INSTITUT LATIHAN KEMENTERIAN KESIHATAN MALAYSIA KOTA KINABALU

KURSUS DIPLOMA PEMBANTU PERUBATAN

CASE STUDY

TITLE
LOWER SEGMENT CAESAREAN
SECTION (LSCS)

NAME : ALIAS BIN SABLE

IDENTITY CARD NO : 940106-12-6227

MATRICS CARD NO : BPP2015-3721

YEAR INTAKE : JULY 2015

SEMESTER : FIVE (5)

PLACEMENT UNIT : OPERATING THEATRE HOSPITAL KOTA BELUD

1
 CONTENT

NO. TITLE PAGE

1 Introduction 3

2 Literature Review 4

3 Discussion 5

4 Conclusion 8

5 References 9

2
INTRODUCTION

A lower (uterine) segment Caesarean section (LSCS), also called the Kerr incision is
the most commonly used type of Caesarean section. It includes a transverse cut 1-2
centimetres above the attachment of the urinary bladder to the uterus, in the lower segment.
This type of incision results in less blood loss and is easier to repair than other types of
Caesarean sections. It also defined as the delivery of a fetus through surgical incisions made
through the abdominal wall (laparotomy) and the uterine wall (hysterotomy). There is a myth
which states that the word "Caesarean" originates from "Caesar", the Roman ruler, who
according to the legend, was delivered by Caesarean section. But this is doubtful as his
mother, Aurelia Cotta, lived for many years afterwards. At that ancient time, Caesarean
section was performed when the mother was dead or dying, as an attempt to save the baby.
Caesarean section at that time was not intended to preserve the life of the mother. It will only
perform when the mother is dying to save the baby.

Development of surgical techniques and anaesthesia, later improves the procedure results in
low morbidity and mortality. The first successful Caesarean section was done in 1882.
However, there were complications due to poor facilities.

The LSCS rate in Malaysian public hospitals has increased to 15.7% from 10.5% in the year
2000. There are inter-state variations in the rate ranging from a high of 25.4% in Melaka to
10.9% in Sabah. The West Coast states generally had a higher caesarean section rate than the
East Coast states as well as East Malaysia.

Most bleeding takes place from the angles of the incision, and forceps can be applied to
control it. Green Armytage forceps are specifically designed for this purpose. Although the
incision is made using a sharp scalpel, care must be taken not to injure the foetus, especially
if the membranes are ruptured, or in emergencies like abruption. The incision can be
extended to either sides using a scissor or by blunt dissection using hands. While using the
scissors, the surgeon should ensure that a finger is placed underneath the uterus so that the
foetus in protected from unintentional injury. If blunt dissection is done, intra-operative blood
loss can be minimized. In cases where Kerr incision cannot be done (such as large
baby), Kronig incision (low vertical incision), classical, J or T incisions may be used to incise
the uterus.

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LITERARTURE REVIEWS

One of the great advances in operative was the development of the Lower Segment Caesarean
Section, which was better than the classical upper segment vertical variety with its risk of
subsequent rupture (Powell, John L. MD, FACOG, FACS, 2001)

The number of caesarean sections has increased over the last two decades, especially in the
developed countries. Hence, it has increasingly become a greater challenge to provide care
for the parturient, but this has given obstetric anaesthetists a greater opportunity to contribute
to obstetric services. While caesarean deliveries were historically performed using general
anaesthesia, there is a recent significant move towards regional anaesthesia.

(Dr. Sean Yeoh, 2010)

The classical operation is performed in 12% of Caesarean sections usually for transverse lie,
failure of development of the lower segment (prematurity 5 breech presentation), dense
adhesions, large veins over the lower segment (placenta praevia), constriction ring and
invasive carcinoma of the cervix. The classical operation is likely to be performed more often
than formerly because more very premature infants (2632 weeks' gestation) are being
delivered by Caesarean section. (Lourdes St George and K. B. Kuah, 1987)

Caesarean section surgery has become one of the most common obstetric operations
worldwide, accounting for over 27% of total deliveries over 2004/05 and 2007/08. The basic
procedure has been modified over the years and improved through its extensive practice.

(Dr Z Shi, 2010)

The caesarean delivery rate is increasing worldwide. Several studies have shown that one
caesarean section implies a high risk for caesarean section in the next pregnancy. Caesarean
section, especially repeat caesarean section, is associated with an increased risk for uterine
rupture, abnormal placental implantation, placental abruption and uterine scar dehiscence in
subsequent pregnancies. (O Vikhareva Osser and L Valentin, 2010)

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DISCUSSION

Out of the reported Caesarean deliveries, 50% are planned (Elective Caesarean) and
another 50% are Emergency Caesarean. Throughout my clinical attachment here at Operating
Theatre Hospital Kota Belud, most of the caesarean deliveries are Emergency Caesarean. The
Elective Caesarean is conducted or planned when the mother has complications such as
multiple pregnancies, baby in breech which the buttocks or feet of the baby is the first
anatomy that comes out from mother vagina or baby in transverse position, placenta praevia
(placenta obstructs the birth canal), mother having a severe high blood pressure and previous
history of birth complications. While Emergency Caesarean carried out to avoid fetal distress
or when cervix does not open sufficiently or mother in labour with baby positions
unfavourable for vaginal delivery.

Before the LSCS is performed, the preoperative management has to be done. Guidelines
recommend a minimum preoperative fasting time of at least 2 hours from clear liquids, 6
hours from a light meal, and 8 hours from a regular meal. However, patients are usually
asked not to eat anything for 12 hours prior to the procedure.

a. The following are also included in preoperative management:

Placement of an intravenous (IV) line
Infusion of IV fluids (eg, lactated Ringer solution or saline with 5% dextrose)
Placement of a Foley catheter (to drain the bladder and to monitor urine output)
Placement of an external fetal monitor and monitors for the patients blood
pressure, pulse, and oxygen saturation
Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective
cesarean delivery by 76%, regardless of the type of cesarean delivery [emergent or
elective])
Evaluation by the surgeon and the anaesthesiologist
Laboratory testing

b. The following laboratory studies may be obtained prior to cesarean delivery:

Complete blood count
Blood type and screen, cross-match
Screening tests for human immunodeficiency virus, hepatitis B, syphilis

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 Coagulation studies (eg, prothrombin and activated partial thromboplastin times,
fibrinogen level)
Imaging studies

In labor and delivery, document fetal position and estimated fetal weight. Although
ultrasonography is commonly used to estimate fetal weight, a prospective study reported the
sensitivity of clinical and ultrasonographic prediction of macrosomia, respectively, as 68%
and 58%.

The first step of caesarean delivery is to open the mother's abdomen through a lower midline
incision. A transverse skin incision is associated with reduced postoperative pain and is more
aesthetically acceptable to patients compared with a vertical incision (classic). The
Pfannenstiel incision is slightly curved and made 2 to 3 cm above the symphysis pubis. The
incision should allow for at least 15 cm of exposure. The skin and subcutaneous fat is incised
with electrocautery.

After the incision of abdomen, the anterior rectus sheath is incised transversely. The rectus
muscles are separated in the midline. The parietal peritoneum is opened. The loose
peritoneum over the lower uterine segment is held and incised transversely, for about 10 cm
in a semilunar fashion with its edges directed upwards. The bladder is dissected downward
and is retained behind a Doyen's retractor placed over the symphysis. Membranes are
ruptured by toothed or Kochers forceps.

The head is delivered by introducing the right hand gently below it and lifting it up helped by
fundal pressure done by the assistant, using one blade of the forceps or, using Wrigleys
forceps. If the head is deep in the pelvis it can be pushed up vaginally by an assistant. The
Doyens retractor is removed after the hand or forceps blade is applied and before head
extraction. Suction for the foetus is carried out before delivery of the head. In breech or
transverse lie the foetus is extracted as breech. Once the umbilical cord is clamped and cut, it
is time to deliver the placenta via spontaneous extraction. Gentle traction is placed on the
cord and oxytocin is used to enhance uterine contractions. The placenta is checked to make
sure it is complete and the uterus is explored with one hand to remove any remaining
membranes or placental tissue. The uterus is than massaged to promote contraction. Oxytocin
is given to promote uterine contraction and involution.

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Closure of the uterine incision is done in 3 layers. The first is a continuous locking suture
taking most of the myometrium but not passing through the decidua to guard against
endometriosis and weakness of the scar. The second is a continuous or interrupted one
inverting the first layer. The third is a continuous or interrupted layer to close the visceral
peritoneum of the uterus. Similarly, the rectus muscles are not surgically reapproximated.
The fascial tissue is carefully closed to provide good wound strength and the skin is closed
with a subcuticular suture. The last is to closing the incision. Abdomen is then closed in
layers.

After the LSCS is performed, postoperative management has to be done by the nurses. The
management are including:

Routine postoperative assessment

Monitoring of vital signs, urine output, and amount of vaginal bleeding

Palpation of the fundus

IV fluids; advance to oral diet as appropriate, early feeding has been shown to shorten
hospital stay

IV or intramuscular (IM) analgesia if patient did not receive a long-acting analgesic or

had general anesthesia; analgesia is usually not needed if patient received regional
anesthesia, with/without a long-acting analgesic

Ambulation on postoperative day 1; advance as tolerated

If patient plans to breastfeed, initiate within a few hours after delivery; if patient plans
to bottle feed, she may use a tight bra or breast binder in the postoperative period

Discharge on postoperative day 2 to 4, if no complications

Discuss contraception as well as refraining from intercourse for 4-6 weeks

postpartum, unless the patient had LARC placed at the time of the procedure

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CONCLUSION

The birth experience with a LSCS is very different from that of a vaginal delivery. For one
thing, the whole operation ordinarily takes no more than an hour, and depending on the
circumstances, you may not experience any labour at all. Another important difference is the
need to use medication that affects the mother and may affect the baby. If given a choice of
anaesthetics, most women prefer to have a regional anaesthesia, an injection in the back that
blocks pain by numbing the spinal nerves such as an epidural or a spinal. Administration of a
regional anaesthesia numbs the body from the waist down, has relatively few side effects, and
allows you to witness the delivery. But sometimes, especially for an emergency LCSC, a
general anaesthetic must be used, in which case you are not conscious at all. Your
obstetrician and the anaesthesiologist in attendance will advise you which approach they
think is best, based on the medical circumstances at the time.

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REFERENCES

BOOKS

i. C. McIntosh Marshall (1939). Caesarean Section: Lower Segment Operation

ii. Eric Jauniaux, William Grobman (2016). Caesarean Section
iii. Helen Churchill, Wendy Savage (2010). Vaginal Birth After Caesarean

ONLINE ARTICLES

i. Radhae Raghavan, Pallavi Arya, Prathibha Arya, Susnata (2014). Abdominal

incisions and sutures in obstetrics and gynaecology. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1111/tog.12063/full

ii. Arwinder Singh (2014). Undergoing a planned lower segment caesarean section.
Retrieved from http://www.magonlinelibrary.com/doi/abs/10.12968/jodp.2014.2.2.79

iii. Caroline De Costa (2005). Vaginal birth after classical Caesarean section. Retrieved
from http://onlinelibrary.wiley.com/doi/10.1111/j.1479-828X.2005.00387.x/full

iv. Philip F. Williams (2006). Caesarean Section, Lower Segment Operation. Retrieved
from http://www.ajog.org/article/S0002-9378(15)31478-2/abstract

v. Hedwige Saint Louis (2017). Cesarean Delivery. Retrieved from

http://emedicine.medscape.com/article/263424-overview