Key priorities for implementation

Key priorities for implementation

The following recommendations have been identified as priorities for implementation.

Morbidly adherent placenta

  • If a colour-flow Doppler ultrasound scan result suggests morbidly adherent placenta:

    • discuss with the woman the improved accuracy of magnetic resonance imaging (MRI) in addition to ultrasound to help diagnose morbidly adherent placenta and clarify the degree of invasion

    • explain what to expect during an MRI procedure

    • inform the woman that current experience suggests that MRI is safe, but that there is a lack of evidence about any long-term risks to the baby

    • offer MRI if acceptable to the woman. [new 2011]

Mother-to-child transmission of HIV

  • Do not offer a caesarean section (CS) on the grounds of HIV status to prevent mother-to-child transmission of HIV to:

    • women on highly active anti-retroviral therapy (HAART) with a viral load of less than 400 copies per ml or

    • women on any anti-retroviral therapy with a viral load of less than 50 copies per ml.

      Inform women that in these circumstances the risk of HIV transmission is the same for a CS and a vaginal birth. [new 2011]

Maternal request for CS

  • When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner. [new 2011]

  • For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS. [new 2011]

  • An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS. [new 2011]

Decision-to-delivery interval for unplanned CS

  • Use the following decision-to-delivery intervals to measure the overall performance of an obstetric unit:

    • 30 minutes for category 1 CS[1]

    • both 30 and 75 minutes for category 2 CS.

      Use these as audit standards only and not to judge multidisciplinary team performance for any individual CS. [new 2011]

Timing of antibiotic administration

  • Offer women prophylactic antibiotics at CS before skin incision. Inform them that this reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision, and that no effect on the baby has been demonstrated. [new 2011]

  • Offer women prophylactic antibiotics at CS to reduce the risk of postoperative infections. Choose antibiotics effective against endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a CS. [new 2011]

  • Do not use co-amoxiclav when giving antibiotics before skin incision. [new 2011]

Recovery following CS

  • While women are in hospital after having a CS, give them the opportunity to discuss with healthcare professionals the reasons for the CS and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date. [new 2011]

Pregnancy and childbirth after CS

  • Inform women who have had up to and including four CS 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. [new 2011]

[1] Category 1 CS is when there is immediate threat to the life of the woman or fetus, and category 2 CS is when there is maternal or fetal compromise which is not immediately life threatening.

  • National Institute for Health and Care Excellence (NICE)