Caesarean section: summary of updated NICE guidance
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7108 (Published 23 November 2011) Cite this as: BMJ 2011;343:d7108
- Maryam Gholitabar, research associate1,
- Roz Ullman, senior research fellow and clinical lead (midwifery)1,
- David James, clinical co-director1,
- Malcolm Griffiths, consultant obstetrician and gynaecologist2
- on behalf of the Guideline Development Group
- 1National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA, UK
- 2Luton & Dunstable Hospital NHS Foundation Trust, Luton LU4 0DZ, UK
- Correspondence to: R Ullman rullman{at}ncc-wch.org.uk
In England, rates of caesarean section have increased from 9% of births in 1980 to 24.8% in 2010.1 The indications for the procedure vary. Healthcare professionals have to provide evidence based information for women about the risks and benefits of both planned and unplanned caesarean section. To advise women appropriately they also need to be aware of specific indications for caesarean section, effective management to avoid unnecessary caesarean section and reduce morbidity from caesarean section, and birth after a caesarean section. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on caesarean section.2
Recommendations
NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets.
Possible reasons for caesarean section
Breech presentation (existing recommendations)
For women who have an uncomplicated singleton breech pregnancy at 36 weeks’ gestation, offer external cephalic version (turning the baby). However, contraindications include women in labour, women with a uterine scar or uterine abnormality, fetal compromise, ruptured membranes, vaginal bleeding or certain medical conditions, such as severe pre-eclampsia and Rhesus isoimmunisation. [Based on high quality evidence from randomised controlled trials]
For women with a singleton breech pregnancy at term for whom external cephalic version is contraindicated or has been unsuccessful, offer caesarean section because it reduces perinatal mortality and neonatal morbidity. [Based on high quality evidence from randomised controlled trials]
Morbidly adherent placenta
Women found antenatally to have morbidly adherent placenta (an abnormal adherence of the placenta to the uterine wall) will be advised to have a caesarean section.
Diagnosis of morbidly adherent placenta (new recommendation)
If a colour flow Doppler ultrasound scan suggests a morbidly adherent placenta:
-Discuss with the woman the improved accuracy of magnetic resonance imaging combined with ultrasonography, and explain what to expect during magnetic resonance imaging
-Inform the woman that current experience suggests that magnetic resonance imaging is safe but that evidence is lacking about any long term risks to the baby
-Offer magnetic resonance imaging to improve the diagnostic accuracy and clarify the degree of invasion if acceptable to the woman. [Based on moderate quality evidence from observational studies]
Maternal request for caesarean section (new recommendations)
When a woman requests a caesarean section explore, discuss, and record the specific reasons for the request. [Based on the experience and opinion of the Guideline Development Group (GDG)]
When a woman requests a caesarean section because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address in a supportive manner. [Based on the experience and opinion of the GDG]
For women requesting a caesarean section, if after discussion and the offer of support (including perinatal mental health support for women with anxiety about childbirth) a vaginal birth is still not an acceptable option, offer a planned caesarean section. [Based on the experience and opinion of the GDG and a health economic analysis]
An obstetrician unwilling to perform a caesarean section should refer the woman to an obstetrician who will carry out the caesarean section. [Based on the experience and opinion of the GDG]
Mother to child transmission of HIV (new recommendations)
Do not offer a caesarean section on the grounds of HIV status to prevent mother to child transmission of HIV to (a) women receiving highly active antiretroviral therapy with a viral load of less than 400 copies per millilitre or (b) women receiving any antiretroviral therapy with a viral load of less than 50 copies per millilitre. Inform women that in these circumstances the risk of HIV transmission is the same for a caesarean section and a vaginal birth. [Based on very low quality evidence from observational studies]
Offer a caesarean section to women with HIV who (a) are not receiving any antiretroviral therapy, or (b) are receiving antiretroviral therapy and have a viral load of ≥400 copies per millilitre. [Based on very low quality evidence from observational studies]
Planning mode of birth (new recommendation)
Table 1 Summary of effects on women’s health of planned caesarean section compared with planned vaginal birth for women with an uncomplicated pregnancy and who have not had a previous caesarean section
Table 2 Summary of effects on babies’ health of planned caesarean section compared with planned vaginal birth for women with an uncomplicated pregnancy and who have not had a previous caesarean section
Discuss with women the risks and benefits of caesarean section compared with vaginal birth (tables 1⇑ and 2⇑), taking into account their circumstances, concerns, priorities and plans for future pregnancies (including the risks of a morbidly adherent placenta with multiple caesarean sections). [Based on the experience and opinion of the GDG]
Factors that reduce the likelihood of caesarean section (existing recommendations)
Inform women that continuous support during labour from women with or without prior training reduces the likelihood of caesarean section. [Based on high quality evidence from randomised controlled trials]
For women with an uncomplicated pregnancy offer induction of labour beyond 41 weeks because this reduces the risk of perinatal death and the likelihood of caesarean section. [Based on high quality evidence from randomised controlled trials]
Use a partogram (graphical representation of labour) with a four hour action line to monitor the progress of labour for women in spontaneous labour with an uncomplicated singleton pregnancy at term because such monitoring reduces the likelihood of caesarean section. [Based on high quality evidence from randomised controlled trials]
Consultant obstetricians should be involved in the decision making for caesarean section because this reduces the likelihood of caesarean section. [Based on low quality evidence from observational studies]
Anaesthesia for caesarean section (existing recommendations)
Provide women with information on the different types of analgesia available to them after a caesarean section so that they can be offered the analgesia best suited to their needs. [Based on the experience and opinion of the GDG]
Offer regional rather than general anaesthesia to women having a caesarean section (including women with a diagnosis of placenta praevia) because it is safer and results in less maternal and neonatal morbidity. [Based on high quality evidence from randomised controlled trials]
Women who are having induction of regional anaesthesia for caesarean section should be cared for in theatre because this does not increase women’s anxiety. [Based on low quality evidence from observational studies]
Timing of antibiotic administration (new recommendations)
Offer prophylactic antibiotics to women having a caesarean section to reduce the risk of postoperative infections. Choose antibiotics effective against endometritis and urinary tract and wound infections, which occur in about 8% of women who have had a caesarean section. [Based on high quality randomised controlled trials in a small number of patients]
Offer prophylactic antibiotics before skin incision. Inform women that this reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision and that research has shown no effect on babies. [Based on high quality randomised controlled trials in a small number of patients]
Do not use co-amoxiclav when giving antibiotics before skin incision because of a proved increased risk of necrotising enterocolitis in babies when used in women presenting with preterm labour. [Based on the experience and opinion of the GDG]
Pregnancy and childbirth after caesarean section (new recommendations)
Inform women who have had up to and including four caesarean sections that the risk of fever, bladder injuries, and surgical injuries does not vary with planned mode of birth and that the risk of uterine rupture, although higher for planned vaginal birth, is rare. [Based on low quality evidence from observational studies]
While women are in hospital after having a caesarean section, give them the opportunity to discuss with healthcare professionals the reasons for the caesarean section and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide the information at a later date. [Based on the experience and opinion of the GDG]
Overcoming barriers
Caesarean section rates in the United Kingdom, as in all developed countries, have risen over recent years, although the absolute rates vary.3 Possible reasons for the rise include changes in sociodemographic factors, clinical practices (including a repeat elective caesarean section in women who have had the procedure before), and the attitudes of professionals and women. Implementing the guideline by providing women with evidence based information on the risks and benefits of planned vaginal birth and caesarean section will promote effective communication and empower them to make informed decisions.
Some service providers and commissioners may feel that the guideline will result in a large increase in caesarean births on maternal request. However, the recommendations clarify the measures needed when discussing women’s reasons for requesting caesarean section, including the offer of perinatal mental health support where appropriate. Providing this support as early as possible in pregnancy is likely to allay women’s concerns and anxieties and reduce unnecessary intervention. Some hesitancy may also arise in supporting women seeking vaginal birth after two or more previous caesarean sections; the guideline shows that the evidence for vaginal birth for such women is robust.
The guidance may reduce the number of unnecessary caesarean sections and the associated morbidity, benefiting women and babies. The aim is for all caesarean sections to be appropriate.
Further information on the guidance
Although in resource rich countries pregnancy and childbirth are only occasionally associated with death of the woman or baby, stillbirth remains a continuing concern in maternity care, and occasional maternal death occurs.4 Childbirth is also responsible for a burden of morbidity in the medium and long term for the woman, the child, the family, and perhaps the wider community. For example, poor fetal growth is associated with several problems in later life such as cardiovascular disease (in line with the Barker hypothesis), diabetes, and impaired neurodevelopment.5
Many factors affecting rates of caesarean section are poorly understood. The guideline has not sought to define acceptable rates of caesarean section but has sought to enable clinicians to give appropriate research based advice to women and their families.
This guideline links with other relevant NICE guidelines such as those on antenatal care,6 induction of labour,7 intrapartum care,8 diabetes in pregnancy,9 hypertension in pregnancy,10 and postnatal care11; the published NICE interventional procedure guidance on intraoperative blood salvage in obstetrics12; and the findings of the National Sentinel Caesarean Section Audit (an audit of all caesarean sections done in England, Wales, and Northern Ireland over three months in 2000)13 and the National Service Framework for Children, Young People, and Maternity Services.14
Methods
This guidance was developed by the National Collaborating Centre for Women’s and Children’s Health in accordance with NICE guideline development methods (www.nice.org.uk/guidelinesmanual). A Guideline Development Group was established by the National Collaborating Centre for Women’s and Children’s Health, which incorporated healthcare professionals (obstetricians, midwives, and an anaesthetist), women with a special interest in caesarean section, and experts in guideline methodology. The Guideline Development Group identified relevant clinical questions, collected and appraised clinical evidence, and evaluated the cost effectiveness of proposed interventions where possible. The draft guideline underwent a rigorous reviewing process in which stakeholder organisations were invited to comment; the Guideline Development Group took all comments into consideration when producing the final version of the guideline.
NICE has produced four different versions of the guideline: a full version containing all the evidence, the process undertaken to develop the recommendations, and all the recommendations; a care pathway; a version containing a list of all the recommendations, known as the “NICE guideline”; and a version for patients and the public. All these versions are available from the NICE website (www.nice.org.uk/CG132). Further updates of the guidance will be produced as part of NICE’s guideline development programme.
Future research
What are the medium to long term risks and benefits for women and their babies of planned caesarean section compared with planned vaginal birth?
What support or psychological interventions would be appropriate for women who have a fear of vaginal childbirth and request a caesarean section?
The National Caesarean Section Sentinel Audit needs to be repeated13
Notes
Cite this as: BMJ 2011;343:d7108
Footnotes
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the technical team of the National Collaborating Centre for Women’s and Children’s Health were Zosia Beckles, Shona Burman-Roy, Rupert Franklin, Maryam Gholitabar, Paul Jacklin, David James, Emma Newbatt, Roz Ullman. Members of the Guideline Development Group were Debbie Chippington Derrick, Malcolm Griffiths (chair), Olujimi Jibodu, Christine Johnson, Nina Khazaezadeh, Andrew Loughney, Nuala Lucas, Pippa Nightingale.
Contributors: All authors contributed to the initial draft as well as making revisions and approved the final version for publication. RU is the guarantor.
Funding: The National Collaborating Centre for Women’s and Children’s Health was commissioned and funded by the National Institute for Health and Clinical Excellence to develop this guideline and summary.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: MG, RU, and DJ have support from the National Institute for Health and Clinical Excellence for the submitted work; no relationships with companies that might have an interest in the submitted work; no non-financial interests that may be relevant to the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.