Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice. They link to details of the evidence and a full description of the committee's discussion.
There was some evidence for a selected number of outcomes on the short- and long-term effects of caesarean birth compared with vaginal birth, although there were some limitations with the quality of the evidence, and not all evidence was from a comparison of planned mode of birth. The committee used this evidence, along with their clinical expertise, to update the advice comparing the relative benefits and risks of these 2 modes of birth.
For some outcomes there was conflicting or limited evidence, and there were also a number of outcomes for which no evidence was identified for inclusion, so the committee highlighted these uncertainties.
As the evidence was limited for this review the committee made a research recommendation.
There were also 3 outcomes included in the 2011 guideline which had not been included in this current review (vaginal tears, length of stay and perineal/abdominal pain) but the committee agreed that the advice was still appropriate and should be carried forward into the updated guideline.
The committee considered that their recommendations would reinforce best practice. It is already current practice to discuss the risks and benefits of alternative modes of birth during the antenatal period and this review has simply led to an update of the information that should be discussed with women.
Full details of the evidence and the committee's discussion are in evidence review A: the benefits and risks of planned caesarean birth.
There was evidence for the effectiveness of active warming measures (for example, forced air warming, under body pads, warmed IV fluids) to prevent shivering and hypothermia in women having a caesarean birth, and there was some evidence for improved thermal comfort and maternal temperature. The committee recommended the use of warmed IV fluids and irrigation fluids for all women having caesarean birth, but because of the low incidence of hypothermia and shivering during caesarean birth, the physiological differences between women having caesarean birth and the general surgical population, the lack of beneficial effect on wound infections, and the fact that warming methods are likely to be as effective at managing hypothermia and shivering as they are at preventing it, the committee recommended that other warming measures should only be used in women who were shivering, said they felt cold or were hypothermic, and not in all women for prevention. The committee recommended forced air warming as the method of choice as this was already widely available, easier to use and could be easily moved with the woman.
There was evidence that pethidine was also effective at reducing shivering, but the committee did not recommend this because of the possible adverse effects on breastfeeding.
The recommendation to use forced air warming will standardise practice across the NHS. There could be resource implications for units to purchase the disposable 'blankets' used, but this could be offset by earlier discharge of women from recovery to the postnatal ward.
The use of warmed intravenous fluids, blood and irrigation fluids is already standard practice, so this recommendation will not change this.
Full details of the evidence and the committee's discussion are in evidence review C: prevention and management of hypothermia and shivering.
There was evidence that alcohol-based chlorhexidine solution skin preparations reduce the risk of surgical site infections, compared with alcohol-based iodine solutions.
There was also evidence that aqueous iodine vaginal preparations reduce the risk of endometritis in women with ruptured membranes. Although there was some evidence on chlorhexidine vaginal preparations, overall the evidence indicated that that iodine vaginal preparations might be more effective.
There was some evidence that negative pressure wound therapy (NPWT) reduces the risk of wound or surgical site infections for women with a BMI of 30 kg/m2 or more but economic evidence indicated that this would not be cost effective in those with a BMI of less than 35 kg/m2 and only borderline cost effective in the group with a BMI of 35 kg/m2 or more.
The evidence showed no difference in wound infection or readmissions into hospital when the dressing was removed either 6 hours or 24 hours after surgery.
There was very limited evidence on the use of 2 different types of dressing, but the committee agreed it was not enough to recommend a specific type.
There was no evidence on the use of incise drapes, diathermy or body hair removal, so the committee did not make recommendations about these, but noted that the NICE guideline on surgical site infections (which covers general surgery rather than caesarean birth) has recommendations on some of these interventions.
The recommendations on skin preparation are broadly in line with current best clinical practice. The committee agreed that the recommendation to use aqueous iodine vaginal preparation will be a change in clinical practice, because the use of vaginal preparation is not routine across England.
The committee identified that considering the use of NPWT for women with a BMI of 35 kg/m2 will be a change of practice for many units (some units do not use it at all, or only at higher BMI thresholds), and could have resource implications, particularly in areas where a higher proportion of pregnant women will meet the criteria.
Full details of the evidence and the committee's discussion are in evidence review B: methods to reduce infectious morbidity at caesarean birth.
There was evidence showing that there was no difference in any outcomes when comparing single and double layer closure of the uterus. There was some evidence of the reduced need for blood transfusions with single layer compared with double layer closure, as part of a comparison of different caesarean birth techniques, but this could have been confounded by other differences in the techniques.
Current practice is to use a double layer uterine closure technique, except in occasional circumstances when there is a specific reason for using single layer closure. This recommendation will allow surgeons to choose single or double layer closure, depending on the individual clinical circumstances at the time of the surgery.
Full details of the evidence and the committee's discussion are in evidence review D: techniques to close the uterus at caesarean birth.
There was no evidence found on the best monitoring schedule for women, but the committee used their knowledge and expertise of current best practice to develop recommendations on the monitoring schedule, including identifying women who would be at higher risk and so would need more intensive monitoring.
The recommendations should lead to a reduction in the frequency and duration of monitoring of most women who have received intrathecal or epidural opioids at the time of caesarean birth, but will mean women need to be assessed for risk factors to determine if they need a more intensive monitoring schedule. However, as only women identified as high risk will need intensive monitoring, it is anticipated that the overall monitoring workload will decrease.
Full details of the evidence and the committee's discussion are in evidence review E: monitoring after intrathecal or epidural opioids for caesarean birth.
The committee developed separate recommendations for women receiving regional or general anaesthesia, based on their knowledge of the likely differences in analgesia requirements. For all women, the committee agreed that any postoperative analgesia should be suitable for use while breastfeeding, but that women should be made aware of any potential adverse effects on their baby.
The committee agreed to retain the previous NICE recommendation to offer diamorphine (delivered intrathecally or by epidural) for women who have regional anaesthesia. Giving spinal or epidural diamorphine in this way reduces the need for additional opioids and other rescue medications during surgery, and it remains effective for up to 12 hours (when pain is likely to be most severe).
The committee agreed that women receiving regional anaesthesia should be offered oral morphine sulfate, as the evidence showed it to be effective.
The evidence on pain relief for women after general anaesthesia was sparse, but the committee agreed that intravenous patient-controlled analgesia (PCA) using morphine should be offered as these women will likely have a higher level of pain. If PCA morphine is not acceptable to the woman, then oral morphine should be considered as a less invasive alternative.
From their knowledge and experience, the committee agreed that paracetamol and a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen should be offered in combination to all women to limit the amount of opioids needed, and to allow opioids to be stopped. Based on the evidence on the benefits of fixed interval pain management timing, the committee recommended these be prescribed to be taken regularly to maintain good pain control, in preference to on-request administration, which had lower rates of satisfaction reported by the women.
Some women will have contraindications to NSAIDs (for example, inflammatory bowel disease, gastric ulcer or pre-eclampsia), and will not get sufficient pain relief from paracetamol alone. Based on their experience, the committee suggested an alternative of dihydocodeine in addition to paracetamol, or co-dydramol, as these are also suitable for use while breastfeeding.
There was evidence for the effectiveness of oxycodone, and some evidence for tramadol, but the committee were aware both of these drugs can cause neonatal sedation and respiratory depression if used when breastfeeding. However, in women with severe pain the committee agreed that a short course of tramadol or oxycodone could be considered as long as the woman was informed of the risks and chose to use them. The length of the course was not defined as there was no evidence for a specific period or dosage.
The committee were aware that there were general recommendations in the BNF on the use of opioids in breastfeeding women and so included these as part of their recommendations. The committee were also aware of an MHRA warning on the risk of serious neonatal respiratory depression and sedation with codeine in some women. Because of this, they recommended that codeine, or medications that include codeine (such as co‑codamol) should not be used, and that women should be advised not to use codeine‑containing medicines while breastfeeding.
Based on their knowledge and experience, the committee recommended that anti-emetics could be prescribed if needed for nausea and vomiting, and that laxatives should be considered for the prevention of constipation.
The committee agreed that these recommendations would reinforce current practice. However, there may be a reduction in the use of intravenous PCA opioids for pain management after caesarean birth, and an increase in the use of oral morphine. The committee agreed that the recommendations relating to dihydrocodeine and codeine‑containing medicines would provide greater clarity and increase safety.
Full details of the evidence and the committee's discussion are in evidence review F: opioids for pain relief after caesarean birth.