Any pregnant woman who wants a caesarean section should not be denied it, says NICE

All pregnant women who ask for an elective caesarean section should be allowed one if they still want the procedure after being made aware of its risks and benefits, the UK National Institute for Health and Clinical Excellence (NICE) says.

NICE’s updated clinical guideline on caesarean sections, published this week, recognises for the first time mental health problems as well as physical conditions as possible indicators for a caesarean section. It says that most women who ask for a caesarean section do so because they are anxious about childbirth (have tokophobia) and should be offered mental health support if they need it. If their fears are not allayed by this support, they should be offered an elective caesarean.

But it also says that women who ask for a caesarean section in the absence of any clinical indication, mental or physical, should be allowed to have one. The guideline says that women should be asked why they are requesting the operation, be given full information about the risks and benefits of the procedure in comparison with a vaginal delivery, and be offered the opportunity to discuss the issue with members of the obstetric team.

Gillian Leng, deputy chief executive of NICE, said, “If, after this, they still want to have a caesarean section they should be allowed to have one. Offering these women a planned caesarean section in these circumstances is a very long way from saying that caesarean section should automatically be offered to every woman.”

However, rather than increasing the number of caesarean sections carried out by the NHS, Dr Leng predicted that the overall figure may in fact go down because of other changes in the guideline.

Around three quarters of caesarean sections are not planned and are carried out as an emergency when a vaginal birth does not go as planned. Most of the rest are elective procedures scheduled for women who are HIV positive or who have had a caesarean section before. But under the new guideline, which updates recommendations published in 2004 (BMJ 2004;328:1031.1, doi:10.1136/bmj.328.7447.1031), these will no longer be automatic reasons for a caesarean section, and many of these women are expected to opt for a natural birth.

Malcolm Griffiths, a consultant obstetrician and gynaecologist at Luton and Dunstable Hospital, who chaired the guideline development group, said, “We want women who do not need to have a caesarean section to be able to avoid such surgery. This will now include women who are HIV positive, as long as they are receiving treatment which is controlling their viral load sufficiently. The guideline also dispels the myth of ‘once a caesarean, always a caesarean.’”

He said that the latest evidence showed that the risk of fever and of bladder and surgical injuries in women who have had up to four caesarean sections was the same whether they had an elective caesarean or had planned a vaginal delivery and that the risk of the uterus rupturing was rare.

The updated guideline also introduces routine use of prophylactic antibiotics to reduce the risk of postoperative infections. For all other operations prophylactic antibiotics are recommended before surgery, but at present women having a caesarean are not offered prophylactic antibiotics until the umbilical cord is cut, because of concerns that they will harm the baby.

Around one in 10 women who have a caesarean section get postoperative infections. Mr Griffiths predicted that giving antibiotics before the procedure will cut that number by a third.