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Caesarean section: Summary of updated NICE guidance

Article  in  BMJ (online) · November 2011

DOI: 10.1136/bmj.d7108 · Source: PubMed

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BMJ 2011;343:d7108 doi: 10.1136/bmj.d7108 (Published 23 November 2011) Page 1 of 6

Practice

PRACTICE

GUIDELINES

Caesarean section: summary of updated NICE guidance

1
Maryam Gholitabar research associate , Roz Ullman senior research fellow and clinical lead
1 1
(midwifery) , David James clinical co-director , Malcolm Griffiths consultant obstetrician and
2
gynaecologist , on behalf of the Guideline Development Group
1
National Collaborating Centre for Women’s and Children’s Health, London W1T 2QA, UK; 2Luton & Dunstable Hospital NHS Foundation Trust,
Luton LU4 0DZ, UK

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.
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.

Correspondence to: R Ullman rullman@ncc-wch.org.uk

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BMJ 2011;343:d7108 doi: 10.1136/bmj.d7108 (Published 23 November 2011)
[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)
• 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
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Page 2 of 6
PRACTICE
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]
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BMJ 2011;343:d7108 doi: 10.1136/bmj.d7108 (Published 23 November 2011)
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.
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.
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Page 3 of 6
PRACTICE
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.
1 Hospital Episode Statistics. Maternity data 2009-10. www.hesonline.nhs.uk/Ease/servlet/
ContentServer?siteID=1937&categoryID=1475.
2 National Institute for Health and Clinical Excellence. Caesarean section (update). (Clinical
guideline 132). 2011. http://guidance.nice.org.uk/CG132.
3 QuickStats: rates of cesarean deliveries—selected countries, 2005. MMWR
4
2008;57(37):1019. www.cdc.gov/mmwr/preview/mmwrhtml/mm5737a7.htm.
Cantwell R, Clutton-Brock T, Cooper G, Dawson A, Drife J, Garrod D, et al. Saving mothers’
lives: reviewing maternal deaths to make motherhood safer 2006-2008. The eighth report
of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG
2011;118(suppl 1):1-203.
5 Eriksson JG. The fetal origins hypothesis—10 years on. BMJ 2005;330:1096-7.
6 National Institute for Health and Clinical Excellence. Antenatal care: routine care for the
healthy pregnant woman. (Clinical guideline 62). 2008. http://guidance.nice.org.uk/CG62.
7 National Institute for Health and Clinical Excellence. Induction of labour. (Clinical guideline
70.) 2008. http://guidance.nice.org.uk/CG70.
8 National Institute for Health and Clinical Excellence. Intrapartum care. (Clinical guideline
55.) 2007. http://guidance.nice.org.uk/CG55.
9 National Institute for Health and Clinical Excellence. Diabetes in pregnancy: management
of diabetes and its complications from preconception to the postnatal period (Clinical
guideline 63.) 2008. http://guidance.nice.org.uk/CG63.
10 National Institute for Health and Clinical Excellence. The management of hypertensive
disorders during pregnancy. (Clincal guidance 107.) 2010. http://guidance.nice.org.uk/
CG107.
11 National Institute for Health and Clinical Excellence. Postnatal care: routine postnatal
care of women and their babies. (Clincal guidance 37.) 2006. http://guidance.nice.org.uk/
CG37.
12 National Institute for Health and Clinical Excellence. Intraoperative blood cell salvage in
obstetrics. (Interventional procedure guidance 144.) 2005. http://guidance.nice.org.uk/
IPG144.
13 Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical
Effectiveness Support Unit. The national sentinel caesarean section audit report. RCOG
Press, 2001.
14 Department of Health. National service framework for children, young people and maternity
services. 2004. www.dh.gov.uk/en/Publicationsandstatistics/Publications/
PublicationsPolicyAndGuidance/DH_4089100.
Cite this as: BMJ 2011;343:d7108
© BMJ Publishing Group Ltd 2011
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BMJ 2011;343:d7108 doi: 10.1136/bmj.d7108 (Published 23 November 2011) Page 4 of 6

PRACTICE

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

Figures

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PRACTICE

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

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PRACTICE

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

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