Guidelines for Lower Segment Caesarean Section (LSCS)

Pre‑operative Preparation

• Antibiotic prophylaxis: Give an intravenous first‑generation cephalosporin within 60 minutes before skin incision.  [American College of Obstetricians and Gynecologists] 1
• Adjunctive azithromycin: Add azithromycin when the patient is in labor or membranes are ruptured to further lower infection risk. [American College of Obstetricians and Gynecologists] 1
• Skin antisepsis: Use chlorhexidine‑alcohol solution for abdominal skin preparation; it is superior to aqueous povidone‑iodine. [American College of Obstetricians and Gynecologists] 1
• Vaginal antisepsis: Apply povidone‑iodine vaginal preparation to reduce post‑cesarean infection rates. [American College of Obstetricians and Gynecologists] 1
• Regional anesthesia: Prefer spinal or epidural anesthesia for LSCS. [American College of Obstetricians and Gynecologists] 1
• Temperature management: Use forced‑air warming devices, warm intravenous fluids, and raise operating‑room temperature to prevent peri‑operative hypothermia. [American College of Obstetricians and Gynecologists] 1

Anesthesia & Analgesia

• Intrathecal opioid dosing: Add 50–100 µg intrathecal morphine (or up to 300 µg diamorphine) to the spinal anesthetic for optimal postoperative pain control. [American Society of Anesthesiologists] 2 3
• Pre‑operative oral paracetamol: Administer a dose of oral paracetamol before incision. [American Society of Anesthesiologists] 2 3
• Multimodal intra‑operative regimen: Give intravenous paracetamol, NSAIDs, and dexamethasone (cautious in patients with glucose intolerance) after delivery to enhance analgesia and provide anti‑emetic effect. [American Society of Anesthesiologists] 2 3

Surgical Technique

• Incision type: Perform a Joel‑Cohen (modified Misgav‑Ladach) transverse abdominal incision; it reduces postoperative pain and improves outcomes compared with a Pfannenstiel incision. [American Society of Anesthesiologists] 2 3
• Fascial opening: Use blunt dissection of the fascia; this technique is associated with less postoperative pain. [American Society of Anesthesiologists] 3
• Bladder flap omission: Avoid creating a bladder flap when possible; its omission improves postoperative pain scores. [American Society of Anesthesiologists] 3
• Uterine entry: Expand the transverse uterine hysterotomy bluntly to lessen intra‑operative blood loss. [No citation – omitted]
• Uterine closure: Close the hysterotomy in two continuous layers in situ (no exteriorization); this lowers the risk of uterine rupture in later pregnancies and reduces postoperative pain. [American Society of Anesthesiologists] 3
• Peritoneal non‑closure: Do not close the peritoneum; high‑quality evidence shows no benefit and a reduction in postoperative pain and operative time. [American Society of Anesthesiologists] 2 3
• Rectus muscle: Do not re‑approximate the rectus muscles; this further decreases postoperative pain. [American Society of Anesthesiologists] 3

Regional Analgesia Considerations

• When intrathecal morphine is used: Transversus abdominis plane (TAP) or quadratus lumborum blocks add minimal benefit and may be omitted. [American Society of Anesthesiologists] 2 3
• When intrathecal morphine is not used: Consider single‑shot wound infiltration or continuous wound infusion, and/or fascial‑plane blocks (TAP or quadratus lumborum) for analgesia. [American Society of Anesthesiologists] 2 3

Post‑operative Analgesia

• Basic analgesics: Continue regular oral or intravenous paracetamol and NSAIDs; they act synergistically with intrathecal morphine and should not be omitted. [American Society of Anesthesiologists] 2 3
• Rescue opioids: Reserve opioid administration for rescue analgesia when other modalities fail or are contraindicated. [American Society of Anesthesiologists] 2 3
• Abdominal binders: Apply abdominal binders (Grade A recommendation) to improve comfort and support. [American Society of Anesthesiologists] 2 3
• TENS: Consider transcutaneous electrical nerve stimulation as an adjunctive analgesic technique. [American Society of Anesthesiologists] 2 3

Interventions to Avoid

• Limited‑evidence agents: Avoid gabapentinoids, intravenous ketamine, and neuraxial clonidine or dexmedetomidine due to limited supporting evidence and concerning side‑effect profiles. [American Society of Anesthesiologists] 2 3

Lower Segment Caesarean Section (LSCS) Guidelines

Pre-operative Preparation

• The American College of Obstetricians and Gynecologists recommends administering intravenous antibiotics within 60 minutes before skin incision 4
• First-generation cephalosporin is the standard choice for antibiotic prophylaxis 4
• In women in labor or with ruptured membranes, add azithromycin for additional reduction in postoperative infections 4
• The American College of Obstetricians and Gynecologists suggests using chlorhexidine-alcohol for abdominal skin cleansing 4
• Perform vaginal preparation with povidone-iodine solution to reduce postcesarean infections 4
• Regional anesthesia (spinal or epidural) is the preferred method as part of enhanced recovery protocols 4
• Pre-operative oral paracetamol should be administered 5, 6
• Intrathecal morphine 50-100 μg (or diamorphine up to 300 μg) provides optimal postoperative analgesia 5, 6

Intraoperative Steps

• Perform Joel-Cohen incision (Grade A recommendation for reduced pain and improved outcomes) 5, 6
• The incision should be made transversely in the lower uterine segment 4
• Use blunt expansion of the transverse uterine hysterotomy to reduce surgical blood loss 4
• Deliver the infant through the hysterotomy 4
• Delay cord clamping for at least 1 minute at term delivery (at least 30 seconds for preterm) 4
• Administer intravenous paracetamol if not given pre-operatively 5, 6
• Give intravenous non-steroidal anti-inflammatory drugs (NSAIDs) 5, 6
• Administer intravenous dexamethasone for pain control and anti-emetic prophylaxis (caution in glucose intolerance) 5, 6, 7

Uterine Closure and Abdominal Closure

• Close the hysterotomy in 2 layers (associated with lower rate of uterine rupture in subsequent pregnancies) 4
• Do not close the peritoneum (not associated with improved outcomes and increases operative time) 5, 6, 4
• In women with ≥2 cm of subcutaneous tissue, reapproximate that tissue layer 4
• Close skin with subcuticular suture in most cases (evidence shows reduced wound separation compared to staples removed at 4 days) 4

Intraoperative Considerations

• Apply forced air warming, intravenous fluid warming, and increase operating room temperature to prevent hypothermia 4
• Monitor patient temperature appropriately throughout the procedure 4
• Maintain perioperative and intraoperative euvolemia for improved maternal and neonatal outcomes 4

Regional Analgesia

• Consider local anesthetic wound infiltration (single-shot or continuous infusion) 5, 6
• Transversus abdominis plane (TAP) blocks or quadratus lumborum blocks may be used 5, 6, 7
• Note: These blocks provide minimal additional benefit when combined with intrathecal morphine 7

Postoperative Care

• Continue oral or intravenous paracetamol 5, 6
• Continue oral or intravenous NSAIDs 5, 6
• Opioids for rescue only when other strategies fail or are contraindicated 5, 6
• Transcutaneous electrical nerve stimulation (TENS) may be used as adjunct 5, 6
• Apply abdominal binders (Grade A recommendation) 5, 6

Critical Pitfalls to Avoid

• Never delay antibiotic administration until after cord clamping - this outdated practice increases infection risk 4
• Avoid closing the peritoneum - this increases operative time without benefit 5, 6, 4
• Do not use staples for skin closure if they will be removed at 4 days - subcuticular sutures reduce wound complications 4
• Avoid gabapentinoids, intravenous ketamine, and neuraxial clonidine/dexmedetomidine - limited evidence and concerning side effects 7
• Do not omit basic analgesics (paracetamol and NSAIDs) when using intrathecal morphine - they work synergistically 5, 6, 7

Cesarean Section Guidelines

Pre-operative Preparation

• Women after 20 weeks gestation should be positioned with left uterine displacement to prevent aortocaval compression, as recommended by the American College of Obstetricians and Gynecologists 8

Evidence‑Based Practices for Lower Segment Caesarean Section (LSCS)

Intra‑operative Maternal Management

• Maintain adequate maternal oxygenation and optimize uteroplacental perfusion throughout the procedure to support fetal oxygen delivery and reduce intra‑operative complications in all parturients undergoing LSCS. 9

Neonatal Management

• After delivery of the infant’s head, suction the mouth and nose to clear secretions and prevent airway obstruction in the newborn. This is recommended for all term and preterm deliveries. 10
• Delay cord clamping for at least 1 minute in term deliveries (≥30 seconds for preterm deliveries) to improve neonatal hematologic status and iron stores without increasing maternal hemorrhage risk. 10
• Avoid routine suctioning of the airway or gastric aspiration unless the newborn shows signs of airway obstruction, thereby reducing unnecessary manipulation and potential trauma. 10

Surgical Considerations for Patients with Obesity

• In women with ≥2 cm of subcutaneous tissue, re‑approximate the subcutaneous layer to lower the incidence of wound infection and wound separation after LSCS. 11
• For patients with BMI > 40 kg/m², obtain intravenous access early and alert operating‑room staff when weight exceeds 120 kg to ensure adequate equipment and personnel are available for safe surgery. 11
• Apply mechanical thromboprophylaxis (pneumatic compression) before the cesarean and consider weight‑based pharmacologic thromboprophylaxis in class III obesity to reduce the risk of peri‑operative venous thromboembolism. 11
• All women with BMI ≥ 30 kg/m² should receive active management of the third stage of labor (e.g., controlled cord traction and uterotonic administration) because of the heightened risk of postpartum hemorrhage. 11