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Caesarean section
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Introduction
This pathway covers caesarean section and has been developed to help ensure consistent quality care for women who:
- have had a caesarean section in the past and are now pregnant again or
- have a clinical indication for a caesarean section or
- are considering a caesarean section when there is no other indication.
It provides evidence-based information for healthcare professionals and women about:
- the risks and benefits of planned caesarean section compared with planned vaginal birth
- specific indications for caesarean section
- effective management strategies to avoid caesarean section
- anaesthetic and surgical aspects of care
- interventions to reduce morbidity from caesarean section
- organisational and environmental factors that affect caesarean section rates.
The pathway has not sought to define acceptable caesarean section rates. Rather the purpose of this pathway is to enable healthcare professionals to give appropriate research-based advice to women and their families. This will enable women to make properly informed decisions.
The recommendations in this pathway update and replace NICE clinical guideline 13 (published in April 2004).
Source guidance
The NICE guidance that was used to create the pathway.
Caesarean section. NICE clinical guideline 132 (2011)
Quality standards
Quality statements
Effective interventions library
Successful effective interventions library details
Implementation
Commissioning
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These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
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NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.
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These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
Pathway information
Information for the public
NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on:
Caesarean section
.. (1) http://publications.nice.org.uk/caesarean-section-ifp132 ‘View information for the public for CG132 at NICE website’.
Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If someone does not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent, the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children. If a young person is moving between paediatric and adult services their care should be planned and managed according to the best practice guidance described in the Department of Health's Transition: getting it right for young people.
Updates to this pathway
1 February 2013 Minor maintenance updates
16 January 2012 Minor maintenance updates
2 November 2012 The following recommendations have been removed from the node titled 'Information for women to support decision-making' in this pathway. The topic 'place of birth' will be addressed by the update of the intrapartum care guideline, which is currently in development. In the meantime, see NICE's current recommendations on place of birth in the antenatal care pathway.
During their discussions about options for birth, inform healthy pregnant women with anticipated uncomplicated pregnancies that planning a home birth reduces the likelihood of caesarean section.
During their discussions about options for birth, inform healthy pregnant women with anticipated uncomplicated pregnancies that planned childbirth in a 'midwifery-led unit' does not reduce the likelihood of caesarean section.
2 November 2012 A cross-reference has been added to the prevention and control of healthcare-associated infections pathway from the node 'Care after caesarean section'.
Supporting information
Glossary
Immediate threat to the life of the woman or fetus
Maternal or fetal compromise which is not immediately life-threatening
Information and consent
Information and consent
Information and consent
Information
Offer pregnant women evidence-based information and support to enable them to make informed decisions about childbirth. Recognise that addressing women's views and concerns is integral to the decision-making process.
Give pregnant women evidence-based information about caesarean section during the antenatal period, because about one in four women will have a caesarean section. Include information such as:
- indications (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 caesarean section.
Provide communication and information 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.
Inform women 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.
Inform women that having isotonic drinks during labour prevents ketosis without a concomitant increase in gastric volume.
NICE has written information for the public explaining the guidance on caesarean section.
Consent
Request consent after providing evidence-based information and in a manner that respects the woman's dignity, privacy, views and culture, while taking into consideration the clinical situation.
A pregnant woman is entitled to decline the offer of treatment such as caesarean section, 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.
When a decision is made to perform a caesarean section, make a record of all the factors that influence the decision, and which of these is the most influential.
Source guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePerforming caesarean section
View the 'Performing caesarean section' pathCare after caesarean section
Care after caesarean section
Care after caesarean section
Care of the baby
An appropriately trained practitioner skilled in the resuscitation of the newborn should be present at caesarean section performed under general anaesthesia or where there is evidence of fetal compromise.
Babies born by caesarean section are more likely to have a lower temperature. Offer thermal care in accordance with good practice for thermal care of the newborn baby.
Encourage and facilitate early skin-to-skin contact between the woman and her baby because it improves maternal perceptions of the infant, mothering skills, maternal behaviour, and breastfeeding outcomes, and reduces infant crying.
NICE has produced a pathway on postnatal care.
Care of the woman
Offer women 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 caesarean section 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.
Allow women who are recovering well after caesarean section and who do not have complications to eat and drink when they feel hungry or thirsty.
Remove the urinary bladder catheter once a woman is mobile after a regional anaesthetic and not sooner than 12 hours after the last epidural 'top up' dose.
Do not offer routine respiratory physiotherapy to women after a caesarean section under general anaesthesia, because it does not improve respiratory outcomes such as coughing, phlegm, body temperature, chest palpation and auscultatory changes.
In addition to general postnatal care, provide women with:
- specific care related to recovery after caesarean section
- care related to management of other complications during pregnancy or childbirth.
Include the following wound careFor more recent recommendations on wound care see the prevention and control of healthcare-associated infections pathway.:
- removing the dressing 24 hours after the caesarean section
- 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.
For women who have urinary symptoms, consider the possible diagnosis of:
- urinary tract infection
- stress incontinence (occurs in about 4% of women after caesarean section)
- urinary tract injury (occurs in about 1 per 1000 caesarean sections).
For women who have heavy and/or irregular vaginal bleeding, consider that this is more likely to be due to endometritis than retained products of conception.
Pay particular attention to women who have chest symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf) because women who have had a caesarean section are at increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism).
Inform women that after a caesarean section they are not at increased risk of difficulties with breastfeeding, depression, post-traumatic stress symptoms, dyspareunia and faecal incontinence.
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 this at a later date.
NICE has written information for the public explaining the guidance on caesarean section.
Length of hospital stay is likely to be longer after a caesarean section (an average of 3–4 days) than after a vaginal birth (average 1–2 days). Offer women who are recovering well, are apyrexial and do not have complications, early discharge (after 24 hours) from hospital and follow-up at home, because this is not associated with more infant or maternal readmissions.
Women who have had a caesarean section should resume activities such as driving a vehicle, carrying heavy items, formal exercise and sexual intercourse once they have fully recovered from the caesarean section (including any physical restrictions or distracting effect due to pain).
NICE has produced a pathway on postnatal care.
Implementation tools
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/implementation-node-multipleSource guidance
Failed to load fragment (default behaviour with no loader supplied): staticcontentfragments/source-guidance-nodePaths in this pathway
- Planning the mode of birth
- Advice on offering caesararean section in specific situations
- Performing caesarean section
Pathway created: November 2011 Last updated: February 2013
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