4 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The Guideline Development Group's full set of research recommendations is detailed in the full guideline (see section 5).

4.1 Decision-to-delivery interval (category 1 urgency)

What factors influence the decision-to-delivery interval when there is a category 1 level of urgency for CS?

Factors to be investigated could include:

  • staff grade/level of experience

  • skill mix in the multidisciplinary team

  • task allocation

  • methods of communication

  • time of day

  • availability of ongoing staff training about emergency procedures and levels of attendance.

The research could be conducted using simulation methods and video observation to determine what factors influence the decision-to-delivery interval for category 1 CS. The videos could also be used to train staff.

Why this is important

'Crash' CS is a psychologically traumatic event for women and their partners and is also stressful for clinical staff. Staff and resources may have to be obtained from other areas of clinical care. This should be undertaken as efficiently and effectively as possible, minimising anxiety and ensuring the safety of the mother and her baby.

For category 1 CS there is a recognised urgency to deliver as quickly as is reasonably possible. The majority of research in this area is quantitative and looks at the impact of the decision-to-delivery interval on various aspects of fetal and maternal outcomes rather than the interplay of factors that can affect this time period itself. Much of this evidence is retrospective. Although some work has been conducted in the UK to examine where the systematic delays lie and how to avoid them (Tuffnell et al. 2001), more work is needed to determine how to optimise the decision-to-delivery interval. This work should use qualitative as well as quantitative research methods to assess which factors influence the decision-to-delivery interval for a category 1 CS. Evaluation of these factors could be used to inform future NICE guidance, for example, specific guidance for management of category 1 CS. Such information could also be used by hospitals for maternity services planning, and at a team level would assist with audit and ongoing evaluation and training of the multidisciplinary team.

A large amount of NHS and other state funding is used to provide continuing care for infants who are disabled as a result of birth asphyxia and in providing lifelong support for the child and their family. In addition, large sums of public money are spent on litigation and compensation in some of these cases through the Clinical Negligence Scheme for Trusts (CNST). If research helped to minimise the impact of birth asphyxia this would reduce the costs of continuing care to the state and the burden to the child, their family and the wider community.

More realistic and more relevant expectations for the decision-to-delivery interval based on evidence would inform debate in the legal system and may help to reduce the cost to the state of related litigation.

4.2 Decision-to-delivery interval (category 2 urgency)

A prospective study to determine whether the decision-to-delivery interval has an impact on maternal and neonatal outcomes when there is a category 2 level of urgency for CS.

Important primary outcomes would be:

  • fetal wellbeing (such as cord blood gases, Apgar score at 5 minutes, hypoxic encephalopathy, neonatal respiratory problems, unanticipated admission to neonatal intensive care unit (NICU), duration of stay in the NICU)

  • maternal wellbeing (such as haemoglobin levels on day 2, need for blood transfusion, duration of hospital stay controlled for prolonged neonatal stay and general health/wellbeing).

Valuable secondary outcomes could include:

  • fetal trauma at delivery

  • iatrogenic maternal bladder or bowel injury

  • postoperative maternal infectious morbidity

  • establishment of breastfeeding

  • psychological outcomes for women, such as the development of postnatal depression/post-traumatic stress disorder.

Why this is important

This research is important to inform the ongoing debate about the management of category 2 CS. The 'continuum of risk' in this setting has been recognised. However, the majority of work in this area, looking at maternal and fetal outcomes, generally considers unplanned CS as a whole group without making any distinction between degrees of urgency. Furthermore much of this work is retrospective. The majority of women who undergo intrapartum CS fall into the category 2 level of urgency (Thomas et al. 2001) and therefore specific information for this group could affect and benefit many women and contribute to the delivery of equity of care.

Delay in delivery with a compromised fetus may result in major and long-term harm including cerebral palsy and other major long-term disability. The immediate and long-term effect on a family of the birth of a baby requiring life-long specialised care and support is enormous. If such harm could be avoided by appropriate haste this would be an important improvement in outcome. However, if such haste is of no benefit then any related risk of adverse maternal outcome needs to be minimised.

A large amount of NHS and other state funding is used to provide continuing care for infants who are disabled as a result of delay in delivery and in providing lifelong support for the child and their family. In addition, large sums of public money are spent on litigation and compensation in some of these cases through the Clinical Negligence Scheme for Trusts (CNST). If research helped to minimise the impact of delay in delivery this would reduce the costs of continuing care to the state and the burden to the child, their family and the wider community.

More realistic and more relevant expectations for the decision-to-delivery interval based on evidence would inform debate within the legal system and may help to reduce the cost to the state of related litigation.

4.3 National audit

Repeat of the National Caesarean Section Sentinel Audit.

The original CS guideline included a set of 'auditable standards'. It would be a straightforward task to produce an updated set of auditable standards based on the important topics covered in the updated guideline. These could include:

  • consent

  • indications (including maternal request)

  • procedural aspects

  • maternal and fetal outcomes.

Many of the outcomes documented in a new CS audit would relate directly to recommendations in this CS guideline update. Researchers may also want to consider categorising different reasons underlying maternal request for CS such as previous poor childbirth experience, longstanding fear of childbirth, belief that CS is safer for the baby etc.

An additional useful feature of the audit would be to record key related data, such as the proportion of CS deliveries for a breech presentation that had an attempted external cephalic version.

Why this is important

During the 10 years since the National Caesarean Section Sentinel Audit was undertaken (2000–2001), many of the findings may have changed significantly. The audit examined who was having a CS and why, as well as the views of women having babies and the obstetricians looking after them. The audit found that a 20% CS rate was considered too high by 51% of obstetricians. UK CS rates now average about 25%.

A repeat of the CS Sentinel Audit would reveal any changes in indications and the views of women and obstetricians. The current literature does not adequately address the issue of maternal request for CS and this is one aspect the audit may address. Women's views on maternal request for CS when there are no obstetric indications are particularly relevant. Such requests may be on the rise and the reasons are not always clearly expressed or documented.

The methodology of the audit is established, making a repeat feasible. This should be given high priority because the benefit to the NHS would be significant.

4.4 Maternal request for CS

What support or psychological interventions would be appropriate for women who have a fear of vaginal childbirth and request a CS?

Interventions for evaluation could include:

  • support from a named member of the maternity team

  • continuity of carer

  • formal counselling

  • cognitive behavioural therapy.

Outcomes could include:

  • mode of birth planned at term

  • psychological outcomes (postnatal depression, post-traumatic stress disorder, self-esteem, mother–infant bonding)

  • breastfeeding.

Why this is important

Fear of vaginal childbirth may stem from:

  • fear of damage to the maternal pelvic floor

  • damage to the baby during childbirth

  • self-doubt on the ability to physically achieve vaginal birth

  • previous childbirth experience

  • unresolved issues related to the genital area.

Currently there is a wide variation in practice and limited resources lead to limited availability of effective interventions. Interventions that may be appropriate include:

  • antenatal clinics dedicated to providing care for women with no obstetric indications who request a CS

  • referral to a psychologist or a mental health professional

  • referral to an obstetric anaesthetist

  • intensive midwifery support.

Continuity of healthcare professional support from the antenatal to the intrapartum periods and 'one to one' midwifery care during labour are also often lacking and may make a difference to women who are anxious or afraid.

All of these interventions have different resource implications and there is no clear evidence to suggest that any are of benefit. The proposed research would compare in a randomised controlled trial two or more of these interventions in women requesting a CS. In the absence of any evidence, there is a case for comparing these interventions with routine antenatal care (that is, no special intervention).

This research is relevant because it would help to guide the optimal use of these limited resources and future guideline recommendations.

4.5 Risks and benefits of CS

What are the medium- to long-term risks and benefits to women and their babies of planned CS compared with planned vaginal birth?

The main focus would be the outcomes in women, which could be measured at 1 year (medium term) and 5–10 years (long term). These outcomes could include:

  • urinary dysfunction

  • gastrointestinal dysfunction

  • dyspareunia

  • breastfeeding

  • psychological health.

Infant outcomes could include medical problems, especially ongoing respiratory and neurological problems.

Why this is important

Morbidities arising intraoperatively or in the days after a CS have been reasonably well described in the literature. Much less is known, however, about physical and emotional outcome measures in the longer term.

The Confidential Enquiries into Maternal Deaths in the UK, most recently published as 'Saving mothers' lives 2006–2008' (Cantwell R et al. 2011), devote a significant proportion of their work to investigating 'late' causes of maternal death. These include events arising in the medium term, namely, up to 1 year after a woman has given birth, many of which originate from the preceding pregnancy. The infectious, psychiatric and other conditions arising in or related to pregnancy do not always cause death but are responsible for arguably a greater burden of morbidity in the medium and long term, long after the pregnancy is over.

To provide more meaningful information to women when they are choosing their mode of birth, there is a pressing need to document medium- to long-term outcomes in women and their babies after a planned CS or a planned vaginal birth. First, it should be possible to gather data using standardised questions (traditional paper-based questionnaires and face-to-face interviews) about maternal septic morbidities and emotional wellbeing up to 1 year after a planned CS in a population of women who have consented for follow-up. Internet-based questionnaires could also be devised to achieve the high response rates required for a full interpretation of the data. Similarly, it would be important to collect high-quality data on infant morbidities after a planned CS compared with a planned vaginal birth. A long-term morbidity evaluation (between 5 and 10 years after the CS) would use similar methodology but assess symptoms related to urinary and gastrointestinal function.

  • National Institute for Health and Care Excellence (NICE)