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

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Caesarean Section.

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4Woman-centred care

4.1. Provision of information

In 1993, the Expert Maternity Group from the Department of Health (DH) released the Changing Childbirth report which made explicit the right of women to be involved in decisions regarding all aspects of their care during pregnancy and childbirth.23 One of the priorities of the report is to enable women to make informed decisions about their care.24 To make these decisions women require access to evidence-based information so that they can take part in discussions with caregivers about these decisions.

In a survey, pregnant women were asked their views about childbirth. This included questions about the information they wanted or had received. About 40% of women reported that they had sufficient information on the risks and benefits of caesarean section (CS): however, almost 50% reported that they would have liked more information on reasons for CS, what to expect and the risks and benefits of CS4 [evidence level 3]. Information from randomised controlled trials (RCTs) on antenatal education suggests that the provision of information is often seen as inadequate by women25 [evidence level 3]. About 1 in 4 pregnant women will be delivered by CS (Department of Health, 2009) therefore when planning the birth of their baby women need information on both vaginal birth and CS. For women who experience a fear of childbirth, it is possible that building up confidence during pregnancy in her ability to give birth has the potential to influence her choices for the birth of her baby and the interventions she receives during birth.26

Information leaflets

An RCT assessed the impact of evidence-based leaflets to promote informed decision making among pregnant women.27 The leaflets were designed to be used in a conscious and controlled way (i.e. not left in a rack at an antenatal clinic or GP office) and the information provided was based on results of systematic reviews of the best available evidence and they were peer-reviewed. No differences were detected in the proportion of women who reported that they had exercised informed choice or among those who reported an ‘active’ decision making role during antenatal care between the women that received these leaflets and those that did not. However, satisfaction with the amount of information received was higher among women who had received the leaflets [evidence level 1b]. Qualitative assessment within the RCT of the use of the leaflets found that their potential as decision aids was reduced due to competing demands within the clinical environment.28 Time pressures limited discussion and the hierarchical nature of the relationship between healthcare professionals and patients determined which ‘choices’ were available. This meant that women complied with their carer's choice rather than making an informed decision [evidence level 3].

Antenatal education

A systematic review based on six RCTs (n = 1443) assessed the effects of antenatal education on knowledge acquisition, anxiety, sense of control, pain, support, breastfeeding, infant care abilities, and psychological and social adjustment.29 The largest RCT (n = 1275) examined an educational intervention to increase vaginal birth after CS. The other five RCTs (combined n = 168, range RCT n = 10 to 67) included more general educational interventions; however the methodological quality of these RCTs is uncertain as they do not report randomisation procedures, allocation concealment or accrual/loss of participants. None of the RCTs included labour and birth outcomes, anxiety, breastfeeding success, or general social support. The effects on knowledge acquisition and infant care competencies were measured but interpretation is difficult because of the size and methodological quality of the RCTs.29 [evidence level 1b]

Recommendations

NumberRecommendation
1Pregnant women should be offered evidence-based information and support to enable them to make informed decisions about childbirth. Addressing women's views and concerns should be recognised as being integral to the decision-making process. [C] [2004]
2Give 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] [new 2011]
3Communication and information should be provided in a form that is accessible to pregnant women, taking into account the information and cultural needs of minority communities and women whose first language is not English or who cannot read, together with the needs of women with disabilities or learning difficulties. [GPP] [2004]

4.2. Planning mode of birth

Risks and benefits of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy

Clinical question

What are the risks and benefits of planned CS compared with planned vaginal birth for both women and babies?

Updating the risks and benefits tables

The original Caesarean section guideline reviewed evidence for this question that included women with an obstetric indication for CS as well as women from a general population including those with both high and low obstetric risk. Data from all studies were presented together and summarised in two tables (labelled Tables 3.1a and 3.1b in the original guideline). These tables included data drawn from RCTs and observational studies. For the RCTs, findings were presented on an “intention to treat basis” truly representing planned CS versus planned vaginal birth. For all observational studies, data were presented depending on actual mode of birth rather than planned mode of birth. For outcomes of interest where the number of events is very small this makes a very big difference to the interpretation of the findings. This is illustrated in Appendix K where for three outcomes it has been possible to compare the findings calculated on an intention to treat basis with those presented according to actual mode of birth.

It should be noted that the sources of observational data presented in Tables 3.1a and 3.1b in the original guideline were not referenced nor detailed in chapter 3 but appeared throughout the guideline under the relevant topic headings according to outcome. The deleted Tables 3.1a and 3.1b from the original guideline have been annotated to provide extra information regarding the source of the data and the population studied (see Appendix K).

For this update to the guideline, the guideline development group (GDG) wanted to focus specifically on women without antenatal complications (either medical or obstetric) so that the review provided information for women who were requesting a CS in the absence of a clinical indication. It was also considered important to ensure that included studies presented findings on an intention to treat basis, thus reflecting the relevant risks during the antenatal period when a woman is planning mode of birth.

The updated reviews were undertaken following protocols that reflected this important difference (see Appendix D). Again, both RCTs and observational studies were considered for inclusion.

The reasons outlined above mean that the data presented in the updated tables for risks and benefits associated with planned CS compared with planned vaginal birth are quite different from the data that appeared in the original guideline. However, the updated tables provide a more valid estimation of these risks for a woman with an uncomplicated pregnancy planning mode of birth.

Overview of evidence

Nine studies were included in this review. One study was conducted in the UK (Homer et al., 2011), three studies were conducted in the USA (MacDorman et al., 2008; Geller et al., 2010a and 2010b), three in Canada (Dahlgren. et al., 2009; Allen et al., 2006; Liu et al., 2007), one in France (Deneux-Tharaux et al., 2006) and one in Austria (Schindl et al., 2003). Three studies employed “intention to treat” analysis regardless of the actual route of delivery in cases and controls (MacDorman, et al., 2008; Geller et al., 2010a and 2010b). Two population-based studies included women who gave birth by planned CS because of breech presentation as an appropriate surrogate for “maternal request” (Liu et al., 2007; Dahlgren et al., 2009). The comparison group in these studies was planned vaginal birth (not vaginal breech birth). One study reported “caesarean section on demand” for cases and women with “planned vaginal birth” for controls (Schindl et al., 2003). Two studies compared the birth outcomes of women undergoing low risk pre-labour CS with those women intending to have a vaginal birth (Allen et al., 2006; Deneux-Tharaux et al., 2006). Eight studies considered primary CS only; however, one study did not report excluding women with a prior CS (Deneux-Tharaux et al., 2006). Two studies reported excluding women who underwent induction of labour (Allen et al., 2006; Dahlgren. et al., 2009).

Four of the studies included in the review solely looked at nulliparous women (Allen et al., 2006; Dahlgren et al., 2009; Geller et al., 2010a & 2010b), while the remainder also included multiparous women. Four studies reported neonatal outcomes, of which three only included women giving birth at 37 weeks or later (Dahlgren et al., 2009; Geller et al., 2010b; MacDorman et al., 2009). The fourth study included babies born before 37 weeks of gestation (Homer et al., 2011). More details of this study are given in the paragraph below, and details for all studies can be found in the evidence tables in Appendix G.

The UK study comprised a population of extremely obese women (body mass index [BMI] of 50 kg/m2 or more) including both nulliparous women (34%) and multiparous women (Homer et al., 2011). It also included women with medical complications (such as pre-eclampsia, diabetes). This study was included in the review as it focussed on a population of women that was identified in the scope as being of particular importance and downgraded due to the indirectness of the sample population. Findings for this study are presented separately and not included in the summary risk–benefits tables (Tables 4.5 and 4.6).

Table 4.5. Summary effect on women's health of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS.

Table 4.5

Summary effect on women's health of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS.

Table 4.6. Summary effect on babies' health of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS.

Table 4.6

Summary effect on babies' health of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS.

All outcomes reported in the included papers are recorded here in order to make the table as comprehensive as possible. The GDG felt it was not appropriate to choose which outcomes would be most important as this will vary from woman to woman. By presenting all the data available it is hoped each individual woman will receive the information she needs to make a fully informed decision.

Evidence profile

Maternal outcomes

Evidence was identified from nine studies. It is important to underline that the findings presented are for planned CS compared with planned vaginal birth; that is, the comparison is based upon what was planned antenatally, not the actual mode of birth. This reflects the risks and benefits as they appear to a woman planning birth and take into account that when planning a vaginal birth, the woman may give birth by CS (usually carried out during labour). The number and percentage of unplanned CSs carried out in the planned vaginal birth group for each study is also included in the table.

All reported outcomes from the included studies are presented in the table in order to provide information that is as comprehensive as possible. The GDG felt it was not appropriate to limit the outcomes included as there will be considerable variation between individual women as to what information they use when deciding mode of birth.

The quality of the evidence was low and very low for all studies included.

Table 4.1. GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS (maternal outcomes).

Table 4.1

GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS (maternal outcomes).

Table 4.2. GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with BMI of 50 kg/m2 or more and no previous CS (maternal outcomes).

Table 4.2

GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with BMI of 50 kg/m2 or more and no previous CS (maternal outcomes).

Table 4.3. GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS (neonatal outcomes).

Table 4.3

GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with an uncomplicated pregnancy and no previous CS (neonatal outcomes).

Table 4.4. GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with BMI of 50 kg/m2 or more and no previous CS (neonatal outcomes).

Table 4.4

GRADE summary of findings for risks of planned CS compared with planned vaginal birth for women with BMI of 50 kg/m2 or more and no previous CS (neonatal outcomes).

Evidence statements

Maternal outcomes: women with an uncomplicated pregnancy
Maternal mortality rate

One study found that the maternal mortality rate in women with a planned CS was higher in women with a planned vaginal birth. This finding was statistically significant. Two other studies did not find a statistically significant difference in the maternal mortality rate between the two groups. The evidence for this outcome was of very low quality

Pain

One study found that the median pain level during birth and 3 days postpartum was lower in women who had a planned CS compared with those who had a planned vaginal birth. This finding was statistically significant. The same study did not find a statistical difference between the two groups at 4 months postpartum. The evidence for this outcome was of very low quality.

Injury to bladder/ureter

One study did not find a statistically significant difference in the incidence of injury to the bladder/ureter for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Injury to cervix

One study did not find a statistically significant difference in the incidence of injury to the cervix for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Injury to vagina

One study found that the incidence of injury to the vagina was lower among women with a planned CS compared with women who had a planned vaginal birth. This finding was statistically significant. The evidence for this outcome was of very low quality.

Iatrogenic surgical injury

One study did not find a statistically significant difference in the rate of iatrogenic surgical injury for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Hysterectomy

Two studies of very low quality found that the rate of hysterectomies was higher in women with a planned CS than in women with a planned vaginal birth. These findings were statistically significant. The evidence for this outcome was of very low quality.

Hysterectomy due to postpartum haemorrhage

One study found that the rate of hysterectomy due to postpartum haemorrhage was higher among women who had a CS without labour compared with women who had a planned vaginal birth. This finding was statistically significant. The evidence for this outcome was of very low quality.

Deep vein thrombosis

One study found that the rate of deep vein thrombosis (DVT) was higher in women who had a planned CS than in women with a planned vaginal birth. This finding was statistically significant. Another study did not find a statistically significant difference in rates of DVT between women who had a pre-labour CS and those who had a planned vaginal birth. The evidence for this outcome was of very low quality.

Pulmonary embolism

One study did not find a statistically significant difference in the rate of pulmonary embolism for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Blood transfusion

One study found that fewer women with a planned CS required a blood transfusion than women with a planned vaginal birth. This finding was statistically significant. Three other studies did not find a statistically significant difference in the number of women requiring a blood transfusion in the two groups. The evidence for this outcome was of very low quality.

Early postpartum haemorrhage

Two studies found that fewer women who had a CS without labour experienced an early postpartum haemorrhage than women who had a planned vaginal birth. This finding was statistically significant. The quality of evidence for this outcome was low in one study and very low in the other.

Wound and postpartum infection

One study of very low quality found that the rate of wound and postpartum infection was higher in women who had CS without labour compared with women who had a planned vaginal birth. This finding was statistically significant. One other study did not find a statistically significant difference in the rate of wound and postpartum infection between women who had a planned CS and those who had a planned vaginal birth. The evidence for this outcome was of very low quality.

Wound infection

Two studies did not find a statistically significant difference in the rate of wound infection for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of low and very low quality.

Anaesthetic complications

One study found that the number of women experiencing anaesthetic complications was higher among women who had CS without labour than among women who had a planned vaginal birth. This finding was statistically significant. One other study found no statistically significant difference in anaesthetic complications between women who had a planned CS and those who had a planned vaginal birth. The evidence for this outcome was of very low quality.

Intraoperative trauma

One study did not find a statistically significant difference in the rate of intraoperative trauma for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Uterine rupture

One study did not find a statistically significant difference in the rate of uterine rupture for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Length of hospital stay

Two studies found that the length of hospital stay was longer for women who had a CS without labour compared with women who had a planned vaginal birth. However, it was not possible to determine if this result was significant. The evidence for this outcome was of low and very low quality.

Assisted ventilation or intubation

One study found that more women who had a CS without labour required assisted ventilation or intubation compared with women who had a planned vaginal birth. This finding was statistically significant. The evidence for this outcome was of very low quality.

Acute renal failure

One study did not find a statistically significant difference in the rate of acute renal failure for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of very low quality.

Cardiac arrest

One study found that more women who had a CS without labour experienced cardiac arrest compared with women who had a planned vaginal birth. This finding was statistically significant. The evidence for this outcome was of very low quality.

Obstetric shock

One study found that fewer women who had a CS without labour experienced obstetric shock compared with women who had a planned vaginal birth. This finding was statistically significant. The evidence for this outcome was of very low quality.

Maternal outcomes: women with BMI of 50 kg/m2 or more
Infection (wound and postpartum)

One study did not find a statistically significant difference in the rate of wound and postpartum infection for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of low quality.

Anaesthetic complication

One study did not find a statistically significant difference in the rate of anaesthetic complications for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of low quality.

Major maternal morbidity

One study did not find a statistically significant difference in the rate of major maternal morbidity for women with a planned CS compared with women with a planned vaginal birth. The evidence for this outcome was of low quality.

Neonatal outcomes: born to women with an uncomplicated pregnancy
Neonatal mortality

One study found that the neonatal mortality rate was higher in neonates born by planned CS compared with neonates born by planned vaginal birth. This finding was statistically significant. One other study did not find a statistically significant difference in the neonatal mortality rate between the two groups. The evidence for this outcome was of very low quality.

Hypoxic-ischemic encephalopathy

One study did not find a statistically significant difference in the rate of hypoxic-ischemic encephalopathy for neonates born by planned CS compared with neonates born by planned vaginal birth. The evidence for this outcome was of very low quality.

Intracranial haemorrhage

One study did not find a statistically significant difference in the rate of intracranial haemorrhage for neonates born by planned CS compared with neonates born by planned vaginal birth. The evidence for this outcome was of very low quality.

Neonatal respiratory morbidity (composite outcome of intermittent positive pressure ventilation, transient tachypnoea, endotracheal tube insertion and pneumonia)

One study did not find a statistically significant difference in the rate of neonatal respiratory morbidity for neonates born by planned CS compared with neonates born by planned vaginal birth. The evidence for this outcome was of very low quality.

Composite of respiratory morbidity

One study did not find a statistically significant difference in the composite respiratory morbidity for neonates born by planned CS compared with neonates born by planned vaginal birth. The evidence for this outcome was of very low quality.

Neonatal intensive care unit (NICU) admission

One study found that the rate of NICU admission was higher in neonates born by planned vaginal birth. This finding was statistically significant. The evidence for this outcome was of low quality.

Apgar score less than 7 at 5 minutes

One study found that fewer neonates born by planned CS had an Apgar score of less than 7 at 5 minutes compared with neonates born by planned vaginal birth. This finding was statistically significant. Another study found no statistically significant difference between the two groups. The evidence for this outcome was of very low quality.

Composite of neurological morbidity

One study did not find a statistically significant difference in the composite neurological morbidity for neonates born by planned CS compared with neonates born by planned vaginal birth. The evidence for this outcome was of very low quality.

Neonatal outcomes: babies born to women with BMI of 50 kg/m2 or more
Neonatal mortality

One study did not find a statistically significant difference in the neonatal mortality rate for neonates born by planned CS compared with neonates born by planned vaginal birth. The evidence for this outcome was of low quality.

NICU admission

One study found that the rate of NICU admission was higher in neonates born by planned vaginal birth. This finding was statistically significant. However, when the data were adjusted for less than 37 weeks of gestation, this finding was not statistically significant. The evidence for this outcome was of low quality.

Evidence to recommendations

Relative value placed on outcomes considered

For this review, all reported outcomes have been presented as the point of the review was to inform women's decision making. By presenting these outcomes it is hoped that women will have the relevant information to assess the risks and benefits of each mode of birth. The relative value of outcomes will vary from woman to woman.

The group noted that deep vein thrombosis and pulmonary embolism were not particularly useful outcomes for individual decision making as they are very rare and are likely to be even rarer in the future as there are recent guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG) on these topics (Greentop guidelines 37a and b, 2009) and from NICE on prevention of venous thromboembolism (NICE, 2009) which should help to standardise and improve prevention and care of these complications.

Trade-off between clinical benefits and harms

The data have been presented in their entirety in order to support women's decision making. The group agreed that it is important that women are presented with evidence-based information so that they are able to make an informed decision. The reported benefits and harms can be discussed with each woman to help her make decisions based on the relative trade-off between the two modes of birth interpreted in light of her own circumstances.

Trade-off between net health benefits and resource use

The outcomes reported in this review were used to inform the economic modelling for the cost effectiveness of CS on maternal request (see Section 5.9 for further details and conclusions).

Quality of the evidence

The evidence was based on observational studies, the findings from which were all of low or very low quality. However, the GDG noted that the inclusion of solely low obstetric risk populations meant that the evidence was more relevant for women requesting a CS with no medical or obstetric indication than the data presented in the original guideline.

The GDG agreed that, as the purpose of the table was to inform women's decision making about their chosen mode of birth, it was appropriate to include the findings for women who underwent an unplanned CS along with those for women who had a vaginal birth. This is because the majority of unplanned or intrapartum CSs will be required by women who had originally planned for a vaginal birth and not those who had planned a CS.

Other considerations

The GDG noted that the findings from the studies were relevant to the current UK population which has a CS rate of approximately 25% of women giving birth. It is anticipated that if the rate of unplanned CSs was to fall, the levels of risks associated with planned vaginal birth would also fall.

The GDG agreed that when discussing the risks and benefits outlined in the table, the healthcare professional and the woman need to consider the woman's individual circumstances as these affect the risks associated with vaginal birth and CS: examples include previous abdominal or pelvic surgery, impaired mobility from pelvic girdle pain, or care of other children. It is also important to discuss the number of future babies that the woman and her partner are planning, as some risks, such as placenta praevia, increase with an increasing number of CSs.

The GDG members noted that the evidence from the one UK study involving extremely obese women suggested that outcomes were similar for women planning a vaginal birth and those planning a CS. They felt this was contrary to what many obstetricians currently believe to be the case and that it was important to make a recommendation to underline this finding.

Recommendations

NumberRecommendation
4Discuss 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). [new 2011]
5Do not use a body mass index (BMI) of over 50 alone as an indication for planned CS. [new 2011]
NumberResearch recommendation
RR 1What are the medium- to long-term risks and benefits to women and their babies of planned CS compared with planned vaginal birth?

The main focus would be the outcomes in women which could be measured at 1 year (medium term) and 5–10 years (long term). These outcomes could include:
  • urinary dysfunction
  • gastrointestinal dysfunction
  • dyspareunia
  • breastfeeding
  • psychological health.
Infant outcomes could include medical problems, especially ongoing respiratory and neurological problems.
Why this is important
Morbidities arising intraoperatively or in the days after a caesarean section have been reasonably well described in the literature. Much less is known, however, about physical and emotional outcome measures in the longer term.

The Confidential Enquiries into Maternal Death in the UK, most recently published as ‘Saving mothers’ lives 2006–2008' (Cantwell R. et al., 2011), devote a significant proportion of their work to investigating ‘late’ causes of maternal death. These include events arising in the medium term, namely, up to 1 year after a woman has given birth, many of which originate from the preceding pregnancy. The infectious, psychiatric and other conditions arising in or related to pregnancy do not always cause death but are responsible for arguably a greater burden of morbidity in the medium and long term, long after the pregnancy is over.

To provide more meaningful information to women when they are choosing their mode of birth, there is a pressing need to document medium- to long-term outcomes in women and their babies after a planned CS or a planned vaginal birth. First, it should be possible to gather data using standardised questions (traditional paper-based questionnaires and face-to-face interviews) about maternal septic morbidities and emotional wellbeing up to 1 year after a planned CS in a population of women who have consented for follow-up. Internet-based questionnaires could also be devised, to achieve the high response rates required for a full interpretation of the data. Similarly, it would be important to collect high-quality data on infant morbidities after a planned CS compared with a planned vaginal birth. A long term morbidity evaluation (between 5 and 10 years after the CS) would use similar methodology but assess symptoms related to urinary and gastrointestinal function.
RR 2Further evaluation is needed to determine the impact of demographic and clinical factors (such as ethnic group, increase in body mass index) and attitudinal factors on CS rates.

Consent for CS

Provision of information is central to the consent process, this should include information about the patient's condition, possible investigations and treatment options; the risks or benefits of these options, including the risk of doing nothing.3032 [evidence level 4] Information should be given in a way that patients can understand.32,33 [evidence level 4] The amount of information provided will vary between patients according to the nature of the condition, the complexity of the treatment, the associated risk of the procedure, the patient's own wishes and individual needs. For the process of seeking consent to be meaningful, refusal of treatment needs to be one of the patient's options. Competent adults are entitled to refuse treatment even when the treatment would clearly benefit their health. Therefore a competent pregnant woman may refuse CS, even if this would be detrimental to herself or the fetus.30 [evidence level 4] Ethical guidance for obtaining consent, points of law and model documentation are available in the above guidance.3032,34 [evidence level 4]

Tubal ligation at CS

It is estimated tubal ligation overall has a failure rate of 1 in 200 lifetime risk.49 We did not identify any studies that describes the failure rate of tubal ligation at CS. Other guidelines recommend that tubal ligation should have been requested before or during pregnancy and agreed at least one week prior to the procedure. This advice is based on expert opinion.49 [evidence level 4]

Recommendations

NumberRecommendation
6Consent for CS should be requested after providing pregnant women with evidence-based information and in a manner that respects the woman's dignity, privacy, views and culture, while taking into consideration the clinical situation. [C] [2004]
7A 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] [2004]
8When 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] [2004]
Copyright © 2011, National Collaborating Centre for Women's and Children's Health.

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The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore for general use.

Bookshelf ID: NBK115308

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