these difficulties and reduce maternal and foetal morbidity.

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