lscs

1. LOWER SEGMENT
CESAREAN SECTION
(LSCS)
NUR FARRA NAJWA BINTI ABDUL AZIM
0820151000035

2. LEARNING OBJECTIVE
1. What if LSCS
2. What it indication
3. The timing of LSCS
4. Steps of LSCS
5. Postoperative care
6. Suture in LSCS
7. Complication of LSCS
8. Classic cesarean section
9. Special cesarean type

3. 1. INTRODUCTION
 Operative procedure : fetuses after the end of 28th
weeks are delivered through an incision on the
abdominal and uterine walls.
 Incidence: steadily rising.
1. Increased safety of the operation
2. Availability of blood transfusion
3. Avaibility of antibiotics,
Primary Cesarean
Section.
Repeat Cesarean Section
First operation
performed on a patient
Performed in
subsequent
pregnancies

4. >> FACTOR RISING CESAREAN SECTION
RATE

5. 2. INDICATION
INDICATION
ABSOLUTE
Vaginal delivery
is not possible
RELATIVE
Vaginal delivery
is possible but
high risk to
mother and baby

8. 3. TIMING
TIMING
ELECTIVE
Done at a
prearranged
time
EMERGENCY
Done due to an
acute obstetric
emergency.
(A time interval
of 30 minutes)

9. a. Elective
 Benefits
 No hazard from labor and
delivery process.
 No pelvic floor
dysfunction.
 Risks
 Placenta previa and
 Hysterectomy
 Longer recovery time
/hospital stay.
TIMING OF ELECTIVE SECTION
Maturity is certain Maturity is uncertain
Done about 1 week prior to the
expected date of confinement
(EDD)
1. Ultrasound assessment in first
or second trimesters
2. Amniocentesis for L:S ratio
used to ensure fetal maturity.
3. Otherwise spontaneous onset of
labor is awaited and then CS is
done.

10. b. Emergency (category)
Category 1 -When there is immediate threat to the
life of the woman or the fetus.
-Decision delivery interval should be
30 minutes
Category 2 -When there is maternal or fetal
compromise which is not immediately
life threatening.
-CS should be done within 75
minutes of making decision
Category 3 There is no maternal or fetal
compromise but needs early delivery
Category 4 Delivery is planned to suit the woman,
family members and the hospital staff.

12. SECTION(type)
LOWER SEGMENT
CESAREAN SECTION
• Extraction through
an incision made in the
lower segment
• Through a
transperitoneal approach.
• Only method practiced in
present day obstetrics
• Cesarean section means
lower segment operation.
CLASSICAL
• Extracted through an
incision made in the upper
segment of the uterus.
• Its indications very much
limited (done under forced
circumstances)

13. Forced Circumstances For Classical
Section
Lower Segment
Approach Is
Difficult:
Dense
adhesions
Severe
contracted
pelvis
Lower Segment
Approach Is Risky
Big fibroid on
the lower
Carcinoma
Repair of high
VVF
Complete anterior placenta
previa with engorged vessels
in the lower segment

14. 4. LSCS SURGERY STEPS
a. Perioperative preparation
b. Incision
c. Delivery of
a. Head
b. Trunk
c. Placenta and membrane
d. Suturing
e. Concluding part

17. a. Perioperative
Premedicative sedative must not be given.
Hair may be clipped.
Abdomen is scrubbed with soap and nonorganic iodide
lotion.
Informed written permission for the procedure, anesthesia
and blood transfusion is obtained.

18. Metoclopramide (10 mg IV) to
increase the tone of the lower esophageal
sphincter as well as to reduce the stomach contents..
The stomach should be emptied, - stomach tube (emergency
procedure).
Ranitidine (H2 blocker) 150 mg is given orally night before
(elective procedure) and it is repeated (50 mg IM or IV) 1
hour before the surgery
Nonparticulate antacid (0.3 molar sodium citrate, 30 ml) is
given orally.

19. IV cannula: sited to administer fluids (ringer’s solution, 5%
dextrose).
Prophylactic antibiotics should be given (IV) before making
the skin incision.
Cross match blood
Neonatologist should be made available.
FHS should be checked once more at this stage.
Bladder should be emptied by a foley catheter which is kept
in place in the perioperative period.

20. ANESTHESIA -Spinal, epidural or general
ANTISEPTIC PAINTING -Painted with 7.5% povidone-iodine
solution/ savlon lotion and properly draped
with sterile towels
POSITION OF THE PATIENT -Dorsal position. In susceptible cases,
-A 15° tilt to her left using a wedge till
delivery of the baby should be done.
INCISION -Vertical or a transverse skin incision.
-Modified pfannenstiel is made 3 cm above
the symphysis pubis.
PACKING -The doyen’s retractor is introduced.
-The peritoneal cavity is now packed off
using two taped large swabs.
-The tape ends are attached to artery
forceps. -This will minimize spilling of the
uterine contents into the general peritoneal
cavity

22. b. incision UTERINE
INCISION
Peritoneal
Incision
The loose
peritoneum of the
uterovesical pouch is
cut transversely
across the lower
segment
The lower flap of
the peritoneum is
pushed down a
little.
Muscle
Incision
The most
commonly used
incision (90%) is
low transverse.

23. Other types of uterine incisions
 Lower vertical—may be extended upwards when
needed.
 Classical incision (upper segment).
 “J” incision—upward vertical extension of the initial
transverse incision.
 Inverted “T” incision—upward extension from the
mid-transverse incision.
 Vertical uterine incision is made when the lower
segment is poorly developed or there is complete
anterior placenta previa or any myona occupying the
lower segment.

26. LOW TRANSVERSE INCISION
 Made at a level slightly below the peritoneal incision
until the membranes of the gestation sac are
exposed.
 Two index fingers are then inserted and the muscles
of the lower segment are split transversely across
the fibers.
 This method minimizes the blood loss but requires
experience.

31. c. Delivery Of The Head
 The membranes are ruptured
 The blood mixed amniotic fluid is sucked
 The doyen’s retractor is removed.
 The head is delivered by hooking the head with the
fingers
 The head is delivered by elevation and flexion using
the palm to act as a fulcrum.
 As the head is drawn to the incision line, the
assistant is to apply pressure on the fundus.
 Push up the head by sterile gloved fingers
introduced into the vagina.
 Delivered using wrigley’s.

32. d. Delivery Of The Trunk
 Mucus from the mouth, pharynx and nostrils is sucked
out
 After the delivery of the shoulders, intravenous Oxytocin
20 units or Methergine 0.2 mg is to be administered.
 The rest of the body is delivered slowly
 Baby is placed in a tray placed in between the mother’s
thighs with the head tilted down for gravitational
drainage.
 The cord is cut in between two clamps and the baby is
handed over to the pediatrician.
 The doyen’s retractor is reintroduced.
 The optimum interval between uterine incision and
delivery should be less than 90 seconds.
 Interval > 90 seconds are associated with poor apgar
scores.

33. e. Removal Of The Placenta And
Membranes
 placenta is separated spontaneously.
 The placenta is extracted by traction on the cord
(controlled cord traction).
 The membranes are carefully removed preferably
intact and even a small piece, if attached to the
decidua should be removed using a dry gauze.
 Exploration of the uterine cavity is desirable

34. f. Suture Of The Uterine Wound
 The suture of the uterine wound is done with the
uterus keeping in the abdomen.
 Some, however, prefer to eventrate the uterus prior
to suture.
 The margins of the wound are picked up by Allis
tissue forceps or Green Armytage hemostatic clamps
(four are required, one each for angle and one for
each margin).
 The uterine incision is sutured in three layers.

35.  FIRST LAYER:
 The first stitch is placed on the far side in the lateral angle of the
uterine incision and is tied.
 The suture material is no “0” chromic catgut or vicryl and the
needle is round bodied.
 A continuous running suture taking deeper muscles excluding or
including the decidua (very difficult to exclude) ensures effective
apposition of the tissues; the stitch is ultimately tied after the
suture includes the near end of the angle.
 SECOND LAYER:
 A similar continuous suture is placed taking the superficial
muscles and Adjacent fascia overlapping the first layer of suture.
 Uterine muscles may be closed using a continuous single layer
stitch taking full thickness muscle and decidua.
 There is controversy as regard the place of single layer or double
layer closure in relation to
 The risk of subsequent scar rupture. The peritoneal flaps may be
apposed by continuous inverting suture (to prevent any raw
surface).
 Nonclosure of visceral and parietal peritoneum is preferred.

37. g. Concluding Part
 The mops placed inside are removed and the
number verified.
 Peritoneal toileting is done and the blood clots are
removed meticulously.
 The 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.
 The vagina is cleansed of blood clots and a sterile
vulval pad is placed

38. 5. POSTOPERATIVE CARE
 First 24 hrs
 Day 1
 Day 2
 Day 5 and 6
 Discharge

39. a. First 24 hours
 Day 0
 Observation for the first 6–8 hours is important.
 Fluid:
 Sodium chloride (0.9%) or Ringer’s lactate drip is continued until
at least 2.0–2.5 L of the solutions are infused.
 Blood transfusion is helpful in anemic mothers and if the blood
loss is more than average during the operation
 Oxytocics:
 Injection oxytocin 5 units IM or IV (slow) or methergine 0.2 mg
IM is given and may be repeated.

40. Cont.
 Prophylactic antibiotics
 (cephalosporins, metronidazole) for all cesarean delivery is
given for 2–4 doses.
 Analgesics
 in the form of pethidine hydrochloride 75–100 mg is
administered and may have to be repeated.
 Ambulation:
 She is encouraged to move her legs and ankles and to breathe
deeply to minimize leg vein thrombosis and pulmonary
embolism.
 The patient can sit on the bed or even get out of bed to
evacuate the bladder.
 Baby is
 Put to the breast for feeding after 3–4 hours when mother is
stable and relieved of pain.

41. b. Day 1
 Oral feeding
 Raw tea may be given.
 Active bowel sounds are observed by the end of the day.

42. c. Day 2
 Light solid diet of the patient’s choice is given.
 Bowel care:
 3–4 teaspoons of lactulose is given at bed time.

43. c. Day 5 or day 6
 The abdominal skin stitches are to be removed on the D-5
(in transverse) or D-6 (in longitudinal)

44. d. Discharge
 The patient is discharged on the day following
removal of the stitches, if otherwise fit.
 Patient may be discharged as early as third to as
late as seventh postoperative days

45. 6. CLASSIC CESAREAN SECTION
 Easy to perform
 Abdominal incision is always longitudinal (paramedian) and about 15
cm (6") in length, 1/3rd of which extends above the umbilicus.
 A longitudinal incision of about 12.5 cm (5") is made on the midline of
the anterior wall of the uterus starting from below the fundus.
 The incision is deepened along its entire length until the membranes
are exposed which are punctured.
 In about 40% cases, the placenta is encountered.
 In such cases, fingers are slipped between the placenta and the
uterine wall until the membranes are reached.
 The baby is delivered commonly as breech extraction.
 Intravenous oxytocin 5 iu iv (slow) or methergine 0.2 mg is
administered following delivery of the baby. T
 The uterus is eventrated.
 The placenta is extracted by traction on the cord or removed
manually.

49. 7. SUTURE OF THE UTERINE INCISION
 The uterus is sutured in three layers.
 The uterus is returned back into the abdominal cavity.
 The abdomen is closed in layers.
A CONTINUOUS SUTURE Chromic catgut no “0” or vicryl taking
deep muscles excluding the decidua
A SECOND LAYER OF
CONTINUOUS SUTURES
(1 cm apart) using chromic catgut no.
“1” or vicryl taking the entire depth of
superficial muscles down to the first
layer of suture.
THE THIRD LAYER OF
CONTINUOUS SUTURE
Taking the peritoneum with the
adjacent muscles using chromic catgut
no “0” and round-bodied needle

51. 8. COMPLICATIONS OF CESAREAN
SECTION
 Operations (inherent hazards)
 Anesthesia
The
Complications Are
Grouped Into
Intraoperative Postoperative

52. a. Intraoperative Complications
 Extension of uterine incision to one or both the sides.
 Uterine lacerations at the lower uterine incision
 Bladder injury— may occur in a repeat procedure.
 Ureteral injury
 Gastrointestinal tract injury
 Haemorrhage
 Morbid adherent placenta

53. b. Postoperative Complications
POSTOPERATIVE
COMPLICATIONS
Maternal
Immediate Remote
Fetal

54. MATERNAL (Immediate)
 Postpartum hemorrhage
 Shock
 Anaesthetic hazard
 Infection
 Intestinal obstruction
 DVT / TED
 Wound complication
 Secondary PPH

55. MATERNAL (remote)
REMOTE
Gynecological
Menstrual excess or
irregularities,
chronic pelvic pain
or backache
General surgical
Incisional hernia,
intestinal
obstruction due to
adhesions and
bands.
Future pregnancy
There is risk of scar
rupture

56. FETAL
 Iatrogenic prematurity
 Development of RDS
 Accidental scalpel injury to the baby may occur.

57. MATERNAL AND PERINATAL MORTALITY:
 Maternal
(1) hemorrhage and shock
(2) anesthetic hazards
(3) infection and
(4) thromboembolic disorders.
 Fetal
(1) Asphyxia
(2) RDS
(3) prematurity
(4) infection and
(5) intracranial hemorrhage— attempting breech delivery
through a small incision.

58. 9. SPECIAL CESAREAN
 Cesarean hysterectomy
 Peripartum hysterectomy
 Perimortem cesarean delivery
 Subtotal hysterectomy
 Extraperitoneal cesarean section

59. >> Cesarean hysterectomy
 Operation where cesarean section is followed by
removal of the uterus.
 The common conditions are:
(1) morbid adherent placenta
(2) atonic uterus and uncontrolled postpartum
hemorrhage
(3) big fibroid (parous women)
(4) extensive lacerations
(5) grossly infected uterus
(6) rupture uterus.

60. >> Peripartum hysterectomy
 Surgical removal of the uterus either at the time of
cesarean delivery or in the immediate postpartum
period (even following vaginal delivery).

61. >> Perimortem cesarean delivery
 Perimortem cesarean
delivery refers to the
caesarean delivery of a
woman who is expected
to die within next few
moments or has just died.
 It is done within 4–5
minutes of start of
cardiopulmonary
resuscitation (CPR) when
the fetus is alive.

62. >> Subtotal hysterectomy
 Subtotal hysterectomy is commonly done as an
emergency (unplanned) procedure.
 Benefits of subtotal hysterectomy are:
 Less operating time,
 less blood loss,
 less risk of injury to other organs (bladder, ureter)
 less postoperative morbidity

63. >> Extraperitoneal cesarean section
 Practised in the past in cases with severe infection.
 Lower segment is approached extraperitoneally by
dissecting through the space of retzius.
 Currently, with the availability of potent antimicrobial
agents, this is rarely performe

64. SUMMARY
1. What if LSCS
2. What it indication
3. The timing of LSCS
4. Steps of LSCS
5. Postoperative care
6. Classic cesarean section
7. Suture in LSCS
8. Complication of LSCS
9. Special cesarean type

65. REFERENCES
 Mudaliar and Menon’s Clinical Obstetrics, 11th
edition, Sarala Gopalan and Vanita Jain, Cesarean
Delivery
 DC Dutta’s Textbook of Obstetrics, 9th edition, Hiralal
Konar, Cesarean Delivery
 Essential Of Obstrectric, Lakshmi Seshadri, Gita
Arjun, Cesarean Delivery