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

Effective interventions library

Successful effective interventions library details

Implementation

Assessment tools

The baseline and self-assessment tools are Excel spreadsheets that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Caesarean section: baseline assessment

Costing support

Costing support includes national cost impact reports that summarise the national costs and savings and discuss the assumptions used; costing templates to assess the impact on local budgets; and costing statements when the impact is not significant or impossible to quantify at a national level.
Caesarean section: costing template
Caesarean section: costing report

Learning resources

Learning resources are designed to support people to run workshops and for individual learning. They include clinical case scenarios, presentations for trainers and tests for participants.
Caesarean section: clinical case scenarios

Podcasts

Interviews that focus on practical actions to overcome specific implementation challenges. They are recorded by NICE with experts in the area, who were usually involved in guidance development.
Caesarean section: podcast

Slide sets

Slide sets provide a framework for discussion and assist in local dissemination of the guidance. The slides contain the key messages from NICE guidance and can be tailored for local presentations.
Caesarean section: slide set

Pathway information

Information for patients and the public

NICE produces booklets for patients and the public, called 'Understanding NICE guidance'. They summarise, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written a booklet for patients and the public explaining its guidance on each of the following topics.
Caesarean section
Intraoperative blood cell salvage in obstetrics

Woman-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution – all NICE guidance is written to reflect these. Treatment and care should take into account women's needs and preferences. Pregnant women should be offered evidence-based information and support to enable them to make informed decisions about their care and treatment. If women do not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should follow advice on consent from the Welsh Government. If the woman is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.

Supporting information

Glossary

Immediate threat to the life of the woman or fetus
Maternal or fetal compromise which is not immediately life-threatening

Pregnant woman

Pregnant woman
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 a booklet for patients and 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

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CG132

Planning the mode of birth

View the 'Planning the mode of birth' path

Performing caesarean section

View the 'Performing caesarean section' path

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 care:
  • 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 a booklet for patients and 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

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Caesarean section: electronic audit tool
Caesarean section: baseline assessment
Caesarean section: clinical case scenarios
Caesarean section: costing template
Caesarean section: costing report
Caesarean section: podcast
Caesarean section: slide set

Source guidance

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CG132

Paths in this pathway

Pathway created: November 2011 Last updated: November 2011

Copyright © 2012 National Institute for Health and Clinical Excellence. All Rights Reserved.

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