Levels of evidence (1a-4) and grading of recommendations (A-D) are defined at the end of the Major Recommendations field.
In addition to the evidence-based recommendations, the guideline development group also identifies points of good clinical practice (GPP).
Woman-centered Care
Provision of Information
C - Pregnant 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.
GPP - Pregnant women should be given evidence-based information about caesarean section (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 - Communication 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.
Information summarising the likely effect of CS on women's and children's health can be found in Appendix A of the original guideline document.
Consent for Caesarean Section (CS)
C - Consent 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.
D - 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.
GPP - 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 - 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.
Classification of Urgency
C - The urgency of CS should be documented using the following standardised scheme in order to aid clear communication between health-care professionals about the urgency of a CS:
- Immediate threat to the life of the woman or fetus
- Maternal or fetal compromise which is not immediately life-threatening
- No maternal or fetal compromise but needs early delivery
- Delivery timed to suit woman or staff
Planned CS
Planned CS refers to a CS that is scheduled before the onset of labour for a specific clinical indication. This section deals only with decisions about the mode of delivery. Other aspects of management of specific conditions or complications of pregnancy are outside the scope of this guideline.
Breech Presentation
A - Women who have an uncomplicated singleton breech pregnancy at 36 weeks gestation should be offered external cephalic version. Exceptions include women in labour and women with a uterine scar or abnormality, fetal compromise, ruptured membranes, vaginal bleeding, or medical conditions.
A - Pregnant women with a singleton breech presentation at term for whom external cephalic version is contraindicated or has been unsuccessful should be offered CS because it reduces perinatal mortality and neonatal morbidity.
Multiple Pregnancy
C - In otherwise uncomplicated twin pregnancies at term where the presentation of the first twin is cephalic, perinatal morbidity and mortality is increased for the second twin. However, the effect of planned CS in improving outcome for the second twin remains uncertain and therefore CS should not routinely be offered outside a research context.
GPP - In twin pregnancies where the first twin is not cephalic, the effect of CS in improving outcome is uncertain, but current practice is to offer a planned CS.
B - 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.
Preterm Birth and CS
C - Preterm birth is associated with higher neonatal morbidity and mortality. However, the effect of planned CS in improving these outcomes remains uncertain and therefore CS should not routinely be offered outside a research context.
Small for Gestational Age and CS
C - The risk of neonatal morbidity and mortality is higher with "small for gestational age" babies. However, the effect of planned CS in improving these outcomes remains uncertain, and therefore CS should not routinely be offered outside a research context.
Placenta Praevia
D - Women with a placenta that partly or completely covers the internal cervical os (grade 3 or 4 placenta praevia) should be offered CS.
Predicting CS for Cephalopelvic Disproportion in Labour
A - Pelvimetry is not useful in predicting "failure to progress" in labour and should not be used in decision making about mode of birth.
B - Shoe size, maternal height, and estimations of fetal size (ultrasound or clinical examination) do not accurately predict cephalopelvic disproportion and should not be used to predict "failure to progress" during labour.
Mother-to-Child Transmission of Maternal Infections
This section exclusively addresses CS as an intervention to reduce mother-to-child transmission of infections. Other interventions to reduce transmission of these infections to the baby are available but are outside the scope of this guideline.
A - Human immunodeficiency virus (HIV)-positive women who are pregnant should be offered a planned CS because it reduces the risk of mother-to-child transmission of HIV.
B - Mother-to-child transmission of hepatitis B can be reduced if the baby receives immunoglobulin and vaccination. In these situations pregnant women with hepatitis B should not be offered a planned CS, because there is insufficient evidence that this reduces mother-to-child transmission of hepatitis B virus.
C - Women who are infected with hepatitis C should not be offered a planned CS because this does not reduce mother-to-child transmission of the virus.
C - Pregnant women who are coinfected with hepatitis C virus and HIV should be offered planned CS because it reduces mother-to-child transmission of both hepatitis C virus and HIV.
C - Women with primary genital herpes simplex virus (HSV) infection occurring in the third trimester of pregnancy should be offered planned CS because it decreases the risk of neonatal HSV infection.
C - Pregnant women with a recurrence of HSV at birth should be informed that there is uncertainty about the effect of planned CS in reducing the risk of neonatal HSV infection. Therefore, CS should not routinely be offered outside a research context.
Maternal Request for CS
GPP - 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 in the absence of an identifiable reason, the overall benefits and risks of CS compared with vaginal birth should be discussed and recorded.
A - 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.
GPP - 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.
Factors Affecting Likelihood of CS During Intrapartum Care
Place of Birth
B - 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.
A - During their discussions about options for birth, healthy pregnant women with anticipated uncomplicated pregnancies should be informed that planned childbirth in a "midwifery-led unit" does not reduce the likelihood of CS.
Reducing Likelihood of CS
The following interventions during intrapartum care have been shown to decrease the likelihood of CS:
A - Women should be informed that continuous support during labour from women with or without prior training reduces the likelihood of CS.
A - Women with an uncomplicated pregnancy should be offered induction of labour beyond 41 weeks because this reduces the risk of perinatal mortality and the likelihood of CS (see also the NICE Clinical Guideline on induction of labour; details in Section 6 of that document).
A - A partogram with a 4-hour action line should be used to monitor progress of labour of women in spontaneous labour with an uncomplicated singleton pregnancy at term, because it reduces the likelihood of CS.
C - Consultant obstetricians should be involved in the decision making for CS, because this reduces the likelihood of CS.
B - Electronic fetal monitoring is associated with an increased likelihood of CS. When CS is contemplated because of an abnormal fetal heart rate pattern, in cases of suspected fetal acidosis, fetal blood sampling should be offered if it is technically possible and there are no contraindications (see also the NICE Clinical Guideline on electronic fetal monitoring; details in Section 6 of that document).
No Influence on Likelihood of CS
A - Women should be informed that the following interventions during intrapartum care have not been shown to influence the likelihood of CS, although they may affect other outcomes that are outside the scope of this guideline:
- Walking in labour
- Nonsupine position during the second stage of labour
- Immersion in water during labour
- Epidural analgesia during labour
- Use of raspberry leaf
D - Women should be informed that the effects on the likelihood of CS of complementary therapies used during labour (such as acupuncture, aromatherapy, hypnosis, herbal products, nutritional supplements, homeopathic medicines, and Chinese medicines) have not been properly evaluated and further research is needed before such interventions can be recommended.
"Failure to Progress" in Labour and CS
A - The following aspects of intrapartum care have not been shown to influence the likelihood of CS for "failure to progress" and should not be offered for this reason, although they may affect other outcomes which are outside the scope of this guideline:
- Active management of labour
- Early amniotomy
Eating during Labour
A - Women should be informed that eating a low-residue diet during labour (toast, crackers, low-fat cheese) results in larger gastric volumes, but the effect on the risk of aspiration if anaesthesia is required is uncertain.
A - Women should be informed that having isotonic drinks during labour prevents ketosis without a concomitant increase in gastric volume.
Procedural Aspects of CS
Timing of CS
B - The risk of respiratory morbidity is increased in babies born by CS before labour, but this risk decreases significantly after 39 weeks. Therefore planned CS should not routinely be carried out before 39 weeks.
Decision-to-Delivery Interval for Emergency CS
C - 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 has been an accepted audit standard for response to emergencies within maternity services.
Preoperative Testing Before CS
C - Pregnant women should be offered a haemoglobin assessment before CS to identify those who have anaemia. Although blood loss of more than 1,000 ml is infrequent after CS (it occurs in 4-8% of CS), it is a potentially serious complication.
C - Pregnant women having CS for antepartum haemorrhage, abruption, uterine rupture, and placenta praevia are at increased risk of blood loss of more than 1,000 ml and should have the CS carried out at a maternity unit with on-site blood transfusion services.
C - Pregnant women who are healthy and who have otherwise uncomplicated pregnancies should not routinely be offered the following tests before CS:
- Grouping and saving of serum
- Cross-matching of blood
- A clotting screen
- Preoperative ultrasound for localisation of the placenta, because this does not improve CS morbidity outcomes (such as blood loss of more than 1,000 ml, injury of the infant, and injury to the cord or to other adjacent structures).
GPP - Women having CS with regional anaesthesia require an indwelling urinary catheter to prevent over-distension of the bladder, because the anaesthetic block interferes with normal bladder function.
Anaesthesia for CS
GPP - Pregnant women having a CS should be given information on different types of post-CS analgesia so that analgesia best suited to their needs can be offered (see recommendation below under "Care of the Woman after CS").
A - Women who are having a CS should be offered regional anaesthesia because it is safer and results in less maternal and neonatal morbidity than general anaesthesia. This includes women who have a diagnosis of placenta praevia.
B - Women who are having induction of regional anaesthesia for CS should be cared for in theatre because this does not increase patient anxiety.
A - Women who are having a CS under regional anaesthesia should be offered intravenous ephedrine or phenylephrine, and volume preloading with crystalloid or colloid to reduce the risk of hypotension occurring during CS.
D - Each maternity unit should have a drill for failed intubation during obstetric anaesthesia.
B - To reduce the risk of aspiration pneumonitis, women should be offered antacids and drugs (such as H2 receptor antagonists or proton pump inhibitors) to reduce gastric volumes and acidity before CS.
A - Women having a CS should be offered antiemetics (either pharmacological or acupressure) to reduce nausea and vomiting during CS.
GPP - General anaesthesia for emergency CS should include preoxygenation, cricoid pressure, and rapid sequence induction to reduce the risk of aspiration.
A - Intravenous ephedrine or phenylephrine should be used in the management of hypotension during CS.
A - The operating table for CS should have a lateral tilt of 15°, because this reduces maternal hypotension.
Surgical Techniques for CS
The following recommendations for surgical techniques apply to pregnancies at term where there is a lower uterine segment. Techniques may need modification in situations such as repeat CS or placenta praevia.
A - Health-care professionals should wear double gloves when performing or assisting at CS on women who have tested positive for HIV, to reduce the risk of HIV infection of health-care professionals during surgery.
C - General recommendations for safe surgical practice should be followed at CS to reduce the risk of HIV infection of staff.
B - CS should be performed using a transverse abdominal incision because this is associated with less postoperative pain and an improved cosmetic effect compared with a midline incision.
A - The transverse incision of choice should be the Joel Cohen incision (a straight skin incision, 3 cm above the symphysis pubis; subsequent tissue layers are opened bluntly and, if necessary, extended with scissors and not a knife), because it is associated with shorter operating times and reduced postoperative febrile morbidity.
B - The use of separate surgical knives to incise the skin and the deeper tissues at CS is not recommended because it does not decrease wound infection.
A - When there is a well formed lower uterine segment, blunt rather than sharp extension of the uterine incision should be used because it reduces blood loss, incidence of postpartum haemorrhage, and the need for transfusion at CS.
C - Women who are having a CS birth should be informed that the risk of fetal lacerations is about 2%.
C - Forceps should only be used at CS if there is difficulty delivering the baby's head. The effect on neonatal morbidity of the routine use of forceps at CS remains uncertain.
C - Oxytocin 5 IU by slow intravenous injection should be used at CS to encourage contraction of the uterus and to decrease blood loss.
A - At CS, the placenta should be removed using controlled cord traction and not manual removal as this reduces the risk of endometritis.
A - Intraperitoneal repair of the uterus at CS should be undertaken. Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection.
B - The effectiveness and safety of single layer closure of the uterine incision is uncertain. Except within a research context, the uterine incision should be sutured with two layers.
A - Neither the visceral nor the parietal peritoneum should be sutured at CS because this reduces operating time and the need for postoperative analgesia and improves maternal satisfaction.
B - In the rare circumstances that a midline abdominal incision is used at CS, mass closure with slowly absorbable continuous sutures should be used because this results in fewer incisional hernias and less dehiscence than layered closure.
A - Routine closure of the subcutaneous tissue space should not be used, unless the woman has more than 2 cm subcutaneous fat, because it does not reduce the incidence of wound infection.
A - Superficial wound drains should not be used at CS because they do not decrease the incidence of wound infection or wound haematoma.
C - Obstetricians should be aware that the effects of different suture materials or methods of skin closure at CS are not certain.
B - Umbilical artery pH should be performed after all CS for suspected fetal compromise, to allow review of fetal well-being and guide ongoing care of the baby.
A - Women having a CS should be offered prophylactic antibiotics, such as a single dose of 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.
D - Women having a CS should be offered thromboprophylaxis because they are at increased risk of venous thromboembolism. The choice of method of prophylaxis (for example, graduated stockings, hydration, early mobilisation, low molecular weight heparin) should take into account risk of thromboembolic disease and follow existing guidelines.
GPP - Women's preferences for the birth, such as music playing in theatre, lowering the screen to see the baby born, or silence so that the mothers voice is the first the baby hears, should be accommodated where possible.
Care of the Baby Born by CS
C - An appropriately trained practitioner skilled in the resuscitation of the newborn should be present at CS performed under general anaesthesia or where there is evidence of fetal compromise.
GPP - Babies born by CS are more likely to have a lower temperature, and thermal care should be in accordance with good practice for thermal care of the newborn baby.
A - Early skin-to-skin contact between the woman and her baby should be encouraged and facilitated because it improves maternal perceptions of the infant, mothering skills, maternal behaviour, and breastfeeding outcomes, and reduces infant crying.
A - Women who have had a CS should be offered additional support to help them to start breastfeeding as soon as possible after the birth of their baby. This is because women who have had a CS are less likely to start breastfeeding in the first few hours after the birth, but, when breastfeeding is established, they are as likely to continue as women who have a vaginal birth.
Care of the Woman after CS
D - After CS, women should be observed on a one-to-one basis by a properly trained member of staff until they have regained airway control and cardiorespiratory stability and are able to communicate.
B - Health-care professionals caring for women after CS should be aware that, although it is rare for women to need intensive care following childbirth, this occurs more frequently after CS (about 9 per 1,000).
GPP - After recovery from anaesthesia, observations (respiratory rate, heart rate, blood pressure, pain, and sedation) should be continued every half hour for 2 hours, and hourly thereafter provided that the observations are stable or satisfactory. If these observations are not stable, more frequent observations and medical review are recommended.
GPP - For women who have had intrathecal opioids, there should be a minimum hourly observation of respiratory rate, sedation, and pain scores for at least 12 hours for diamorphine and 24 hours for morphine.
GPP - For women who have epidural opioids or patient-controlled analgesia with opioids, there should be routine hourly monitoring of respiratory rate, sedation, and pain scores throughout treatment and for at least 2 hours after discontinuation of treatment.
A - Women should be offered diamorphine (0.3-0.4 mg intrathecally) for intra- and postoperative analgesia because it reduces the need for supplemental analgesia after a CS. Epidural diamorphine (2.5-5 mg) is a suitable alternative.
GPP - Patient-controlled analgesia using opioid analgesics should be offered after CS because it improves pain relief.
A - Providing there is no contraindication, nonsteroidal anti-inflammatory drugs should be offered post-CS as an adjunct to other analgesics, because they reduce the need for opioids.
A - Women who are recovering well after CS and do not have complications can eat and drink when they feel hungry or thirsty.
D - Removal of the urinary bladder catheter should be carried out once a woman is mobile after a regional anaesthetic and not sooner than 12 hours after the last "top up" dose.
A - Routine respiratory physiotherapy does not need to be offered to women after a CS under general anaesthesia, because it does not improve respiratory outcomes such as coughing, phlegm, body temperature, chest palpation, and auscultatory changes.
GPP - Women who have had a CS should be offered the opportunity to discuss with their health-care providers the reasons for the CS and implications for the child or future pregnancies.
A - Length of hospital stay is likely to be longer after a CS (an average of 3-4 days) than after a vaginal birth (average 1-2 days). However, women who are recovering well, are apyrexial, and do not have complications following CS should be offered early discharge (after 24 hours) from hospital and follow-up at home, because this is not associated with more infant or maternal readmissions.
Recovery Following CS
GPP - In addition to general postnatal care, women who have had a CS should be provided with:
- Specific care related to recovery after CS
- Care related to management of other complications during pregnancy or childbirth
D - Women who have a CS should be prescribed and encouraged to take regular analgesia for postoperative pain, using:
- For severe pain, co-codamol with added ibuprofen
- For moderate pain, co-codamol
- For mild pain, paracetamol
D - CS wound care should include:
- Removing the dressing 24 hours after the CS
- Specific monitoring for fever
- Assessing the wound for signs of infection (such as increasing pain, redness, or discharge), separation, or dehiscence
- Encouraging the woman to wear loose, comfortable clothes and cotton underwear
- Gently cleaning and drying the wound daily
- If needed, planning the removal of sutures or clips
D - Health-care professionals caring for women who have had a CS and who have urinary symptoms should consider the possible diagnosis of:
- Urinary tract infection
- Stress incontinence (occurs in about 4% of women after CS)
- Urinary tract injury (occurs in about 1 per 1,000 CS)
D - Health-care 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 - Women who have had a CS are at increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism), so health-care professionals need to pay particular attention to women who have chest symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf).
GPP - Women who have had a CS should resume activities such as driving a vehicle, carrying heavy items, formal exercise, and sexual intercourse once they have fully recovered from the CS (including any physical restrictions or distracting effect due to pain).
D - Health-care professionals caring for women who have had a CS should inform women that after a CS they are not at increased risk of difficulties with breastfeeding, depression, post-traumatic stress symptoms, dyspareunia, and faecal incontinence.
Pregnancy and Childbirth Following CS
GPP - 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 (see Appendix A of the original guideline document)
- Risk of uterine rupture
- Risk of perinatal mortality and morbidity
B - 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 a planned vaginal birth (about 10 per 10,000), but higher than for a planned repeat CS (about 1 per 10,000).
- The effect of planned vaginal birth or planned repeat CS on cerebral palsy is uncertain.
GPP - 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
B - Women who have had a previous CS can be offered induction of labour, but both women and health-care 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 nonprostaglandin agents
- 240 per 10,000 when labour is induced using prostaglandins.
GPP - During induction of labour, women who have had a previous CS should be monitored closely, with access to electronic fetal monitoring and with immediate access to CS, because they are at increased risk of uterine rupture.
B - Pregnant women with both previous CS and a previous vaginal birth should be informed that they have an increased likelihood of a vaginal birth than women who have had a previous CS but no previous vaginal birth.
Definitions:
Levels of Evidence
1a: Evidence obtained from systematic review or meta-analysis of randomised controlled trials
1b: Evidence obtained from at least one randomised controlled trial
2a: Evidence obtained from at least one well-designed controlled study without randomisation
2b: Evidence obtained from at least one well-designed quasi-experimental study, such as a cohort study
3: Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies, case-control studies, and case series
4: Evidence obtained from expert committee reports, or opinions and/or clinical experience of respected authorities
Grading of Recommendations
Grade A Based directly on level 1 evidence
Grade B Based directly on level 2 evidence or extrapolated from level 1 evidence
Grade C Based directly on level 3 evidence or extrapolated from level 1 or level 2 evidence
Grade D Based directly on level 4 evidence or extrapolated from level 1, level 2, or level 3 evidence
Good Practice Points (GPP) The view of the Guideline Development Group
