Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in Making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

1.1 Planning mode of birth

Provision of information

1.1.1 Offer all pregnant women information and support to enable them to make informed decisions about childbirth. Make sure that:

  • the information is evidence based

  • any information provided is accessible, ideally with a choice of formats to suit different women's needs

  • the language used in any information (written or oral) is respectful and suitable for the woman, taking into account any personal, cultural or religious factors that could form part of the woman's choices

  • the women's preferences and concerns are central to the decision-making process. [2004, amended 2021]

1.1.2 Discuss mode of birth with all pregnant women early in their pregnancy. Cover information such as:

  • around 25% to 30% of women have a caesarean birth

  • factors that mean women may need a caesarean birth (for example, increased maternal age and BMI)

  • common indications for emergency caesarean birth include slow progression of labour or concern about fetal condition

  • planned place of birth may affect the mode of birth (see choosing planned place of birth in the NICE guideline on intrapartum care)

  • what the caesarean birth procedure involves

  • how a caesarean birth may impact on the postnatal period (for example, need for pain relief)

  • implications for future pregnancies and birth after caesarean birth or vaginal birth (for example, after a caesarean birth the chances of caesarean birth in a future pregnancy may be increased). [2011, amended 2021]

Benefits and risks of caesarean and vaginal birth

1.1.3 Discuss the benefits and risks of both caesarean and vaginal birth with women, taking into account their circumstances, concerns, priorities and plans for future pregnancies. [2021]

1.1.4 Using the information in appendix A, explain to women that:

  • there are benefits and risks associated with both vaginal and caesarean birth, some of which are very small absolute risks and some are greater absolute risks, and they will need to decide which risks are more (or less) acceptable to them

  • there are other risks not included in these tables that might be relevant to their individual circumstances (for example placental adherence problems from multiple caesarean births, fetal lacerations in caesarean birth, term birth injuries with vaginal birth or caesarean birth)

  • these tables give summary estimates only and are intended to help discussions, but precise numerical risk estimates cannot be given for individual women. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on benefits and risks of caesarean and vaginal birth.

Full details of the evidence and the committee's discussion are in evidence review A: the benefits and risks of planned caesarean birth.

1.2 Planned caesarean birth

Breech presentation

1.2.1 Discuss with women the benefits and risks of planned vaginal birth versus planned caesarean birth for breech presentation, and the option of external cephalic version. [2004, amended 2021]

1.2.2 Offer women who have an uncomplicated singleton breech pregnancy after 36+0 weeks, external cephalic version, unless:

  • the woman is in established labour

  • there is fetal compromise

  • the woman has ruptured membranes or vaginal bleeding

  • the woman has any other medical conditions (for example, severe hypertension) that would make external cephalic version inadvisable. [2004, amended 2021]

1.2.3 Before carrying out a caesarean birth for an uncomplicated singleton breech pregnancy, carry out an ultrasound scan to check that the baby is in the breech position. Do this as late as possible before the caesarean birth procedure. [2021]

Multiple pregnancy

1.2.4 For recommendations on mode of birth in multiple pregnancy, see mode of birth in the NICE guideline on twin and triplet pregnancy. [2021]

Preterm birth

1.2.5 For recommendations on mode of birth in preterm labour and birth, see mode of birth in the NICE guideline on preterm labour and birth. [2021]

Placenta praevia

1.2.6 Offer caesarean birth to women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia). [2004, amended 2011]

Morbidly adherent placenta

1.2.7 For women who have had a previous caesarean birth, offer colour-flow Doppler ultrasound at 32 to 34 weeks as the first diagnostic test for morbidly adherent placenta if low-lying placenta is confirmed. [2011, amended 2021]

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

  • discuss with the woman how MRI in addition to ultrasound can help diagnose morbidly adherent placenta and clarify the degree of invasion, particularly with a posterior placenta

  • 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 this is acceptable to the woman. [2011, amended 2021]

1.2.9 Discuss birth options (for example, timing of birth, operative interventions including possibility of hysterectomy, need for blood transfusion) with a woman suspected to have morbidly adherent placenta. This discussion should be carried out by a consultant obstetrician, or with a consultant obstetrician present. [2011, amended 2021]

1.2.10 When performing a caesarean birth for a woman suspected to have a morbidly adherent placenta, ensure that:

  • a consultant obstetrician and a consultant anaesthetist are present in the operating theatre

  • a paediatric registrar, consultant, or equivalent, is present

  • a haematology registrar, consultant, or equivalent, is available for advice

  • a critical care bed is available

  • sufficient cross-matched blood and blood products are readily available. [2011, amended 2021]

1.2.11 Before performing a caesarean birth for women suspected to have morbidly adherent placenta, the multidisciplinary team should agree which other healthcare professionals need to be consulted or present, and the responsibilities of each team member. [2011, amended 2021]

1.2.12 All hospitals should have a locally agreed protocol for managing morbidly adherent placenta that sets out how these elements of care should be provided. [2011]

Predicting caesarean birth for cephalopelvic disproportion in labour

1.2.13 Do not use pelvimetry for decision making about mode of birth. [2004, amended 2021]

1.2.14 Do not use the following for decision making about mode of birth, as they do not accurately predict cephalopelvic disproportion:

  • maternal shoe size

  • maternal height

  • estimations of fetal size (ultrasound or clinical examination). [2004, amended 2021]

Mother-to-child transmission of maternal infections

HIV

1.2.15 Provide women with HIV information about the benefits and risks for them and their baby of the HIV treatment options and mode of birth as early as possible in their pregnancy, so that they can make an informed decision. Obtain specialist advice about HIV in pregnancy from a sexual health specialist if necessary. [2011, amended 2021]

Hepatitis B virus

1.2.16 Do not offer pregnant women with hepatitis B a planned caesarean birth for this reason alone, as mother-to-baby transmission of hepatitis B can be reduced if the baby receives immunoglobulin and vaccination. [2004, amended 2021]

Hepatitis C virus

1.2.17 Do not offer women who are infected with hepatitis C a planned caesarean birth for this reason alone. [2004, amended 2021]

1.2.18 Offer pregnant women who are co-infected with hepatitis C virus and HIV a planned caesarean birth to reduce mother-to-baby transmission of hepatitis C virus and HIV. [2004, amended 2021]

Herpes simplex virus

1.2.19 Offer women with primary genital herpes simplex virus (HSV) infection occurring in the third trimester of pregnancy a planned caesarean birth to decrease the risk of neonatal HSV infection. [2004]

1.2.20 Do not routinely offer pregnant women with recurrent HSV infection a planned caesarean birth outside of the context of research. [2004, amended 2021]

Body mass index

1.2.21 Do not use a body mass index (BMI) of over 50 kg/m2 alone as an indication for planned caesarean birth. [2011]

Shared decision making

1.2.22 Ask for consent for caesarean birth only after providing pregnant women with evidence-based information. Ensure the woman's dignity, privacy, views and culture are respected, while taking the woman's clinical situation into account. [2004, amended 2021]

1.2.23 Advise women that they are entitled to decline the offer of treatment such as caesarean birth, even when it would benefit their or their baby's health. [2004, amended 2021]

1.2.24 When a woman decides on or declines a caesarean birth, document the factors that that are important to the woman when making her decision. [2004, amended 2021]

Maternal request for caesarean birth

1.2.25 When a woman with no medical indication for a caesarean birth requests a caesarean birth, explore, discuss and record the specific reasons for the request. [2011, amended 2021]

1.2.26 If a woman requests a caesarean birth, discuss the overall benefits and risks of caesarean birth compared with vaginal birth (see the section on planning mode of birth) and record that this discussion has taken place. [2011]

1.2.27 If a woman requests a caesarean birth, offer discussions with the woman, a senior midwife and/or obstetrician and other members of the team if necessary, for example an anaesthetist, to explore the reasons for the request, and ensure the woman has accurate information. [2011, amended 2021]

1.2.28 If a woman requests a caesarean birth because she has tokophobia or other severe anxiety about childbirth (for example, following abuse or a previous traumatic event), offer referral to a healthcare professional with expertise in providing perinatal mental health support to help with her anxiety. See the NICE guideline on antenatal and postnatal mental health for more detailed advice on providing mental health services for pregnant women. [2011, amended 2021]

1.2.29 Ensure healthcare professionals providing perinatal mental health support to women requesting a caesarean birth have access to the planned place of birth during the antenatal period in order to provide care. [2011, amended 2021]

1.2.30 If a vaginal birth is still not an acceptable option after discussion of the benefits and risks and offer of support (including perinatal mental health support if appropriate; see recommendation 1.2.28), offer a planned caesarean birth for women requesting a caesarean birth. [2011, amended 2021]

1.2.31 If a woman requests a caesarean birth but her current healthcare team are unwilling to offer this, refer the woman to an obstetrician willing to perform a caesarean birth. [2011, amended 2021]

1.3 Factors affecting the likelihood of emergency caesarean birth during intrapartum care

Factors reducing the likelihood of caesarean birth

1.3.1 Inform women that continuous support during labour from women, with or without prior training, reduces the likelihood of caesarean birth. [2004]

1.3.2 Use a partogram with a 4‑hour action line to monitor progress of women in spontaneous labour with an uncomplicated singleton pregnancy at term to reduce the likelihood of caesarean birth. [2004]

1.3.3 Involve a consultant obstetrician in decision-making for caesarean birth. [2004, amended 2021]

No influence on the likelihood of caesarean birth

1.3.4 Inform women that the following interventions during intrapartum care have not been shown to influence the likelihood of caesarean birth, although they can affect other outcomes:

  • walking in labour

  • non-supine position during the second stage of labour

  • immersion in water during labour

  • epidural analgesia during labour

  • the use of raspberry leaves. [2004, amended 2021]

1.3.5 Inform women that the effects on the likelihood of caesarean birth of complementary therapies used during labour (such as acupuncture, aromatherapy, hypnosis, herbal products, nutritional supplements, homeopathic medicines, and Chinese medicines) are uncertain. [2004, amended 2021]

Slow progression in labour and caesarean birth

1.3.6 Do not offer the following as they do not influence the likelihood of caesarean birth for slow progression in labour, although they can affect other outcomes:

  • active management of labour (comprising a strict definition of established labour, early routine amniotomy, routine 2‑hourly vaginal examination, oxytocin if labour becomes slow)

  • early amniotomy. [2004, amended 2021]

Eating during labour

1.3.7 Inform women that eating a low-residue diet during labour (toast, crackers, low-fat cheese) results in larger gastric volumes, but the effect on the risk of aspiration if anaesthesia is needed is uncertain. [2004]

1.3.8 Inform women that having isotonic drinks during labour prevents ketosis without a concomitant increase in gastric volume. [2004]

1.4 Procedural aspects of caesarean birth

Timing of planned caesarean birth

1.4.1 Do not routinely carry out planned caesarean birth before 39 weeks, as this can increase the risk of respiratory morbidity in babies. [2004]

Classification of urgency for caesarean birth

1.4.2 Use the following standardised scheme to document the urgency of caesarean birth and aid clear communication between healthcare professionals:

  • Category 1. Immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia).

  • Category 2. Maternal or fetal compromise which is not immediately life-threatening.

  • Category 3. No maternal or fetal compromise but needs early birth.

  • Category 4. Birth timed to suit woman or healthcare provider. [2004, amended 2021]

Decision-to-birth interval for unplanned and emergency caesarean birth

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

1.4.3 Perform category 1 caesarean birth as soon as possible, and in most situations within 30 minutes of making the decision. [2011, amended 2021]

1.4.4 Perform category 2 caesarean birth as soon as possible, and in most situations within 75 minutes of making the decision. [2011, amended 2021]

1.4.5 Take into account the condition of the woman and the unborn baby when making decisions about rapid birth. Be aware that rapid birth can be harmful in certain circumstances. [2011]

Preoperative testing and preparation for caesarean birth

1.4.6 Before caesarean birth, carry out a full blood count to identify anaemia, antibody screening, and blood grouping with saving of serum. [2004, amended 2021]

1.4.7 Do not routinely carry out the following tests before caesarean birth:

  • cross-matching of blood

  • a clotting screen

  • preoperative ultrasound for localisation of the placenta. [2004, amended 2021]

1.4.8 Carry out caesarean birth for pregnant women with antepartum haemorrhage, abruption or placenta praevia at a maternity unit with on-site blood transfusion services, as they are at increased risk of blood loss of more than 1,000 ml. [2004, amended 2021]

1.4.9 Give women having caesarean birth with regional anaesthesia an indwelling urinary catheter to prevent over-distension of the bladder. [2004, amended 2021]

Anaesthesia for caesarean birth

1.4.10 Provide pregnant women having a caesarean birth with information on the different types of post‑caesarean birth analgesia, so that they can make an informed choice (see recommendation 1.6.9). [2004]

1.4.11 Offer women who are having a caesarean birth regional anaesthesia in preference to general anaesthesia, including women who have a diagnosis of placenta praevia. [2004, amended 2021]

1.4.12 Carry out induction of anaesthesia, including regional anaesthesia, for caesarean birth in theatre. [2004, amended 2021]

1.4.13 Apply a left lateral tilt of up to 15 degrees or appropriate uterine displacement once the woman is in a supine position on the operating table to reduce maternal hypotension. [2004, amended 2021]

1.4.14 Offer women who are having a caesarean birth under spinal anaesthesia a prophylactic intravenous infusion of phenylephrine, started immediately after the spinal injection. Adjust the rate of infusion to keep maternal blood pressure at 90% or more of baseline value and avoid decreases to less than 80% of baseline. [2004, amended 2021]

1.4.15 When using phenylephrine infusion, give intravenous ephedrine boluses to manage hypotension during caesarean birth, for example if the heart rate is low and blood pressure is less than 90% of baseline. [2004, amended 2021]

1.4.16 Use intravenous crystalloid co-loading in addition to vasopressors to reduce the risk of hypotension occurring during caesarean birth. [2004, amended 2021]

1.4.17 Ensure each maternity unit has a set of procedures for failed intubation during obstetric anaesthesia. [2004]

1.4.18 Offer women antacids and drugs (such as H2‑receptor antagonists or proton pump inhibitors) to reduce gastric volumes and acidity before caesarean birth.

In March 2021, this was an off-label use of proton pump inhibitors. See NICE's information on prescribing medicines. [2004, amended 2021]

1.4.19 Offer women having a caesarean birth anti-emetics (either pharmacological or acupressure) to reduce nausea and vomiting during caesarean birth. [2004]

1.4.20 Include pre-oxygenation, cricoid pressure and rapid sequence induction in general anaesthesia for caesarean birth to reduce the risk of aspiration. [2004, amended 2011]

Prevention and management of hypothermia and shivering

1.4.21 Warm IV fluids (500 ml or more) and blood products used during caesarean birth to 37 degrees Celsius using a fluid warming device. [2021]

1.4.22 Warm all irrigation fluids used during caesarean birth to 38 to 40 degrees Celsius in a thermostatically controlled cabinet. [2021]

1.4.23 Consider forced air warming for women who shiver, feel cold, or have a temperature of less than 36 degrees Celsius during caesarean birth. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on prevention and management of hypothermia and shivering.

Full details of the evidence and the committee's discussion are in evidence review C: prevention and management of hypothermia and shivering.

Surgical techniques for caesarean birth

Methods to reduce infectious morbidity

1.4.24 Use alcohol-based chlorhexidine skin preparation before caesarean birth to reduce the risk of wound infections. If alcohol-based chlorhexidine skin preparation is not available, alcohol-based iodine skin preparation can be used. See the NICE guideline on surgical site infections. [2021]

1.4.25 Use aqueous iodine vaginal preparation before caesarean birth in women with ruptured membranes to reduce the risk of endometritis. If aqueous iodine vaginal preparation is not available or is contraindicated, aqueous chlorhexidine vaginal preparation can be used. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on methods to reduce infectious morbidity and wound care after caesarean birth.

Full details of the evidence and the committee's discussion are in evidence review B: methods to reduce infectious morbidity at caesarean birth.

Methods to prevent HIV transmission in theatre

1.4.26 Wear double gloves when performing or assisting a caesarean birth for women who have tested positive for HIV, to reduce the risk of HIV infection of staff. [2004]

1.4.27 Follow general recommendations for safe surgical practice during caesarean birth to reduce the risk of HIV infection of staff. [2004]

Abdominal wall incision

1.4.28 Perform caesarean birth using a transverse abdominal incision to:

  • make postoperative pain less likely

  • give an improved cosmetic effect compared with a midline incision. [2004]

1.4.29 Perform caesarean birth using a transverse incision (a straight skin incision, 3 cm above the symphysis pubis; subsequent tissue layers are opened bluntly and, if necessary, extended with scissors and not a knife). This allows for shorter operating times and reduces postoperative febrile morbidity. [2004]

Instruments for skin incision

1.4.30 Do not use separate surgical knives to incise the skin and the deeper tissues in caesarean birth, as it does not decrease wound infection. [2004]

Extension of the uterine incision

1.4.31 When there is a well formed lower uterine segment, use blunt rather than sharp extension of the uterine incision to reduce blood loss, incidences of postpartum haemorrhage and the need for transfusion during caesarean birth. [2004]

Fetal laceration

1.4.32 Inform women who are having a caesarean birth that the risk of fetal lacerations is about 2%. [2004]

Use of forceps

1.4.33 Only use forceps in caesarean birth if there is difficulty delivering the baby's head. The effect on neonatal morbidity of the routine use of forceps at caesarean birth remains uncertain. [2004]

Use of uterotonics

1.4.34 Use oxytocin 5 IU by slow intravenous injection in caesarean birth to encourage contraction of the uterus and decrease blood loss. [2004]

Method of placental removal

1.4.35 Remove the placenta in caesarean birth using controlled cord traction and not manual removal to reduce the risk of endometritis. [2004]

Exteriorisation of the uterus

1.4.36 Perform intraperitoneal repair of the uterus for caesarean birth. Routine exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection. [2004, amended 2021]

Closure of the uterus

1.4.37 Use single layer or double layer uterine closure in caesarean birth, depending on the clinical circumstances. Note that single layer closure does not increase the risk of postoperative bleeding or uterine rupture in a subsequent pregnancy. [2021]

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on closure of the uterus.

Full details of the evidence and the committee's discussion are in evidence review D: techniques to close the uterus at caesarean birth.

Closure of the peritoneum

1.4.38 Do not suture the visceral or the parietal peritoneum in caesarean birth to reduce operating time and the need for postoperative analgesia, and improve maternal satisfaction. [2004]

Closure of the abdominal wall

1.4.39 If a midline abdominal incision is used in caesarean birth, use mass closure with slowly absorbable continuous sutures as this results in fewer incisional hernias and less dehiscence than layered closure. [2004]

Closure of subcutaneous tissue

1.4.40 Do not routinely close the subcutaneous tissue space in caesarean birth unless the woman has more than 2 cm subcutaneous fat, as it does not reduce the incidence of wound infection. [2004]

Use of superficial wound drains

1.4.41 Do not routinely use superficial wound drains in caesarean birth as they do not decrease the incidence of wound infection or wound haematoma. See recommendation 1.7.2 on the use of negative pressure wound therapy. [2004, amended 2021]

Closure of the skin

1.4.42 Consider using sutures rather than staples to close the skin after caesarean birth to reduce the risk of superficial wound dehiscence. See closure methods in the NICE guideline on surgical site infections. [2019]

Umbilical artery pH measurement

1.4.43 Perform paired umbilical artery and vein measurements of cord blood gases after caesarean birth for suspected fetal compromise, to allow for assessment of fetal wellbeing and guide ongoing care of the baby. [2004, amended 2021]

Timing of antibiotic administration

1.4.44 Offer women prophylactic antibiotics before skin incision for caesarean birth, choosing antibiotics that are effective against endometritis, urinary tract and wound infections. [2011, amended 2021]

1.4.45 Inform women that:

  • endometritis, urinary tract and wound infections occur in about 8% of women who have had a caesarean birth

  • using prophylactic antibiotics before skin incision reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision, and that there is no known effect on the baby. [2011, amended 2021]

1.4.46 Do not use co-amoxiclav when giving prophylactic antibiotics before skin incision for caesarean birth. [2011]

Thromboprophylaxis for caesarean birth

1.4.47 Offer thromboprophylaxis to women having a caesarean birth. Take into account the risk of thromboembolic disease when choosing the method of prophylaxis (for example, graduated stockings, hydration, early mobilisation, low molecular weight heparin). [2011]

Women's preferences during caesarean birth

1.4.48 Accommodate a woman's preferences for her caesarean birth whenever possible, such as, music playing in theatre, lowering the screen to see the baby born, or silence so that the mother's voice is the first the baby hears. [2004]

1.5 Care of the baby born by caesarean birth

Presence of paediatrician at caesarean birth

1.5.1 Ensure an appropriately trained practitioner skilled in the resuscitation of newborn babies is present for caesarean birth performed under general anaesthesia, or if there is evidence of fetal compromise. [2004]

Thermal care for babies born by caesarean birth

1.5.2 As babies born by caesarean birth are more likely to have a lower temperature, ensure thermal care is in accordance with good practice for thermal care of newborn babies. [2004]

Maternal contact (skin-to-skin)

1.5.3 Offer and facilitate early skin-to-skin contact between the woman and her baby. [2004, amended 2021]

Breastfeeding

1.5.4 Offer women who have had a caesarean birth and who wish to breastfeed support to help them to start breastfeeding as soon as possible after the birth of their baby. [2004, amended 2021]

1.6 Care of the woman after caesarean birth

High-dependency unit/intensive therapy unit admission

1.6.1 Be aware that, although it is rare for women to need intensive care after childbirth, this may occur after caesarean birth. [2004, amended 2021]

Monitoring after caesarean birth

After general anaesthesia

1.6.2 After caesarean birth under a general anaesthetic, a healthcare professional with airway skills should carry out continuous, one-to-one observation of the woman until:

  • she has regained airway control, and

  • is haemodynamically stable, and

  • is able to communicate. [2021]

1.6.3 When a woman has regained airway control, is haemodynamically stable, and is able to communicate after caesarean birth under a general anaesthetic:

  • continue observations (oxygen saturation, respiratory rate, heart rate, blood pressure, temperature, pain and sedation) every half hour for 2 hours

  • after 2 hours, if these observations are stable, carry out routine observations in accordance with local protocols

  • if these observations are not stable, or the woman has other risk factors or complications (for example, severe hypertension, or signs of infection or sepsis), carry out a medical review and increase the duration and frequency of observations. [2021]

After spinal or epidural anaesthesia

1.6.4 After caesarean birth under a spinal or epidural anaesthetic, a healthcare professional should carry out continuous one-to-one observation of the woman until she is haemodynamically stable (for example when pulse and blood pressure have returned to baseline values). [2021]

1.6.5 Provide a woman who has had spinal or epidural diamorphine for caesarean birth, and who is at an increased risk of respiratory depression (for example, a significantly raised BMI, or diagnosed obstructive sleep apnoea syndrome), with:

  • continuous pulse oximetry monitoring, and

  • hourly monitoring of

    • respiratory rate

    • heart rate

    • blood pressure

    • temperature

    • pain

    • sedation.

      Monitor the woman for at least 12 hours, continue until they are stable enough to be discharged from anaesthetic care, and then carry out routine observations in accordance with local protocols. [2021]

1.6.6 For a woman who has had spinal or epidural diamorphine for caesarean birth, but is not at an increased risk of respiratory depression, carry out routine observations in accordance with local protocols. [2021]

1.6.7 When deciding on the location and frequency of monitoring for respiratory depression in women who have had spinal or epidural diamorphine for caesarean birth, take into account other factors that could affect monitoring needs (for example, a complicated birth, or unstable observations in first 2 hours after birth). [2021]

1.6.8 Ensure women who have patient-controlled analgesia with opioids after caesarean birth have routine hourly monitoring of respiratory rate, sedation and pain scores throughout treatment, and for at least 2 hours after discontinuation of treatment. [2004, amended 2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on monitoring after caesarean birth.

Full details of the evidence and the committee's discussion are in evidence review E: monitoring after intrathecal or epidural opioids for caesarean birth.

Pain management after caesarean birth

1.6.9 Offer women diamorphine (0.3 to 0.4 mg intrathecally) for analgesia to reduce the need for supplemental analgesia after a caesarean birth. Epidural diamorphine (2.5 to 5 mg) is a suitable alternative where intrathecal diamorphine has not been given.

In March 2021, this was an off-label use of diamorphine (both intrathecal and epidural). See NICE's information on prescribing medicines. [2004, amended 2021]

1.6.10 Discuss options with women for pain relief after caesarean birth and explain that:

  • pain after caesarean birth can be controlled using oral or injectable medicines

  • their choice of pain relief medicines after caesarean birth will depend on:

    • the severity of pain

    • whether they had spinal or epidural anaesthesia, or general anaesthesia

  • if they wish to breastfeed, they will usually be able to do this and care for their baby while taking pain relief medicines. [2021]

1.6.11 Offer oral morphine sulfate to women who have received spinal or epidural anaesthesia for caesarean birth. If the woman cannot take oral medication (for example, because of nausea or vomiting), offer intravenous, intramuscular or subcutaneous morphine. [2021]

1.6.12 Consider intravenous patient-controlled analgesia (PCA) using morphine for women who have had a general anaesthetic for caesarean birth. If intravenous PCA is not acceptable to the woman, or the pain is less severe, consider oral morphine sulfate. [2021]

1.6.13 Use paracetamol and, unless contraindicated, a non-steroidal anti-inflammatory drug (for example, ibuprofen) in combination after caesarean birth, to reduce the need for opioids, and to allow them to be stepped down and stopped as early as possible. [2004, amended 2021]

1.6.14 If paracetamol does not provide sufficient pain relief after caesarean birth, or non-steroidal anti‑inflammatory drugs cannot be taken, consider adding dihydrocodeine to paracetamol, or changing to co-dydramol (combination preparation of paracetamol and dihydrocodeine) as an alternative to paracetamol. [2021]

1.6.15 Do not offer codeine or co‑codamol (combination preparation of paracetamol and codeine) to women who are currently breastfeeding, because this can lead to serious neonatal sedation and respiratory depression. Follow the MHRA safety advice on Codeine for analgesia: restricted use in children because of reports of morphine toxicity. [2021]

1.6.16 When using paracetamol, dihyrocodeine, co-dydramol or a non-steroidal anti-inflammatory drug after caesarean birth, prescribe them to be taken regularly and not just when needed for pain relief. [2021]

1.6.17 For women with severe pain after caesarean birth, when other pain relief is not sufficient:

  • perform a full assessment to exclude other causes for the pain (for example, sepsis, haemorrhage, urinary retention)

  • discuss with the woman that stronger pain relief medicines are available

  • make sure the woman is aware that, if taken while breastfeeding, these medicines could increase the risk of neonatal sedation and respiratory depression.

    If the women chooses to take stronger medicines, consider a short course of tramadol or oxycodone at the lowest effective dose. [2021]

1.6.18 In breastfeeding women, use opioid analgesics (for example, morphine, dihyrocodeine, tramadol or oxycodone) at the lowest effective dose and for the shortest duration, and not for more than 3 days without close supervision. [2021]

1.6.19 If, after a caesarean birth, a woman is discharged home on opioids, advise the woman to contact their healthcare provider if they are concerned about their baby (for example drowsiness, breathing difficulties, constipation or difficulty feeding). [2021]

1.6.20 Consider laxatives for women taking opioids, for the prevention of constipation. [2021]

1.6.21 Consider anti-emetics for women taking opioids, if needed for nausea and vomiting. [2021]

1.6.22 Advise women that some over-the-counter medicines contain codeine, and should not be taken while breastfeeding because this can lead to serious neonatal sedation and respiratory depression. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on pain management after caesarean birth.

Full details of the evidence and the committee's discussion are in evidence review F: opioids for pain relief after caesarean birth.

Early eating and drinking after caesarean birth

1.6.23 If women are recovering well after caesarean birth and do not have complications, they can eat and drink as normal. [2004]

Urinary catheter removal after caesarean birth

1.6.24 Offer removal of the urinary bladder catheter once a woman is mobile after a regional anaesthetic for caesarean birth, but no sooner than 12 hours after the last 'top-up' dose. [2004, amended 2021]

Respiratory physiotherapy after caesarean birth

1.6.25 Do not offer routine respiratory physiotherapy to women after a caesarean birth under general anaesthesia as it does not improve respiratory outcomes (for example, coughing, phlegm, body temperature, chest palpation or auscultatory changes). [2004]

Length of hospital stay and readmission to hospital

1.6.26 Inform women that length of hospital stay is likely to be longer after caesarean birth than after a vaginal birth. [2004, amended 2021]

1.6.27 Offer women who are recovering well, are apyrexial and do not have complications after caesarean birth, discharge from hospital after 24 hours and follow up at home, as this is not associated with more readmissions for babies or mothers. [2004, amended 2021]

1.7 Recovery after caesarean birth

1.7.1 In addition to general postnatal care, provide women who have had a caesarean birth with:

  • specific care related to recovery after caesarean birth

  • care related to management of other complications during pregnancy or childbirth. [2004]

Wound care

1.7.2 Consider negative pressure wound therapy after caesarean birth for women with a BMI of 35 kg/m2 or more to reduce the risk of wound infections. [2021]

1.7.3 When using standard (not negative pressure) wound dressings after caesarean birth take into account that:

  • no type of wound dressing has been shown to be better than another at reducing the risk of wound infections

  • there is no difference in the risk of wound infection when dressings are removed 6 hours postoperatively, compared with 24 hours postoperatively. [2021]

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on methods to reduce infectious morbidity and wound care after caesarean birth.

Full details of the evidence and the committee's discussion are in evidence review B: methods to reduce infectious morbidity at caesarean birth.

1.7.4 Ensure caesarean birth wound care includes:

  • removing standard dressings 6 to 24 hours after the caesarean birth

  • specific monitoring for fever

  • assessing the wound for signs of infection (such as increasing pain, redness or discharge), separation or dehiscence

  • encouraging the woman to wear loose, comfortable clothes and cotton underwear

  • gently cleaning and drying the wound daily

  • if needed, planning the removal of sutures or clips.

    Follow the recommendations in the NICE guideline on surgical site infections. [2004, amended 2021]

Management of symptoms

1.7.5 When caring for women who have had a caesarean birth who have urinary symptoms, consider possible diagnoses of:

  • urinary tract infection

  • stress incontinence (occurs in about 4% of women after caesarean birth)

  • urinary tract injury (occurs in about 1 per 1,000 caesarean births)

  • urinary retention. [2004, amended 2021]

1.7.6 When caring for women who have had a caesarean birth who have heavy and/or irregular vaginal bleeding, consider whether this is more likely to be because of endometritis than retained products of conception, and manage accordingly. [2004, amended 2021]

1.7.7 Pay particular attention to women who have respiratory symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf), as women who have had a caesarean birth may be at increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism). [2004, amended 2021]

Resuming activities and discharge home

1.7.8 Inform women who have had a caesarean birth that they can resume activities such as driving a vehicle, carrying heavy items, formal exercise and sexual intercourse when they feel they have fully recovered from the caesarean birth (including any physical restrictions or pain). [2004, amended 2021]

1.7.9 When caring for women who have had a caesarean birth, discuss that after a caesarean birth they are not at increased risk of depression, post-traumatic stress symptoms, pain on sexual intercourse, faecal incontinence or difficulties with breastfeeding. [2004, amended 2021]

1.7.10 While women are in hospital after having an emergency or unplanned caesarean birth, give them the opportunity to discuss with healthcare professionals the reasons for the caesarean birth, and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date. [2011, amended 2021]

1.7.11 Inform the woman's GP if follow-up investigations are needed after discharge from hospital (for example, a repeat full blood count if there has been a large amount of blood loss), and include details of the plan or course of action if the results are abnormal. [2021]

1.8 Pregnancy and childbirth after caesarean birth

1.8.1 When advising about the mode of birth after a previous caesarean birth, consider:

  • maternal preferences and priorities

  • the risks and benefits of repeat planned caesarean birth

  • the risks and benefits of planned vaginal birth after caesarean birth, including the risk of unplanned caesarean birth. [2011]

1.8.2 Inform women who have had up to and including 4 caesarean births that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth, but that the risk of uterine rupture is higher for planned vaginal birth. [2011]

1.8.3 Offer women planning a vaginal birth who have had a previous caesarean birth:

  • electronic fetal monitoring during labour

  • care during labour in a unit where there is immediate access to caesarean birth and on-site blood transfusion services. [2011]

1.8.4 During induction of labour, women who have had a previous caesarean birth should be monitored closely, with access to electronic fetal monitoring and with immediate access to caesarean birth, as they are at increased risk of uterine rupture. For further information see the NICE guideline on inducing labour. [2011]

1.8.5 Pregnant women with both previous caesarean birth and a previous vaginal birth should be informed that they have an increased likelihood of having a vaginal birth than women who have had a previous caesarean birth but no previous vaginal birth. [2004]

  • National Institute for Health and Care Excellence (NICE)