The document discusses techniques for lower segment cesarean section (LSCS). It summarizes the evolution of cesarean section over time and reviews evidence and recommendations from studies and guidelines on various aspects of performing LSCS, including skin preparation, abdominal entry, uterine incision, placental delivery, wound closure, and thromboprophylaxis. Large trials have compared techniques such as single versus double layer uterine closure, and closure versus non-closure of the peritoneum.

1. Review of techniques of
LSCS
Veerendrakumar C.M
MD.,DNB
VIMS, Bellary

2. James Young Simpson
1811-1870
 Obstetrics is not one of the exact
sciences and in our penury of truth
- we ought to be accurate in our
statements,
- generous in our doubts,
- tolerant in our convictions.

3. evolution
 Being Bipedal
 Being intelligent

4.  Caesarean has evolved over centuries. It has
meant different things to different people at
different times.
 Dead mother dead baby
 Dead mother live baby
 Live mother live baby
 Healthy mother healthy baby
 Healthy mother, healthy baby & healthy pelvic floor.

5. IS C.S. SAFE ?
NO !

6. ….if a C.S is not
done, the woman
and her baby take
the risks
….while if the
C.S is done,
The doctor
takes the risk

7. ‘REDUCE THE QUANTITY
IMPROVE THE QUALITY’

8. ‘8’ hours Vs ‘8’ minutes

9. easy normal delivery or s. c. s.

10. O. T.
 A. Good Boyle’s apparatus
 B. Multipara monitor
 C. Suction apparatus
 D. Defibrillator ‘?’

11. Decorum of the O.T.

12. Timing of antibiotic administration
NICE RECOMMENDATION [new 2011]
• Offer women prophylactic antibiotics at CS
before skin incision.
• Offer women prophylactic antibiotics at CS to
reduce the risk of postoperative infections.

13.  Choose antibiotics effective against
endometritis, urinary tract and wound
infections, which occur in about 8% of women who
have had a CS.
Do not use co-amoxiclav when giving antibiotics
before skin incision.

14. Skin preparation
 Shaving results in microscopic nicks
and tears of the epidermis
 Actually increases the risk of skin
infection unless done immediately
preoperatively.
Surgical obstetrics 1992

15. Betadine spray
Before shifting to OT abdomen
cleansed and betadine spray applied
 operating area covered with sterile
drape
 Prepackaged adhesive draping

16. Incision
 Pfannensteil
 Joel cohen
 Midline vertical
 Supraumbilical in morbidly obese
Am J obst gynecol 2000

17. Abdominal entry

18. Abdominal incision
NICE RECOMMENDATIONS
 The transverse incision of choice should be the Joel
Cohen incision (straight skin incision, 3 cm above
the symphysis pubis; subsequent tissue layers are
opened bluntly and if necessary extended with
scissors and not a knife).
 It is associated with shorter operating times and
reduced postoperative febrile morbidity. A

19. Meticulous attention to
placement of skin incision
 Allis clamp test
Am J Obst Gynecol 1991

20. Abdominal exposure
 Tubular plastic
retractor with a
rolled edge

21. UV fold entry
 Blunt or sharp
 Previous surgery- sharp better

22.  Uterine incision
-CLASSICALLY - several centimetres
below the UV fold
- just below the UV fold

23. Uterine incision
NICE RECOMMENDATIONS
 When there is a well formed lower uterine
segment, blunt rather than sharp extension of the uterine
incision should be used as it reduces blood
loss, incidence of postpartum haemorrhage and the
need for transfusion at CS.
A

24.  T incision is the weakest and poorest of
uterine wound healing
 Use J or double J (trap door) incision
 Use of intravenous dilute 150 mcg-300 mcg
NTG
O’grady, operative obstetrics

25. E R R-
for extraction of the head

Elevation
Rotation
Reduction
Cho, OBG management 2003

26. Difficult cranial delivery
 Thinking ahead is a great boon
 keep relaxants ready
 Vaccum/short forceps/vectis
 Keep asst ready for ‘Passing it up”
technique

27. Delivery of the baby
NICE RECOMMENDATIONS
 Forceps should only be used at CS if there is
difficulty delivering the babies head. The effect on
neonatal morbidity of the routine use of forceps at
CS remains uncertain. C
 [Either forceps or a vacuum device may be used to
deliver the fetal head-Williams]

28. Delayed cord clamping
 Suggested benefits of delayed cord clamping include
decreased neonatal anaemia;
 Better systemic and pulmonary perfusion; and better
breastfeeding outcomes.
 Possible harms are
polycythaemia, hyperviscosity, hyperbilirubinaemia, trans
ient tachypnoea of the newborn and risk of maternal fetal
transfusion in rhesus negative women.

29. Delivery of placenta
NICE RECOMMENDATION
 Oxytocin 5 iu by slow intravenous injection should
be used at CS to encourage contraction of the
uterus and to decrease blood loss.
C
 At CS, the placenta should be removed using
controlled cord traction and not manual removal
as this reduces the risk of endometritis.
A.

30. Mechanical dilatation of the cervix
Three trials with a total of 735 women(CDSR)
There was insufficient evidence of mechanical
dilatation of the cervix at non-labour caesarean
section for reducing postoperative morbidity.

31. EXTERIORISATION OF UTERUS
"Misgav Ladach" Cesarean Section

32. Extra-abdominal versus intra-abdominal
repair of the uterine incision at caesarean
 Six studies were included, with 1294 women
(CDSR)
 There is no evidence from this review to make
definitive conclusions about which method of
uterine closure offers greater advantages

33. Uterine closure
NICE RECOMMENDATION
 Intraperitoneal repair of the uterus at CS should be
undertaken. Exteriorisation of the uterus is not
recommended because it is associated with more pain
and does not improve operative outcomes such as
haemorrhage and infection. A
 The effectiveness and safety of single layer closure of
the uterine incision is uncertain.
 Except within a research context the uterine incision
should be sutured with two layers.
B

34. Correct method of uterine
closure

35. Uterine closure
 auto stapler preloaded with dissolving
copolymer staples made of polylactic
and polyglycolic acid
 Incises and staples the myometrium in
single action
No advantage -cochrane review 2006
 May be of use in fetal surgery

36. Suction… mop…GUTTER CLEANING

37. Routine gutter cleaning with mop
 To be avoided
 May result in microscopic abrasions
 Adhesions may develop

38. Forgotten mop with sigmoid
injury !!!

39. Closure versus non-closure of the
peritoneum at caesarean section
 Fourteen trials, involving 2908
women.(CDSR)
 There was improved short-term
postoperative outcome if the peritoneum
was not closed.
 Long-term studies --limited

40. Examination of adnexa
mandatory

41. NICE RECOMMENDATION
 Routine closure of the subcutanoues tissue space
should not be used, unless the woman has more
than 2 cm subcutaneous fat, because it does not
reduce the incidence of wound infection.
A
 Superficial wound drain should not be used at CS
because they do not decrease the incidence of
wound infection or wound haematoma.
A

42. NICE RECOMMENDATION
 Women having a CS should be offered
thromboprophylaxis as they are at increased
risk of venous thromboembolism.

44. CAESAR trial european study
3000 women recruited
 2x2x2 factorial multicentric RCT
 Single- versus double-layer uterine
closure.
 Closure of the peritoneum
 Liberal versus restricted use of a
subsheath drain.

45.  there is a difference in the duration of
surgery(mean difference, 2.4 minutes; 95%
CI, 1.3–3.6 minutes),favouring nonclosure.
However, the duration of surgery is a poor
surrogate for morbidity.

46.  However, there have been
suggestions that non closure of the
peritoneum may be harmful in the
longer term.
Lyell D, Peritoneal closure at primary caesarean
delivery and adhesions.
Obstet Gynecol 2005;106:275–80.

47. CORONIS
2x2x2x2x2fractional factorial randomised
TRIAL in developing countries 15936 women
 Blunt versus sharp abdominal entry
 Exteriorisation of the uterus for repair versus intra-
abdominal repair
 Single versus double layer closure of the uterus
 Closure versus non-closure of the peritoneum
(pelvic and parietal)
 Chromic catgut versus Polyglactin-910 for uterine
repair

48. References
THE COCHRANE
LIBRARY
 Cochrane Database
of Systematic
Reviews
NICE GUIDELINES
Issued: November 2011
NICE clinical guideline
132