RecommendationReplaced withReason for change/deletion
Provision of information
Pregnant women should be given evidence-based information about CS during the antenatal period, because about 1 in 5 women will have a CS. This should include information about CS, such as:
  • indications for CS (such as presumed fetal compromise, ‘failure to progress’ in labour, breech presentation)
  • what the procedure involves
  • associated risks and benefits
  • implications for future pregnancies and birth after CS. [GPP]
Give pregnant women evidence-based information about CS during the antenatal period, because about 1 in 4 women will have a CS. Include information about CS, such as:
  • indications for CS (such as presumed fetal compromise, ‘failure to progress’ in labour, breech presentation)
  • what the procedure involves
  • associated risks and benefits
  • implications for future pregnancies and birth after CS. [GPP]
Newer data available about the number of women who have a CS. Minor wording changes to make active statement
Consent for CS
When considering a CS there should be discussion on the benefits and risks of CS compared with vaginal birth specific to the woman and her pregnancy.[GPP]Discuss the risks and benefits of CS compared with vaginal birth with women. (see tables 4.5 and 4.6, and also recommendation 118), taking into account their circumstances, concerns, priorities and plans for future pregnancies (including the risks of placental problems with multiple CS).
A competent pregnant woman is entitled to refuse the offer of treatment such as CS, even when the treatment would clearly benefit her or her baby's health. Refusal of treatment needs to be one of the patient's options. [D]A pregnant woman is entitled to decline the offer of treatment such as CS, even when the treatment would clearly benefit her or her baby's health. Refusal of treatment needs to be one of the woman's options. [D]Stylistic changes
When the decision is made to perform a CS, a record should be made of all the factors that influence the decision, and which of these is the most influential. [GPP]When a decision is made to perform a CS, a record should be made of all the factors that influence the decision, and which of these is the most influential. [GPP]Stylistic change
Placenta praevia
Women with a placenta that partly or completely covers the internal cervical os (grade 3 or 4 placenta praevia) should be offered CS. [D]Women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia) should be offered CS. [D]Terminology change
Mother-to-child transmission of maternal infections
HIV-positive women who are pregnant should be offered a planned CS because it reduces the risk of mother-to-child transmission of HIV. [A]As early as possible give women with HIV information about the risks and benefits for them and their child of the HIV treatment options and mode of birth so that they can make an informed decision.
Do not offer a CS on the grounds of HIV status to prevent mother-to-child transmission of HIV to:
  • women on highly active anti-retroviral therapy (HAART) with a viral load of less than 400 copies per ml or
  • women on any anti-retroviral therapy with a viral load of less than 50 copies per ml.
Inform women that in these circumstances the risk of HIV transmission is the same for a CS and a vaginal birth.
Consider either a vaginal birth or a CS for women on anti-retroviral therapy (ART) with a viral load 50-400 copies per ml because there is insufficient evidence that a CS prevents mother-to-child transmission of HIV.
Offer a CS to women with HIV who:
  • are not receiving any anti-retroviral therapy or
  • are receiving any anti-retroviral therapy and have a viral load of 400 copies per ml or more.
Researchers and national bodies responsible for the collection of UK population data should continue to collect data about HIV diagnoses in pregnant women, including treatment, mode of birth, and mother-to-child transmission rates.
Maternal request
Maternal request is not on its own an indication for CS and specific reasons for the request should be explored, discussed and recorded. [GPP]When a woman requests a CS explore, discuss and record the specific reasons for the request.
When a woman requests a CS in the absence of an identifiable reason, the overall benefits and risks of CS compared with vaginal birth should be discussed and recorded [GPP]If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth (see tables 4.5 and 4.6) and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and to ensure the woman has accurate information.
When a woman requests a CS because she has a fear of childbirth, she should be offered counselling (such as cognitive behavioural therapy) to help her to address her fears in a supportive manner, because this results in reduced fear of pain in labour and shorter labour. [A]When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.
An individual clinician has the right to decline a request for CS in the absence of an identifiable reason. However the woman’s decision should be respected and she should be offered referral for a second opinion. [GPP]For women requesting a CS, if after discussion and 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 CS.
An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.
Planned CS for uncomplicated twin pregnancy should not be carried out before 38 weeks because this increases the risk of respiratory problems in these babies. [B]Deleted as timing of birth for multiple pregnancies will be covered in the forthcoming guideline on multiple pregnancy
Place of birth
During their discussions about options for birth, healthy pregnant women with anticipated uncomplicated pregnancies should be informed that delivering at home reduces the likelihood of CS. [B]During their discussions about options for birth, healthy pregnant women with anticipated uncomplicated pregnancies should be informed that planning a home birth reduces the likelihood of CS. [B]Amended for clarity
Decision to delivery interval
Delivery at emergency CS for maternal or fetal compromise should be accomplished as quickly as possible, taking into account that rapid delivery has the potential to do harm. A decision-to-delivery interval of less than 30 minutes is not in itself critical in influencing baby outcome, but remains an audit standard for response to emergencies within maternity services. [C]Perform category 1 and 2 CS (see recommendation 53) as quickly as possible after making the decision, particularly for category 1.
Perform category 2 CS in most situations within 75 minutes of making the decision.
Take into account the condition of the woman and the unborn baby when making decisions about rapid delivery. Remember that rapid delivery may be harmful in certain circumstances.
Use the following decision to delivery intervals to measure the overall performance of an obstetric unit:
  • 30 minutes for category 1 CS
  • both 30 and 75 minutes for category 2 CS.
Use these as audit standards only and not to judge multidisciplinary team performance for any individual CS.
Anaesthesia for CS
Women who are having induction of regional anaesthesia for CS should be cared for in theatre because this does not increase patient anxiety. [B]Women who are having induction of regional anaesthesia for CS should be cared for in theatre because this does not increase women's anxiety.Stylistic changes
General anaesthesia for emergency CS should include preoxygenation, cricoid pressure and rapid sequence induction to reduce the risk of aspiration. [GPP]General anaesthesia for unplanned CS should include preoxygenation, cricoid pressure and rapid sequence induction to reduce the risk of aspiration. [GPP]Terminology change
Surgical techniques for CS
Women who are having a CS birth should be informed that the risk of fetal lacerations is about 2%. [C]Women who are having a CS should be informed that the risk of fetal lacerations is about 2%. [C]‘birth’ deleted for terminological consistency
Women having a CS should be offered prophylactic antibiotics, such as a first generation cephalosporin or ampicillin to reduce the risk of postoperative infections (such as endometritis, urinary tract and wound infection), which occur in about 8% of women who have had a CS. [A]Women having a CS should be offered prophylactic antibiotics, to reduce the risk of postoperative infections. The antibiotics chosen should be effective against endometritis, urinary tract and wound infections which occur in about 8% of women who have had a CS. [A]The GDG was aware that first generation cephalosporins are no longer available in the UK in an intravenous form.
Recovery following CS
Healthcare professionals caring for women who have had a CS and who have irregular vaginal bleeding should consider that this is more likely to be due to endometritis than retained products of conception. [D]Healthcare professionals caring for women who have had a CS and who have heavy and/or irregular vaginal bleeding should consider that this is more likely to be due to endometritis than retained products of conception. [D]Amended for consistency
Pregnancy and childbirth after CS
The risks and benefits of vaginal birth after CS compared with repeat CS are uncertain. Therefore the decision about mode of birth after a previous CS should take into consideration:
  • maternal preferences and priorities
  • a general discussion of the overall risks and benefits of CS
  • risk of uterine rupture
  • risk of perinatal mortality and morbidity. [GPP]
When advising about the mode of birth after a previous CS consider:
  • maternal preferences and priorities
  • the risks and benefits of repeat CS
  • the risks and benefits of planned vaginal birth after CS, including the risk of unplanned CS
Pregnant women who have a previous CS and who want to have a vaginal birth should be supported in this decision. They should be informed that:
  • uterine rupture is a very rare complication, but is increased in women having a planned vaginal birth (35 per 10,000 women compared with 12 per 10,000 women having planned repeat CS)
  • the risk of an intrapartum infant death is small for women who have planned vaginal birth (about 10 per 10,000); however, this is higher than for planned repeat CS (about 1 per 10,000)
  • the effect of planned vaginal birth or planned repeat CS on cerebral palsy is uncertain. [B]
deletedThe GDG felt it was inappropriate to focus on these particular adverse events given that their overall risk is very low. In addition, it was felt that it could be misleading to talk about these general risks and that it was more appropriate for the healthcare professional to counsel the woman based on her own clinical and obstetric needs. Instead there should be a discussion of the risks and benefits of CS
Women who have had a previous CS should be offered:
  • electronic fetal monitoring during labour
  • care during labour in a unit where there is immediate access to CS and on-site blood transfusion services. [GPP]
Offer women planning a vaginal birth who have had a previous CS:
  • electronic fetal monitoring during labour
  • care during labour in a unit where there is immediate access to CS and on-site blood transfusion services.
The GDG felt that it was important to clarify that this recommendation only applies to women planning a vaginal birth after a previous CS. Stylistic changes have also been made.
Women who have had a previous CS can be offered induction of labour, but both women and healthcare professionals should be aware that the likelihood of uterine rupture in these circumstances is increased to:
  • 80 per 10,000 when labour is induced with non-prostaglandin agents
  • 240 per 10,000 when labour is induced using prostaglandins. [B]
deletedThere is a more updated recommendation on this topic in the ‘Induction of labour’ guideline (NICE, 2008). This has been signposted in the text
Debriefing for women after CS
Women who have had a CS should be offered the opportunity to discuss with their healthcare providers the reasons for the CS and implications for the child or future pregnancies. [GPP]While women are in hospital after having a CS, give them the opportunity to discuss with healthcare professionals the reasons for the CS and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date.

From: Appendix J, Changes to original recommendations

Cover of Caesarean Section
Caesarean Section.
NICE Clinical Guidelines, No. 132.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2011 Nov.
Copyright © 2011, National Collaborating Centre for Women's and Children's Health.

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