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Caesarean birth

About

What is covered

This NICE Pathway covers when to offer caesarean birth, procedural aspects of the operation and care after caesarean birth. It aims to improve the consistency and quality of care for women who:
  • have had a caesarean birth in the past and are now pregnant again or
  • have a clinical indication for a caesarean birth or
  • are considering a caesarean birth when there is no other indication.

Updates

Updates to this NICE Pathway

15 July 2021 Removed reference to Joel-Cohen transverse incision from carrying out surgery to clarify what should be done in the meantime. See the exceptional surveillance review on surgical opening technique for more information.
31 March 2021 Updated and renamed on publication of caesarean birth (NICE guideline NG192).
3 February 2021 Leukomed Sorbact for preventing surgical site infection (NICE medical technologies guidance 55) added to carrying out surgery.
3 September 2019 The recommendations on planned caesarean birth in multiple pregnancy were replaced by a link to recommendations on mode of birth in the NICE Pathway on twin and triplet pregnancy.
19 August 2019 The recommendation on patient-controlled analgesia after caesarean section was withdrawn because of safety concerns and changes in practice in the UK.
10 April 2019 A recommendation on wound closure methods when carrying out surgery was withdrawn and replaced by a link to wound management in theatre in the NICE Pathway on prevention and control of healthcare-associated infections, which has newer advice on the topic.
30 September 2016 Restructured and summarised recommendations replaced by full recommendations.
24 March 2015 Insertion of a balloon device to disimpact an engaged fetal head before an emergency caesarean section (NICE interventional procedures guidance 515) added to carrying out surgery.
10 June 2013 Caesarean section (NICE quality standard 32) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on caesarean birth in an interactive flowchart

What is covered

This NICE Pathway covers when to offer caesarean birth, procedural aspects of the operation and care after caesarean birth. It aims to improve the consistency and quality of care for women who:
  • have had a caesarean birth in the past and are now pregnant again or
  • have a clinical indication for a caesarean birth or
  • are considering a caesarean birth when there is no other indication.

Updates

Updates to this NICE Pathway

15 July 2021 Removed reference to Joel-Cohen transverse incision from carrying out surgery to clarify what should be done in the meantime. See the exceptional surveillance review on surgical opening technique for more information.
31 March 2021 Updated and renamed on publication of caesarean birth (NICE guideline NG192).
3 February 2021 Leukomed Sorbact for preventing surgical site infection (NICE medical technologies guidance 55) added to carrying out surgery.
3 September 2019 The recommendations on planned caesarean birth in multiple pregnancy were replaced by a link to recommendations on mode of birth in the NICE Pathway on twin and triplet pregnancy.
19 August 2019 The recommendation on patient-controlled analgesia after caesarean section was withdrawn because of safety concerns and changes in practice in the UK.
10 April 2019 A recommendation on wound closure methods when carrying out surgery was withdrawn and replaced by a link to wound management in theatre in the NICE Pathway on prevention and control of healthcare-associated infections, which has newer advice on the topic.
30 September 2016 Restructured and summarised recommendations replaced by full recommendations.
24 March 2015 Insertion of a balloon device to disimpact an engaged fetal head before an emergency caesarean section (NICE interventional procedures guidance 515) added to carrying out surgery.
10 June 2013 Caesarean section (NICE quality standard 32) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Caesarean birth (2021) NICE guideline NG192
Intraoperative blood cell salvage in obstetrics (2005) NICE interventional procedures guidance 144
Leukomed Sorbact for preventing surgical site infection (2021) NICE medical technologies guidance 55
Caesarean birth (2013, updated 2021) NICE quality standard 32

Quality standards

Quality statements

Vaginal birth after a caesarean birth

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

Quality statement

Pregnant women who have had 1 or more previous caesarean births 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 birth and a planned vaginal birth in women who have had up to 4 previous caesarean births. 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 measures

Structure
Evidence of local arrangements to ensure that pregnant women who have had 1 or more previous caesarean births have a documented discussion of the option to plan a vaginal birth.
Data source: Local data collection.
Process
The proportion of pregnant women who have had 1 or more previous caesarean births 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 births.
Data source: Local data collection.
Outcome
a) Women’s satisfaction that they were supported in their choice for planned birthing option.
Data source: Local data collection.
b) Rates of delivery modes for women who have had previous caesarean births.
Data source: The NHS Digital Maternity services secondary uses dataset collects data on delivery method and previous caesarean sections.

What the quality statement means for different audiences

Service providers ensure that systems are in place for pregnant women who have had 1 or more previous caesarean births 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 births that they have the option to plan a vaginal birth and support them in their choice.
Commissioners ensure that ensure that they commission services that have systems in place for pregnant women who have had 1 or more previous caesarean births to have a documented discussion of the option to plan a vaginal birth.
Pregnant women who have had a caesarean birth 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

Caesarean birth. NICE guideline NG192 (2021), recommendations 1.8.1, 1.8.2 and 1.8.5

Definitions of terms used in this quality statement

Documented discussion
Pregnant women should be informed by members of the maternity team that in women who have had 4 or fewer previous caesarean births the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth but that the risk of uterine rupture is higher for planned vaginal birth. This discussion should be documented in the woman’s notes. [NICE’s guideline on caesarean birth, recommendation 1.8.2]

Equality and diversity considerations

Good communication between healthcare professionals and pregnant women is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Women should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England’s Accessible Information Standard or the equivalent standards for the devolved nations.

Maternal request for a caesarean birth: maternity team involvement

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

Quality statement

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

Structure
Evidence of local arrangements to ensure that pregnant women who request a caesarean birth (when there is no medical indication) have a documented discussion with members of the maternity team about the overall benefits and risks of a caesarean birth compared with vaginal birth.
Data source: Local data collection.
Process
The proportion of pregnant women who request a caesarean birth (when there is no medical indication) who have a documented discussion with members of the maternity team about the overall benefits and risks of a caesarean birth 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 benefits and risks of a caesarean birth compared with vaginal birth.
Denominator – the number of pregnant women who request a caesarean birth when there is no medical indication.
Data source: Local data collection.
Outcome
Women’s satisfaction with the process of discussing options with the maternity team.
Data source: Local data collection.

What the quality statement means for different audiences

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

Source guidance

Caesarean birth. NICE guideline NG192 (2021), recommendations 1.2.25, 1.2.26 and 1.2.27

Definitions of terms used in this quality statement

Documented discussion
The discussion should include the reasons for the request and ensure that the woman has accurate information (including written information) about the overall benefits and risks associated with different modes of birth, based on the section on planning mode of birth in NICE’s guideline on caesarean birth. This discussion should be documented in the woman’s antenatal notes. [Adapted from NICE’s guideline on caesarean birth, recommendations 1.2.25 to 1.2.27]
Maternity team
The core membership of the maternity team should include a senior midwife, an obstetrician and an anaesthetist. [Adapted from NICE’s guideline on caesarean birth, recommendation 1.2.27]

Equality and diversity considerations

Good communication between healthcare professionals and women who request a caesarean birth is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Women who request a caesarean birth should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England’s Accessible Information Standard or the equivalent standards for the devolved nations.

Maternal request for a caesarean birth: maternal anxiety

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

Quality statement

Pregnant women who request a caesarean birth 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 birth 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 birth 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 measures

Structure
Evidence of local arrangements to ensure that pregnant women who request a caesarean birth because of anxiety about childbirth are offered a referral to a healthcare professional with expertise in perinatal mental health support.
Data source: Local data collection.
Process
The proportion of pregnant women who request a caesarean birth 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 birth because of anxiety about childbirth.
Data source: Local data collection.
Outcome
Women’s satisfaction with the support provided for anxiety about childbirth.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for pregnant women who request a caesarean birth 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 birth 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 birth 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 birth 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

Caesarean birth. NICE guideline NG192 (2021), recommendation 1.2.28

Definitions of terms used in this quality statement

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 birth. [Expert opinion]
Referral
The referral could be an informal referral within a maternity team or formal referral to another member of staff in a different team. [Expert opinion]
Anxiety
Tokophobia or other severe anxiety about childbirth (for example, following abuse or a previous traumatic event). [NICE’s guideline on caesarean birth, recommendation 1.2.28]

Equality and diversity considerations

Good communication between healthcare professionals and women who request a caesarean birth is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Women who request a caesarean birth should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England’s Accessible Information Standard or the equivalent standards for the devolved nations.

Consultant obstetrician involvement in decision making for planned caesarean birth

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

Quality statement

Pregnant women who may require a planned caesarean birth 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 birth 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 measures

Structure
Evidence of local arrangements to ensure that pregnant women who may require a planned caesarean birth have consultant involvement in decision making.
Data source: Local data collection.
Process
The proportion of pregnant women who may require a planned caesarean birth 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 birth.
Data source: Local data collection.
Outcome
Women’s satisfaction with the decision-making process.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers ensure that systems are in place for pregnant women who may require a planned caesarean birth to have consultant involvement in decision making.
Healthcare professionals ensure that pregnant women who may require a planned caesarean birth 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 birth to have consultant involvement in decision making.
Pregnant women who may need a planned caesarean birth have a consultant obstetrician involved in making the decision.

Source guidance

Caesarean birth. NICE guideline NG192 (2021), recommendation 1.3.3

Definitions of terms used in this quality statement

Pregnant women who may require a planned caesarean birth
This includes both women who have medical indications that would suggest that a planned caesarean birth would be the safest way of delivering the baby, and women who request a caesarean birth when there are no medical indications. [Adapted from NICE’s guideline on caesarean birth, section 1.2 and expert opinion]
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. [Expert opinion]

Equality and diversity considerations

Good communication between healthcare professionals and women who may need a caesarean birth is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Women who may need a caesarean birth should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England’s Accessible Information Standard or the equivalent standards for the devolved nations.

Timing of planned caesarean birth

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

Quality statement

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

Rationale

Babies born by planned caesarean birth 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 birth should not routinely be carried out before 39 weeks.

Quality measures

Structure
Evidence of local arrangements to ensure that pregnant women having a planned caesarean birth have the procedure at or after 39 weeks, unless an earlier delivery is necessary because of maternal or fetal indications.
Data source: Local data collection.
Process
The proportion of pregnant women having a planned caesarean birth and not needing an earlier delivery because of maternal and fetal indications who have the procedure carried out at or after 39 weeks.
Numerator – the number of women in the denominator who have the caesarean birth carried out at or after 39 weeks.
Denominator – the number of pregnant women having a planned caesarean birth who do not need an earlier delivery because of maternal or fetal indications.
Data source: The NHS Digital Maternity services secondary uses data set collects data on delivery method and gestational length at birth.

What the quality statement means for different audiences

Service providers ensure that systems are in place for pregnant women having a planned caesarean birth to have the procedure at or after 39 weeks, unless an earlier delivery is necessary because of maternal or fetal indications.
Healthcare professionals ensure that pregnant women having a planned caesarean birth have the procedure at or after 39 weeks, 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 birth have the procedure at or after 39 weeks, unless an earlier delivery is necessary because of maternal or fetal indications.
Women having a planned caesarean birth 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

Caesarean birth. NICE guideline NG192 (2021), recommendation 1.4.1

Definitions of terms used in this quality statement

Planned caesarean birth
A planned caesarean birth that is scheduled before the onset of labour. Planned caesarean birth 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 birth is for services to have dedicated planned caesarean birth lists. The lists should have protected surgical and anaesthetic time and appropriate staffing to ensure that planned caesarean births are not delayed because of surgical time being prioritised for emergency cases. [NICE’s 2011 full guideline on caesarean section, glossary and expert opinion]
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. [Expert opinion]

Consultant obstetrician involvement in decision making for unplanned caesarean birth

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

Quality statement

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

Rationale

Involving a consultant obstetrician in urgent decisions about whether an unplanned caesarean birth 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 measures

Structure
Evidence of local arrangements to ensure that women being considered for an unplanned caesarean birth have a consultant obstetrician involved in the decision.
Data source: Local data collection.
Process
The proportion of women being considered for an unplanned caesarean birth 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 birth.
Data source: Local data collection.
Outcomes
a) Unplanned caesarean birth rates.
Data source: The NHS Digital Maternity services secondary uses data set collects data on delivery method.
b) Women’s satisfaction with the decision-making process.
Data source: Local data collection.

What the quality statement means for different audiences

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

Source guidance

Caesarean birth. NICE guideline NG192 (2021), recommendation 1.3.3

Definitions of terms used in this quality statement

Unplanned caesarean birth
This refers to the classification of urgency for caesarean birth described in NICE’s guideline on caesarean birth, recommendation 1.4.2.
  • Category 1. Immediate threat to the life of the woman or fetus.
  • Category 2. Maternal or fetal compromise which is not immediately life-threatening.
  • Category 3. No maternal or fetal compromise but needs early birth.
  • Category 4. Birth timed to suit women or healthcare provider.
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. [Expert opinion]

Equality and diversity considerations

Good communication between healthcare professionals and women who may need a caesarean birth is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Women who may need a caesarean birth should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England’s Accessible Information Standard or the equivalent standards for the devolved nations.

The use of fetal blood sampling

This statement has been removed. For more details, see update information in the NICE quality standard.

Post caesarean birth discussion

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

Quality statement

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

Rationale

While women are in hospital after having an emergency or unplanned caesarean birth, it is important to discuss the reasons for the caesarean birth 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 measures

Structure
Evidence of local arrangements to ensure that women who have had an emergency or unplanned caesarean birth are offered a discussion and are given written information about the reasons for their caesarean birth and birth options for future pregnancies.
Data source: Local data collection.
Process
The proportion of women who have had an emergency or unplanned caesarean birth who have had a discussion and were given written information about the reasons for their caesarean birth 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 birth and birth options for future pregnancies.
Denominator – The number of women who have had an emergency or unplanned caesarean birth.
Data source: Local data collection.
Outcome
Women’s satisfaction with post-caesarean birth discussion and information.
Data source: Local data collection.

What the quality statement means for different audiences

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

Source guidance

Caesarean birth. NICE guideline NG192 (2021), recommendation 1.7.10

Definitions of terms used in this quality statement

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. [Adapted from NICE’s guideline on caesarean birth, recommendation 1.7.10]
Discussion
An opportunity for women to discuss the reasons for the caesarean birth 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. [Adapted from NICE’s guideline on caesarean birth, recommendation 1.7.10 and expert opinion]

Equality and diversity considerations

Good communication between healthcare professionals and women who have had an emergency or unplanned caesarean birth is essential. Treatment and care, and the information given about it, should be culturally appropriate. It should also be accessible to women with additional needs such as physical, sensory or learning disabilities, and to women who do not speak or read English. Women who have had a caesarean birth should have access to an interpreter or advocate if needed. For women with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in NHS England’s Accessible Information Standard or the equivalent standards for the devolved nations.

Monitoring for postoperative complications following caesarean birth

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

Quality statement

Women who have had a caesarean birth 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 birth. This needs to happen alongside the core postnatal care all women receive in hospital immediately after giving birth.

Quality measures

Structure
Evidence of local arrangements to ensure that women who have had a caesarean birth are monitored for immediate postoperative complications.
Data source: Local data collection.
Process
The proportion of women who have had a caesarean birth 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 birth.
Data source: Local data collection.
Outcome
Rates of complications in women who have had a caesarean birth.
Data source: Local data collection.

What the quality statement means for different audiences

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

Source guidance

Caesarean birth. NICE guideline NG192 (2021), recommendations 1.6.1 to 1.6.8, 1.7.4 and 1.7.7

Definitions of terms used in this quality statement

Monitoring complications
MMBRACE-UK’s report Saving lives, improving mothers care (2020) states that NHS England and NHS Improvement are rapidly developing a chart for an early warning score for pregnant and postpartum women, and a clear response pathway. The report provides an example tool called the modified early obstetric warning score (MEOWS) to support monitoring.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Appendix A – Likeliness of outcomes for caesarean and vaginal birth

Outcomes for women and babies that are likely to be similar for caesarean or vaginal birth

Outcomes for women:
  • thromboembolic disease
  • major obstetric haemorrhage
  • postnatal depression
  • faecal incontinence (occurring more than 1 year after birth; compared to unassisted vaginal birth).
Outcomes for babies/children:
  • admission to neonatal unit
  • infectious morbidity
  • persistent verbal delay
  • infant mortality (up to 1 year)
More details on the differences in risk, how they were estimated and uncertainty in the evidence including confidence intervals are provided in appendix M of evidence review A.

Outcomes for women and babies that have conflicting or limited evidence about the risk with caesarean or vaginal birth

Outcomes for women:
  • ITU admission
  • stillbirth in a subsequent pregnancy.
Outcomes for babies/children:
  • respiratory morbidity
  • cerebral palsy
  • autism spectrum condition
  • type 1 diabetes.
More details on the differences in risk, how they were estimated and uncertainty in the evidence including confidence intervals are provided in appendix M of evidence review A.

Outcomes for women and babies that may be more likely with caesarean birth

Outcomes
Estimated risk with vaginal birth
Risk difference
For women:
Peripartum hysterectomy
About 80 women per 100,000 would be expected to have this outcome
About 70 more women per 100,000 who had caesarean birth would be expected to have this outcome; so the method of birth would have made no difference to the chance of the outcome for about 99,930 women per 100,000.
Maternal death
About 4 women per 100,000 would be expected to have this outcome
About 20 more women per 100,000 who had caesarean birth would be expected to have this outcome; so the method of birth would have made no difference to the chance of the outcome for about 99,980 women per 100,000.
Longer hospital stay
About 2 and a half days on average
About 1 to 2 days longer on average.
For babies/children:
Neonatal mortality
About 60 babies per 100,000 would be expected to have this outcome
About 80 more babies per 100,000 whose mothers had caesarean birth would be expected to have this outcome; so the method of birth would have made no difference to the chance of the outcome for about 99,920 babies per 100,000.
Asthma
About 1,500 per 100,000 children would be expected to have this outcome
About 310 more children per 100,000 whose mothers had caesarean birth would be expected to have this outcome; so the method of birth would have made no difference to the chance of the outcome for about 99,690 babies or children per 100,000.
Childhood obesity
About 4,050 per 100,000 children would be expected to have this outcome
About 510 more children per 100,000 whose mothers had caesarean birth would be expected to have this outcome; so the method of birth made would have made no difference to the chance of the outcome for more than 99,490 children per 100,000.
More details on the differences in risk, how they were estimated and uncertainty in the evidence including confidence intervals are provided in appendix M of evidence review A.

Outcomes for women that may be less likely with caesarean birth

Outcomes
Estimated risk with vaginal birth
Risk difference
Urinary incontinence occurring more than 1 year after birth
About 48,700 per 100,000 women would be expected to have this outcome
About 21,180 fewer women per 100,000 who had caesarean birth would be expected to have this outcome, so the method of birth would have made no difference to the chance of the outcome for about 78,820 women per 100,000.
Faecal incontinence occurring more than 1 year after birth; compared to assisted vaginal birth
About 15,100 per 100,000 women would be expected to have this outcome after assisted vaginal birth
About 7,690 fewer women per 100,000 who had caesarean birth would be expected to have this outcome; so the method of birth would have made no difference to the chance of the outcome for about 92,310 women per 100,000.
Vaginal tear: third- and fourth-degree tears
About 560 per 100,000 women would be expected to have this outcome
About 560 fewer women per 100,000 who had caesarean birth would be expected to have this outcome; so the method of birth would have made no difference to the chance of the outcome for about 99,440 women per 100,000.
Perineal/abdominal pain during birth and 3 days after birth
Median pain scores of 7.3 (during birth) and 5.2 (3 days after birth) (scored out of 10)
Reduction in pain scores of 6.3 during birth and 0.7 3 days after birth (scored out of 10)
More details on the differences in risk, how they were estimated and uncertainty in the evidence including confidence intervals are provided in appendix M of evidence review A.
When advising about the mode of birth after a previous caesarean birth, consider:
  • maternal preferences and priorities
  • the risks and benefits of repeat caesarean birth
  • the risks and benefits of planned vaginal birth after caesarean birth, including the risk of unplanned caesarean birth.
Inform women who have had up to and including 4 caesarean births that 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.
Pregnant women with both previous caesarean birth and a previous vaginal birth should be informed that they have an increased likelihood of achieving having a vaginal birth than women who have had a previous caesarean birth but no previous vaginal birth.

Women planning a vaginal birth after previous caesarean birth

Offer women planning a vaginal birth who have had a previous caesarean birth:
  • electronic fetal monitoring during labour
  • care during labour in a unit where there is immediate access to caesarean birth and on-site blood transfusion services.
During induction of labour, women who have had a previous caesarean birth should be monitored closely, with access to electronic fetal monitoring and with immediate access to caesarean birth, as they are at increased risk of uterine rupture. For further information see the NICE Pathways on induction of labour.
Be aware that, although it is rare for women to need intensive care after childbirth, this may occur after caesarean birth.
Inform women that length of hospital stay is likely to be longer after caesarean birth than after a vaginal birth.

Glossary

body mass index
(immediate threat to the life of the woman or fetus)
(maternal or fetal compromise which is not immediately life-threatening)

Paths in this pathway

Pathway created: November 2011 Last updated: September 2021

© NICE 2021. All rights reserved. Subject to Notice of rights.

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