LSCS

BY DR. PRUTHA KALYANI

JR2 OBGY,
GUIDE:DR.SHIRISH DHULEWAD
DR.SCGMC
It is an operative procedure whereby the fetus is 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 cesareandelivery.
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.
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
6) Previous cesarean delivery
7) Non- reassuring FHR (fetal distress)
8) Dystocia
9) Antepartum hemorrhage (placenta previa & placental abruption)
10) Misrepresentation
11) Failed surgical induction of labor, failure to progress in labor
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
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
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)
INSTRUMENTS REQUIRED FOR
CAESAREAN SECTION:
  Suction
Towel clips
 Sponge holding forceps  BP handle and blade
 Allis tissue holding forceps  Doyen' retractor
 Green armytage haemostatic  Mayo scissors
forceps  Kidney tray
 Artery forceps  Electric cautery
 Toothed forceps  Clamps
 Dissecting forceps (toothed and
non-toothed)
 Needle holder
PRE-OPERATIVE PREPARATION
 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
 Anesthesia
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.
Advantages of transverse i.e. Pfannsteil 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.
Steps

Assessment of the presenting part

Identifying the incision line
Pfannesteil incision
Incision to the rectus sheath
Open the rectus muscle and retract laterally
Opening the peritoneal cavity
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
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
Umbilical cord is clamped at two places and cut. D
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
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. O 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. Peritoneall flaps are oppposed by continuous inverting suture but
it is not necessary to close the visceral and parietal peritoneal
layers
The mops placed inside are removed and numbers & 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
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.
1st Postoperative day: oral feeding in the form sips is
given.Ambulation is done and patie 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.
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) Gl tract injury
6) Excessive hemorrhage
Post-operative complications
Immediate complications
1) post-partum haemorrhage- Due to uterine atony.
2) Shock
3) Anesthetic 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 orparalytic ileus
following peritonitis.
6) DVT and thromboembolic disorders
7) Wound complications: wound sepsis, haematoma, dehiscence, burst abdomen
(involving the peritoneal coat)
8) Secondary PPH
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
• latrogenic prematurity and development of RDS