Research recommendation(s) from an individual piece of guidance
Research recommendations coming out of this guidance
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 Caesarean Section (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.
Women should be informed that the effects on the likelihood of Caesarean Section (CS) of complementary therapies used during labour (such as acupuncture, aromatherapy, hypnosis, herbal products, nutritional supplements, homeopathic medicines, and Chinese medicines) have not been properly evaluated and further research is needed before such interventions can be recommended. 
The effectiveness and safety of single layer closure of the uterine incision is uncertain. Except within a research context, the uterine incision should be sutured with two layers. 
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 Caesarean Section (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/posttraumatic stress disorder.
National audit:- Repeat of the National Caesarean Section Sentinel Audit. The original Caesarean Section (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:
• 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.
Maternal request for Casarean Section (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)
Risks and benefits of Caesarean Section (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
• psychological health.
Infant outcomes could include medical problems, especially ongoing respiratory and neurological problems.
In otherwise uncomplicated twin pregnancies at term where the presentation of the first twin is cephalic, perinatal morbidity and mortality is increased for the second twin. However, the effect of planned Caesarean Section (CS) in improving outcome for the second twin remains uncertain and therefore CS should not routinely be offered outside a research context. 
Preterm birth is associated with higher neonatal morbidity and mortality. However, the effect of planned Caesarean Section (CS) in improving these outcomes remains uncertain and therefore CS should not routinely be offered outside a research context. 
The risk of neonatal morbidity and mortality is higher with 'small for gestational age' babies. However, the effect of planned Caesarean Section (CS) in improving these outcomes remains uncertain and therefore CS should not routinely be offered outside a research context. 
Pregnant women with a recurrence of herpes simplex virus (HSV) at birth should be informed that there is uncertainty about the effect of planned Caesarean Section (CS) in reducing the risk of neonatal HSV infection. Therefore, CS should not routinely be offered outside a research context.