Intended for healthcare professionals

Practice Guidelines

Caesarean section: summary of updated NICE guidance

BMJ 2011; 343 doi: (Published 23 November 2011) Cite this as: BMJ 2011;343:d7108
  1. Maryam Gholitabar, research associate1,
  2. Roz Ullman, senior research fellow and clinical lead (midwifery)1,
  3. David James, clinical co-director1,
  4. Malcolm Griffiths, consultant obstetrician and gynaecologist2
  5. on behalf of the Guideline Development Group
  1. 1National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA, UK
  2. 2Luton & Dunstable Hospital NHS Foundation Trust, Luton LU4 0DZ, UK
  1. Correspondence to: R Ullman rullman{at}

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


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 …

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