Caesarean section

Short Text

This pathway covers caesarean section and has been developed to help ensure consistent quality care for women who are planning, or need, a caesarean section.

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)
Intraoperative blood cell salvage in obstetrics. NICE interventional procedure guidance 144 (2005)

Quality standards

Quality statements

Vaginal birth after a caesarean section

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Pregnant women who have had 1 or more previous caesarean section have a documented discussion of the option to plan a vaginal birth.

Rationale

Clinically there is little or no difference in the risk associated with a planned caesarean section and a planned vaginal birth in women who have had up to 4 previous caesarean sections. If a woman chooses to plan a vaginal birth after she has previously given birth by caesarean section, she should be fully supported in her choice.

Quality measure

Structure
Evidence of local arrangements to ensure that pregnant women who have had 1 or more previous caesarean section have a documented discussion of the option to plan a vaginal birth.
Process
The proportion of pregnant women who have had 1 or more previous caesarean section who have a documented discussion of the option to plan a vaginal birth.
Numerator: the number of women in the denominator who have a documented discussion of the option to plan a vaginal birth.
Denominator: the number of pregnant women who have had 1 or more previous caesarean section.
Outcomes
a) Women's satisfaction that they were supported in their choice for planned birthing option.
b) Rates of delivery modes for women who have had previous caesarean sections.

What the quality statement means for each audience

Service providers ensure that systems are in place for pregnant women who have had 1 or more previous caesarean section to have a documented discussion of the option to plan a vaginal birth.
Healthcare professionals ensure that they have a documented discussion with women who have had 1 or more previous caesarean section that they have the option to plan a vaginal birth and support them in their choice.
Commissioners ensure that they commission services that have systems in place for pregnant women who have had 1 or more previous caesarean section to have a documented discussion of the option to plan a vaginal birth.
Pregnant women who have had a caesarean section in the past have a discussion with a member of their maternity team (which is recorded in their notes) about the option to plan a vaginal birth.

Source guidance

NICE clinical guideline 132 recommendations 1.8.1, 1.8.2 (key priority for implementation) and 1.8.5.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcomes
a) Local data collection.
b) The Maternity services secondary uses dataset will collect data on 'the method for delivering baby' (global number 17206160) and on 'pregnancy previous caesarean sections' (global number 17200570), once implemented.

Definitions

Documented discussion
Pregnant women should be informed by members of the maternity team that in women who have had 4 or fewer previous caesarean sections 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. This discussion should be documented in the woman's notes.

Maternal request for a caesarean section: maternity team involvement

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Pregnant women who request a caesarean section (when there is no clinical indication) have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.

Rationale

The purpose of this statement is to inform decisions about the planned mode of birth. It is important that the woman can talk to the most relevant member of the maternity team depending on what her question or concern is about her request for a caesarean section. It is important that access to members of the maternity team is possible at any point during the woman's pregnancy and promptly arranged following a request.

Quality measure

Structure
Evidence of local arrangements to ensure that pregnant women who request a caesarean section (when there is no clinical indication) have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.
Process
The proportion of pregnant women who request a caesarean section (when there is no clinical indication) who have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.
Numerator: the number of women in the denominator who have a documented discussion with at least 1 member of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.
Denominator: the number of pregnant women who request a caesarean section when there is no clinical indication.
Outcome
Women's satisfaction with the process of discussing options with the maternity team.

What the quality statement means for each audience

Service providers ensure that systems are in place for pregnant women who request a caesarean section (when there is no clinical indication) to have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.
Healthcare professionals ensure that pregnant women who request a caesarean section (when there is no clinical indication) have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.
Commissioners ensure that they commission services that have systems in place for all pregnant women who request a caesarean section (when there is no clinical indication) to have a documented discussion with members of the maternity team about the overall risks and benefits of a caesarean section compared with vaginal birth.
Pregnant women who ask for a caesarean section (when there is no medical reason) have a discussion with members of the maternity team (which is recorded in their notes) about the risks and benefits of a caesarean section compared with a vaginal birth.

Source guidance

NICE clinical guideline 132 recommendation 1.2.9.1 and 1.2.9.2.

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE CG132 clinical audit tool, criterion 2.
Outcome
Local data collection.

Definitions

Documented discussion
The discussion should include the reasons for the request and ensure that the woman has accurate information (including written information) about the relative risks and benefits associated with different modes of birth, based on box A in NICE clinical guideline 132. This discussion should be documented in the woman's antenatal notes.
Maternity team
The core membership of the maternity team should include a midwife, an obstetrician and an anaesthetist.

Maternal request for a caesarean section: maternal anxiety

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Pregnant women who request a caesarean section because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in perinatal mental health support.

Rationale

When a woman who is requesting a caesarean section due to anxiety is given the opportunity to discuss this with someone who can answer their questions and understand their concerns in a supportive manner, the anxieties can often be reduced to the point where the woman is able to choose a planned vaginal birth. This discussion is an important part of the decision making process and should happen before a decision on caesarean section is made with the maternity team. A referral can be to a member of the maternity team with interest and experience in this area of antenatal support.

Quality measure

Structure
Evidence of local arrangements to ensure that pregnant women who request a caesarean section because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in perinatal mental health support.
Process
The proportion of pregnant women who request a caesarean section because of anxiety about childbirth who are referred to a healthcare professional with expertise in perinatal mental health support.
Numerator: the number of women in the denominator who are referred to a healthcare professional with expertise in perinatal mental health support.
Denominator: the number of pregnant women who request a caesarean section because of anxiety about childbirth.

Outcome

Women's satisfaction with the support provided for anxiety about childbirth.

What the quality statement means for each audience

Service providers ensure that systems are in place for pregnant women who request a caesarean section because of anxiety about childbirth to be offered a referral to a healthcare professional with expertise in perinatal mental health support.
Healthcare professionals ensure that pregnant women who request a caesarean section because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in perinatal mental health support.
Commissioners ensure that they commission services that offer women who request a caesarean section because of anxiety about childbirth a referral to a healthcare professional with expertise in perinatal mental health support.
Pregnant women who ask for a caesarean section because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in mental health support for women approaching childbirth.

Source guidance

NICE clinical guideline 132 recommendation 1.2.9.3 (key priority for implementation).

Data source

Structure
Local data collection.
Process
Local data collection. Contained within NICE CG132 clinical audit tool, criterion 3.
Outcomes
Local data collection.

Definitions

Healthcare professional with expertise in perinatal mental health support
Someone, usually from the maternity team, who has an interest and expertise in providing support to women with higher than normal anxiety levels, to the extent that they are requesting a caesarean section.
Referral
The referral could be an informal referral within a maternity team or formal referral to another member of staff in a different team.
Anxiety
Anxiety that goes beyond the general anxiety that women have about childbirth. This refers to women whose anxiety is preventing them from wanting to attempt a vaginal birth.

Consultant obstetrician involvement in decision-making for planned caesarean section

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Pregnant women who may require a planned caesarean section have consultant involvement in decision-making.

Rationale

Consultant obstetricians are best placed to advise a woman who may need or want to plan a caesarean section about the potential benefits and risks for each option based on their specific circumstances and needs. The involvement of a consultant is intended to ensure that the best possible outcomes are achieved for the woman and the baby.

Quality measure

Structure
Evidence of local arrangements to ensure that pregnant women who may require a planned caesarean section have consultant involvement in decision-making.
Process
The proportion of pregnant women who may require a planned caesarean section who have consultant involvement in decision-making.
Numerator: the number of women in the denominator who have a consultant involved in decision-making.
Denominator: the number of pregnant women who may require a planned caesarean section.
Outcome
Women's satisfaction with the decision-making process.

What the quality statement means for each audience

Service providers ensure that systems are in place for pregnant women who may require a planned caesarean section to have consultant involvement in decision-making.
Healthcare professionals ensure that pregnant women who may require a planned caesarean section have consultant involvement in decision-making.
Commissioners ensure that they commission services that have systems in place for pregnant women who may require a planned caesarean section to have consultant involvement in decision-making.
Pregnant women who may require a planned caesarean section have a consultant obstetrician involved in making the decision whether this is the best option or not.

Source guidance

NICE clinical guideline 132 recommendation 1.3.2.4.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Pregnant women who may require a planned caesarean section
This includes both women who have clinical indications that would suggest that a planned caesarean section would be the safest way of delivering the baby, and women who request a caesarean section when there are no clinical indications.
Decision-making
The nature of the decision-making process and the extent to which the consultant will need to be involved in the process will vary between each woman and will depend on the complexity of their specific circumstances.

Timing of planned caesarean section

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Pregnant women having a planned caesarean section have the procedure carried out at or after 39 weeks 0 days, unless an earlier delivery is necessary because of maternal or fetal indications.

Rationale

Babies born by planned caesarean section at term but before the due date are at a higher risk of respiratory complications. The level of risk decreases with gestational age, particularly from 39 weeks onwards. Therefore planned caesarean section should not routinely be carried out before 39 weeks.

Quality measure

Structure
Evidence of local arrangements to ensure that pregnant women having a planned caesarean section have the procedure at or after 39 weeks 0 days, unless an earlier delivery is necessary because of maternal or fetal indications.
Process
The proportion of pregnant women having a planned caesarean section and not needing an earlier delivery because of maternal and fetal indications who have the procedure carried out at or after 39 weeks 0 days.
Numerator: the number of women in the denominator who have the caesarean section carried out at or after 39 weeks 0 days.
Denominator: the number of pregnant women having a planned caesarean section who do not need an earlier delivery because of maternal or fetal indications.

What the quality statement means for each audience

Service providers ensure that systems are in place for pregnant women having a planned caesarean section to have the procedure at or after 39 weeks 0 days, unless an earlier delivery is necessary because of maternal or fetal indications.
Healthcare professionals ensure that pregnant women having a planned caesarean section have the procedure at or after 39 weeks 0 days, unless an earlier delivery is necessary because of maternal or fetal indications.
Commissioners ensure that they commission services in which women having a planned caesarean section have the procedure at or after 39 weeks 0 days, unless an earlier delivery is necessary because of maternal or fetal indications.
Women having a planned caesarean section have the procedure at or after 39 weeks of pregnancy, unless an earlier delivery is needed because of problems with the baby or the mother.

Source guidance

NICE clinical guideline 132 recommendation 1.4.1.1.

Data source

Structure
Local data collection.
Process
The Maternity services secondary uses data set will collect data on ‘the method for delivering baby’ (global number 17206160) and on ‘gestational age at birth’ (global number 17206160), once implemented.

Definitions

Planned caesarean section
Planned caesarean section should be agreed between the woman and the maternity team. The woman should be given a specific day and time at which the caesarean section will be performed. A model for delivering planned caesarean section is for services to have dedicated planned caesarean section lists. The lists should have protected surgical and anaesthetic time and appropriate staffing to ensure that planned caesarean section are not delayed because of surgical time being prioritised for emergency cases.
Maternal or fetal indications
Maternal or fetal indications include but are not limited to the following significant conditions: hypertensive disease, diabetes or gestational diabetes, significant antepartum haemorrhage, intrauterine/fetal growth restriction, congenital abnormality, hydrops or compromise resulting from blood group incompatibility, acute fetal compromise, and multiple pregnancy.

Consultant obstetrician involvement in decision-making for unplanned caesarean section

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Women being considered for an unplanned caesarean section have a consultant obstetrician involved in the decision.

Rationale

Involving a consultant obstetrician in urgent decisions about whether an unplanned caesarean section is necessary helps to ensure that all the relevant factors are taken into consideration. This should ensure the best possible outcome for the woman and the baby.

Quality measure

Structure
Evidence of local arrangements to ensure that women being considered for an unplanned caesarean section have a consultant obstetrician involved in the decision.
Process
The proportion of women being considered for an unplanned caesarean section who have a consultant obstetrician involved in the decision.
Numerator: the number of women in the denominator who have a consultant obstetrician involved in the decision.
Denominator: the number of women being considered for an unplanned caesarean section.
Outcome
a) Unplanned caesarean section rates.
b) Women's satisfaction with the decision-making process.

What the quality statement means for each audience

Service providers ensure that systems are in place to ensure women being considered for an unplanned caesarean section have a consultant obstetrician involved in the decision.
Healthcare professionals ensure that women being considered for an unplanned caesarean section have a consultant obstetrician involved in the decision.
Commissioners ensure that they commission services that have systems in place for women being considered for an unplanned caesarean section to have a consultant obstetrician involved in the decision.
Women who, during labour, are being considered for an unplanned caesarean section because of complications have a consultant obstetrician involved in the decision.

Source guidance

NICE clinical guideline 132 recommendation 1.3.2.4.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
a) The Maternity services secondary uses data set will collect data on 'the method for delivering baby' (global number 17206160) once implemented.
b) Local data collection.

Definitions

Unplanned caesarean section
This refers to the categories described in NICE clinical guideline 132 section 1.2.
Consultant obstetrician involvement
This should include direct involvement in the decision either in person or via telephone if consultant cover is through on-call arrangements. Their involvement and the way in which they were involved (that is, by phone or in person) should be documented in the woman's maternity notes.

The use of fetal blood sampling

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Women in labour for whom a caesarean section is being considered for suspected fetal compromise are offered fetal blood sampling to inform decision-making.

Rationale

Fetal blood sampling is recommended if delivery by caesarean section is contemplated because of an abnormal fetal heart rate pattern or in cases of suspected fetal acidosis. Fetal blood sampling helps the maternity team to make a more informed judgement about whether to recommend a caesarean section or to continue with a vaginal delivery.

Quality measure

Structure
a) Evidence of local arrangements to ensure that women in labour for whom a caesarean section is being considered for suspected fetal compromise are offered fetal blood sampling to inform decision-making.
b) Evidence of local arrangements to ensure that maternity units have access to a functioning and serviced fetal blood gas analyser.
Process
a) The proportion of women in labour for whom a caesarean section is being considered for suspected fetal compromise who are offered fetal blood sampling to inform the decision.
Numerator: The number of women in the denominator who are offered fetal blood sampling.
Denominator: The number of women in labour for whom a caesarean section is being considered for suspected fetal compromise without contraindications for fetal blood sampling.
b) The proportion of women in labour in whom a fetal blood sample was attempted and a fetal blood reading was made.
Numerator: the number of women in the denominator in whom the fetal blood sample was successfully obtained and a reading made.
Denominator: the number of pregnant women in whom a fetal blood sample was attempted.
Outcome
Unplanned caesarean section rates.

What the quality statement means for each audience

Service providers ensure that systems are in place for women in labour for whom a caesarean section is being considered for suspected fetal compromise to be offered fetal blood sampling to inform decision-making.
Healthcare professionals ensure that women in labour for whom a caesarean section is being considered for suspected fetal compromise are offered fetal blood sampling to inform decision-making.
Commissioners ensure that they commission services that have systems in place for women in labour for whom a caesarean section is being considered for suspected fetal compromise to be offered fetal blood sampling to inform decision-making.
Women in labour for whom a caesarean section is being considered because of concerns about the baby are offered a blood test from the baby's scalp (called fetal blood sampling) to help decide whether a caesarean section is needed.

Source guidance

NICE clinical guideline 132 recommendation 1.3.2.5.

Data source

Structure
a) and b) Local data collection.
Process
a) and b) Local data collection.
Outcome
Local data collection.

Definitions

Suspected fetal compromise
Abnormal fetal heart rate pattern or suspected fetal acidosis.
Fetal blood sampling
Sampling should be undertaken when it is technically possible to do so and there are no contraindications. The National Sentinel Caesarean Section Audit defines 'technically possible' as cervical dilation of 4 cm or more. If there is clear evidence of acute fetal compromise (for example, prolonged deceleration greater than 3 minutes), fetal blood sampling should not be undertaken and urgent preparations to expedite birth should be made. If fetal blood sampling is not attempted because of contraindications, the contraindications should be documented in the woman's maternity notes.

Post caesarean section discussion

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Women who have had a caesarean section are offered a discussion and are given written information about the reasons for their caesarean section and birth options for future pregnancies.

Rationale

While women are in hospital after having a caesarean section, it is important to discuss the reasons for the caesarean section with them and their partners so that they know what this means for them when planning their family, including birth options for any future pregnancies. Because women and their partners receive a large amount of information during the immediate postnatal period, this information should be provided both verbally and in written formats.

Quality measure

Structure
Evidence of local arrangements to ensure that women who have had a caesarean section are offered a discussion and are given written information about the reasons for their caesarean section and birth options for future pregnancies.
Process
The proportion of women who have had a caesarean section who have had a discussion and were given written information about the reasons for their caesarean section and birth options for future pregnancies.
Numerator: The number of women in the denominator who have had a discussion and were given written information about the reasons for their caesarean section and birth options for future pregnancies.
Denominator: The number of women who have had a caesarean section.
Outcome
Women's satisfaction with post-caesarean section discussion and information.

What the quality statement means for each audience

Service providers ensure that systems are in place for women who have had a caesarean section to be offered a discussion and be given written information about the reasons for their caesarean section and birth options for future pregnancies.
Healthcare professionals ensure that women who have had a caesarean section are offered a discussion and are given written information about the reasons for their caesarean section and birth options for future pregnancies.
Commissioners ensure that they commission services that offer women who have had a caesarean section a discussion and written information about the reasons for their caesarean section and birth options for future pregnancies.
Women who have had a caesarean section are offered a discussion and are given written information about the reasons for their caesarean section and birth options for future pregnancies.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Offered
The offer of a discussion should be made when the woman is still in the postnatal ward, with the option to provide this at a later date, if the woman prefers.
Discussion
An opportunity for women to discuss the reasons for the caesarean section and how successful the procedure was with healthcare professionals and receive verbal and printed information about birth options for future pregnancies. The healthcare professional should be appropriately trained and experienced to provide accurate information. The level of experience needed will depend on the complexity of the case.

Monitoring for postoperative complications following caesarean section

This quality statement is taken from the caesarean section quality standard. The quality standard defines clinical best practice for caesarean section and should be read in full.

Quality statement

Women who have had a caesarean section are monitored for postoperative complications.

Rationale

Postoperative monitoring with regular observations in the immediate post-surgical period by someone with expertise in postoperative care is a key part of managing potential complications associated with surgery, including caesarean section. This needs to happen alongside the core postnatal care all women receive in hospital immediately after giving birth.

Quality measure

Structure
Evidence of local arrangements to ensure that women who have had a caesarean section are monitored for immediate postoperative complications.
Process
The proportion of women who have had a caesarean section who were monitored for immediate postoperative complications.
Numerator: the number of women in the denominator who are monitored for immediate postoperative complications.
Denominator: the number of women who have a caesarean section.
Outcomes
Rates of complications in women who have had a caesarean section.

What the quality statement means for each audience

Services providers ensure that systems are in place for women who have had a caesarean section to be monitored for postoperative complications.
Healthcare professionals ensure that women who have had a caesarean section are monitored for postoperative complications.
Commissioners ensure that they commission services in which women who have had a caesarean section are monitored for postoperative complications.
Women who have had a caesarean section are monitored for complications following the operation.

Source guidance

NICE clinical guideline 132 recommendations 1.6.1.1, 1.6.2.1 to 1.6.2.4, 1.7.1.3 and 1.7.1.6.

Data source

Structure
Local data collection.
Process
Local data collection.
Outcome
Local data collection.

Definitions

Monitoring complications
NICE clinical guideline 132 section 1.6.2 recommends the following in women who have had a caesarean section:
  • After caesarean section by general anaesthetic, 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.
  • After recovery from all forms of 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.
The Centre for Maternal and Child Enquiries provided an example tool called the modified early obstetric warning score (MEOWS) to support monitoring after caesarean section.

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

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.

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
NICE has also written a document for patients and the public explaining its quality standard for caesarean section.

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 the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, 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.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Updates to this pathway

6 February 2014 Minor maintenance updates.
10 June 2013 Caesarean section quality standard added to the 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

Care 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.

Quality standards

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Caesarean section quality standard

Source guidance

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Patient experience in adult NHS services pathway

View the 'Patient experience in adult NHS services overview' path

Paths in this pathway

Pathway created: November 2011 Last updated: February 2014

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