AJAZ AHMAD KHANBSC OTT 3RD YEAR

LOWER SEGMENT CAESAREAN SECTION(LSCS)

Definition, Indications, Types etc.

KUZWERA CHADOORABUDGAM J&K

DEFINITION

• Operation procedure where by the fetus after the end of 28th week is delivered through an incision on the abdominal and uterine wall.

• In this operation the extraction of the baby is done through an incision made in the lower segment (3rd and 4th quadrant, 2-2.5 inches) above the symphiasis pubis.

INDICATIONS ABSOLUTE:-Vaginal delivery is not possible. Caesarean section is needed even with a dead fetus Central placenta praevia Contracted pelvis or Cephalo pelvic disproportion(absolute) Pelvic mass causing obstruction(cervical or broad ligament

fibroid Vaginal obstruction(atresia, stenosis)

RELATIVE Cephalo pelvic disproportion Non reassuring FHR(fetal distress) Dystocia due to (three p’s) relatively large fetus(passenger), small

pelvis(passage), or inefficient uterine contractions(power) Antepartum haemorrhage-placenta praevia and abruptio placenta Malpresentation-Breech, Shoulder(transverse lie), Brow Failed surgical induction of labour, Failure to progress in labour Bad obstetric history-with recurrent fetal wastage Hypertensive disorders-Severe pre eclampsia, Eclampsia-uncontrolled

fits even with antiseizure therapy

TIME OF OPERATION1. ELECTIVE:- When the operation is done at a prearranged

time during pregnancy to ensure the best quality of obstetrics, anesthesia, neonatal resuscitation and nursing services. The operation is done at least one week before the expected date of delivery.

2. EMERGENCY:- When the operation is performed due to unforeseen or acute obstetric emergencies. It is done 30 minutes before the rupture of membrane .

TYPES OF OPERATIONSLOWER SEGMENT- In this operation the extraction of

baby is done through an incision made in the lower segment through a trans peritoneal approach.

CLASSICAL- In this operation the baby is extracted through an incision made in the upper segment in uterus.

LSCS Preoperative preparation Abdomen is scrubbed with soap and nonorganic iodine lotion. Hair

may be clipped off. Premedicative seddative must not be given. Non particulate antacid (0.3 molar sodium citrate ,30 ml) is given

orally before transferring the patient to theatre. It is given to neutralise the existing gastric acid.

Ranitidine(H2 blocker) 150 mg is given orally night before(elective procedure) and is repeated (50 mg I.M or I.V) one hour before the surgery to raise the gastric pH.

Metoclopramide (10 mg I.V) is given to increase the tone of the lower esophageal sphincter as well as to reduce the stomach contents. It is administered after about 3 minutes of pre-oxygenation in the theatre.

CONT.

The stomach should be emptied, if necessary by a stomach tube(elective procedure).

Bladder should be emptied by a soft rubber catheter which is kept in place till the end of operation.

FHS should be checked once more at this stage. Neonatologist should be made available.ANESTHESIA:- Spinal, epidural or general. However, choice

of the patient and urgency of delivery are also considered.POSITION:- Dorsal positionINCISION:- The surgeon may choose either a vertical or

transverse incision. Vertical incision may be infraumblical midline or paramedian. Transverse incision, modified pfannenstiel is made 3 cm above symphisis pubis.

CONT.

First incision is made on the abdominal layer followed by clamping it with hemostatic forceps.

The next incision is provided to the fat layer with a pin point scalpel (pfannensteil incision).

Place the Doyen’s retractor after the peritoneal layer is incised. The loose peritoneum of uterovesical pouch is cut transversely with convexity downwards (1.25 cm) below which is attachment to the uterus.

Then the uterine layer is identified and packs are placed properly at all the four sides of peritoneum in order to avoid the mixing of peritoneal fluid into the amniotic cavity.

CONT.

A transverse or S shaped incision is given to the uterine membrane. The small incision may extend 3.5cm in length, 2 index fingers are the inserted through the incision and split transversely across the fetus, this will minimize the spilling of amniotic fluid.

DELIVERY OF HEADThe membranes are ruptured if still intact. The blood mixed amniotic fluid is sucked out by continuous suction. The doyen’s retractor is removed and the baby is delivered by hooking the head with the fingers which are carefully insinuated between the lower uterine flap and the head until the palm is placed below the head. As the head is drawn to the incision line the assistant has to apply pressure on the fundus. If head is jammed, an assistant may push up the head by sterile gloved fingers introduced into the vagina. The head can also be delivered using either Wrigley’s or Barton’s forceps.

DELIVERY OF TRUNKAs soon as the head is delivered, the mucus from the mouth, pharynx and nostrils is sucked out using rubber catheter attached to an electric sucker and the delivery of shoulder is done. Intravenous oxytocin 20 units or 0.2mg methergin is administered. The rest of the body is delivered slowly and baby is placed in a tray between mother’s legs with the head tilted down for gravitional drainage. The umbilical cord is cut in between two clamps and the baby is handed over to the nurse. The Doyen’s retractor is re introduced. REMOVAL OF PLACENTA AND MEMBRANES:- By this time (10-15 minutes) the placenta is likely to be separated and it is extracted by traction on the cord with simultaneous pushing the uterus towards the umbilicus per abdomen using the left hand controlled cord traction. The membranes are scrapped off using uterine curette. The removed placenta is taken in a tray for an inspection. Introduce light warm normal saline to wash the uterine cavity.

SUTURES OF UTERINE & ABDOMINAL LAYERSThe margins are picked up by Allis forcep or Green armytage. All the layers are sutured seperatively using running continuous sutures in the deeper layers and interrupted or interlock continuous sutures in the superficial layers.

POST OPERATIVE CARE• The patient is observed for at least 4-6 hours with periodic checkup of

pulse and uterine contractions.• Fluid replacement of about 2-2.5 litres should be done within an hour.• On first day oral feeding in the form of plain or electrolyte water or raw

tea may be given. Active bowel sounds are observed by the end of the day.

• Light solid diet of patient’s choice is given on day 2.• 3-4 teaspoons of lactulose may be given at bed time if bowels don’t

move spontaneously.• The abdominal stitches are to be removed on day 5(in transverse), or day

6(in longitudinal) incisions.

TRAY SETUP TRAY ONE TRAY SECOND• Towel clip (Backhaus) Cord clamp• Wrigley’s obstetric forcep Cord cutting scissor • Curved artery forcep Sponge holding forcep st.

• Green armytage Suction catheter• Allis tissue forcep Artery forcep small• Sponge holding forcep Bull suction• BP handle Bowl with NS & distil water• Doyen’s retractor Gauze packs• Morris retractor• Mayo’s scissor• Spencer scissor• Little wood tissue forcep

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