NICE publishes updated guidelines on caesarean section

  • New recommendations mean more women may avoid unnecessary surgery
  • Major change in practice will reduce post-operative infections
  • Mental health issues, as well as physical conditions, are recognised as possible indications for caesarean section

NICE has today published an update to its existing guidelines on caesarean section (CS).

NICE's original clinical guideline on caesarean section was published in April 2004. Since then, much new evidence has been published and there have been changes in clinical practice. These factors were felt to warrant a review and update of the guideline.

The updated guideline contains several new and updated recommendations on various aspects of the procedure, but recent media speculation has been wrong to suggest that NICE is saying that all pregnant women should be offered the option of an elective CS.

Dr Gillian Leng, NICE Deputy Chief Executive, said: “This guideline is not about offering free caesareans for all on the NHS; it is about ensuring that women give birth in the way that is most appropriate for them and their babies. For a very small number of women, their anxiety about childbirth will lead them to ask for a CS. The new recommendations in this guideline mean that these fears will be taken seriously and women will be offered mental health support if they need it. If the woman's anxiety is not allayed by this support, then she should be offered a planned CS. For women who ask for a CS in the absence of any clinical indication, physical or mental, the guideline says they should be asked why they are requesting the operation, and be provided with full information about the risks and benefits. They should also be offered the opportunity to discuss the procedure with other members of the obstetric team. If, after this, they still want to have a CS, they should be allowed to have one. Offering these women a planned CS in these circumstances is a very long way from saying that CS should automatically be offered to every woman.”

Malcolm Griffiths, consultant obstetrician and gynaecologist at Luton and Dunstable hospital, who chaired the guideline development group, said: ”Caesarean section is major surgery which most pregnant women want to avoid if they can. We want women who do not need to have a CS to be able to avoid such surgery. This will now include women who are HIV positive, as long as they are receiving treatment which is controlling their viral load sufficiently. The guideline also dispels the myth that ‘once a caesarean, always a caesarean' because the evidence shows that for women who have had up to and including four previous CS, the risk of fever, bladder injuries and surgical injuries is the same with a planned CS as it is with a planned vaginal delivery, and the risk of the uterus rupturing is rare.

“A major change in practice recommended in the new guideline is that women should be offered prophylactic antibiotics to reduce the risk of possible post-operative infections before the skin incision is made, rather than after the umbilical cord is cut. With any other surgery where prophylactic antibiotics are indicated, we give them before the operation. Around one in ten women who have CS suffer infections after surgery, and this new recommendation will result in a lower rate of infections, without any increase in risk to the baby.”

When NICE consulted on whether or not the guideline should be updated, many stakeholders said that they particularly welcomed the tables outlining the relative risks and benefits of caesarean section versus vaginal birth. This information has therefore been updated and included in the new guideline, so that health professionals can help women make an informed decision.

Nina Khazaezadeh, consultant midwife at St Thomas' Hospital and guideline developer, said: “The importance of good communication between pregnant women, their families and their health professionals is a key aspect of the new guideline. In particular, it highlights the importance of providing accurate information about the relative risks and benefits of CS and vaginal birth. This guideline also recognises that provision of information alone is not sufficient and therefore recommends that women with a fear of childbirth should be given an opportunity to discuss and explore their reasons for such a request and should be offered support from professionals with expertise in perinatal mental health, ensuring that appropriate care is provided based on their needs and concerns.

“In my clinical practice I often come across women who request a planned CS due to perceived lack of control, fears of inadequate care provision and lack of support during labour and delivery. But, after a discussion of all the pros and cons of both types of birth, and having been assured one to one midwifery support and an individualised birth plan, they will choose to try for a vaginal birth. CS does mean a longer recovery time and a longer stay in hospital, at a time when women are keen to get their new baby home and start or resume family life.”

Christine Johnson, mother with experience of CS and guideline developer, said: “I had planned a water birth at home, and the last thing I wanted was a caesarean section. But after three failed inductions in hospital I ended up having an emergency CS because there was clearly something wrong with my baby. Thankfully, after a week in the neonatal intensive care unit, my son was well enough to go home with no long-term health problems. But during that week in hospital, I received no information about how my operation would impact on any future births. Instead, I picked up from health professionals and other women that, as I'd had a CS, I would have to have one next time. This misinformation was ongoing as many people reinforced the ‘once a CS, always a CS' myth and I had no medical advice to counter this.

“Over four years later, when I was pregnant with my second child, my midwife told me I did not need a CS and that I should plan for a vaginal delivery. The trauma of my first birth re-emerged and I was in floods of tears and unable to talk about my birth plan in a calm way. It took three appointments with midwives for them to realise I needed help and refer me for counselling. This updated guideline will mean that women in hospital following their first CS will get clear information, both verbally and printed, about birth options for any future pregnancies, and it will also mean that women traumatised by a previous birth experience will be offered mental health support earlier so that they can plan the birth that is right for them and enjoy their pregnancy. In my case, I had a planned CS second time around which was a very positive experience that I greatly appreciate having.”

Dr Anthony Falconer, President of the Royal College of Obstetricians and Gynaecologists said: “We must remember that caesarean sections are clinically indicated to improve safety and outcome for mothers and babies in well defined situations. Recent advances in medical science have made the procedure much safer and for most women the complications of this operation are low. The NICE clinical guidelines ensure that the highest standards of care for women and their babies are maintained for those undergoing caesarean section.

“The decision to perform a caesarean section should be based on sound clinical indications and doctors are duty-bound to ensure that women are aware of the risks and benefits of the operation. These new guidelines provide women and their families with good information on what to expect should they have a caesarean section and the implications of such action on future birth options.”

Cathy Warwick, Chief Executive of the Royal College of Midwives, said: "The RCM is pleased to see the recommendation that women who have anxiety about birth 'be referred to a health professional with expertise in providing perinatal mental health support'. We know that when such individualised support is offered, for example in consultant midwives' clinics, these anxieties can be allayed for many women, and they can go on to have a normal vaginal birth.

"Midwives need to be able to give time to women to really discuss what they want, and then be able to fully support and advise women towards this. One-to-one care in labour from a midwife a woman ideally knows and certainly trusts is particularly important. The RCM believes that if midwives are able to help women to understand what their choices mean for them and their baby and feel they will be supported in labour then very few women will want an elective CS. They will be making decisions from a fully informed position and from a position of trust in maternity services, not one based simply on hearsay.”

Maureen Treadwell, co-founder of the Birth Trauma Association said: “We are delighted that this updated guideline recognises the terrible impact that fear of childbirth can have on women and their families. We hear accounts from women whose fear of vaginal birth has driven them to abort a much-wanted baby because their health professionals could not guarantee them a planned CS. The outcomes for women who have been traumatised by a previous birth experience, or who have a serious fear of childbirth will be hugely improved by this guideline.”

Belinda Phipps, Chief Executive of NCT, the UK's largest charity for parents, said: “It is vital that the health services recognise that women and their partners want to be and feel safe during their birth. However, they also want their birth to be a positive experience, one that is fulfilling and starts them off as parents in a way that gives them confidence and good memories to look back on.

“It is unacceptable for women to be offered a caesarean section in ignorance of the risks. It is also unacceptable for women who have a phobia of labour or birth or have had a previous poorly supported birth to have their experience ignored and their request refused when they have considered the options and are making an informed decision. We are glad, therefore, that this new guideline emphasises the need for good communication between women and health professionals, and does not suggest that caesarean section should be offered as an option to all women.”


Notes to Editors

About the guidance

1. Further information about the recommendations on Caesarean Section will be available on the NICE website from Wednesday 23 November.

2. For an embargoed copy of the guideline, please contact the press office.

About NICE

1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

2. NICE produces guidance in three areas of health:

  • public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
  • health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
  • clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

3. NICE produces standards for patient care:

  • quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
  • Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

4. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.

This page was last updated: 22 November 2011