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## Complete Summary

#### GUIDELINE TITLE

Caesarean section.

#### BIBLIOGRAPHIC SOURCE(S)

National Collaborating Centre for Women\'s and Children\'s Health.
Caesarean section. London (UK): National Institute for Clinical
Excellence (NICE); 2004 Apr. 142 p. \[688 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [February 28, 2008, Heparin Sodium
    Injection](http://www.fda.gov/medwatch/safety/2008/safety08.htm#HeparinInj2):
    The U.S. Food and Drug Administration (FDA) informed the public that
    Baxter Healthcare Corporation has voluntarily recalled all of their
    multi-dose and single-use vials of heparin sodium for injection and
    their heparin lock flush solutions. Alternate heparin manufacturers
    are expected to be able to increase heparin production sufficiently
    to supply the U.S. market. There have been reports of serious
    adverse events including allergic or hypersensitivity-type
    reactions, with symptoms of oral swelling, nausea, vomiting,
    sweating, shortness of breath, and cases of severe hypotension.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Conditions for which women should be offered planned Caesarean
    section (CS)

-   Conditions for which women should not be normally offered planned CS

-   Conditions that affect likelihood of CS

-   Childbirth

#### GUIDELINE CATEGORY

Counseling\
Evaluation\
Management\
Risk Assessment

#### CLINICAL SPECIALTY

Anesthesiology\
Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Hospitals\
Nurses\
Patients\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To help ensure consistency of quality of care experienced by women
    having Caesarean section (CS)

-   To provide evidence based information for health care professionals
    and women about:

    -   the risks and benefits of CS

    -   certain specific indications for CS

    -   effective management strategies which avoid CS

    -   anaesthetic and surgical aspects of care

    -   interventions to reduce morbidity from CS

    -   aspects of organisation and environment which affect CS rates

#### TARGET POPULATION

-   Pregnant women who are making decisions about mode of delivery, and
    women undergoing or who have undergone Caesarean section

-   Newborn babies delivered by Caesarean section

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Making the Decision for Caesarean Section (CS)**

1.  Providing information on risks and benefits of CS to the pregnant
    woman in an accessible form

2.  Offering planned CS to women based on maternal and neonatal risk

3.  Reducing likelihood of CS by offering external cephalic version to
    women with uncomplicated singleton breech pregnancy, offering women
    continuous support during labour, offering induction of labour
    beyond 41 weeks, monitoring progress of labour, involving a
    consultant obstetrician in decision for CS, and using fetal blood
    sampling for suspected acidosis

4.  Requesting and obtaining consent for CS

5.  Timing of planned CS (after 39 weeks\' gestation)

6.  Documenting urgency of CS

7.  Performing emergency CS as soon as possible

**Procedural Aspects of CS**

1.  Preoperative assessment

    -   Hemoglobin check

    -   Prescription of antibiotics

    -   Assessment of risk for thromboembolic disease

    -   Use of indwelling bladder catheter

> Note: Grouping and saving of serum, cross-matching of blood, clotting
> screen, and preoperative ultrasound to localize the placenta are not
> recommended for healthy women with an uncomplicated pregnancy.

2.  Anesthetic care

    -   Discussion of post-CS anesthesia

    -   Offering antacids and H~2~ receptor antagonists

    -   Offering antiemetics

    -   Offering regional anesthesia

    -   Reducing risk of hypotension by using

        -   Intravenous ephedrine or phenylephrine infusion

        -   Volume preloading with crystalloid or colloid

        -   Lateral lift of 15 degrees

    -   Preoxygenation and rapid sequence induction during general
        anesthesia for emergency CS

    -   Maternity unit drills for failed intubation

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3.  Surgical techniques

    -   Use of double gloves in women who are human immunodeficiency
        virus (HIV) positive

    -   Use of transverse lower abdominal incision

    -   Use of blunt extension of the uterine incision

    -   Use of oxytocin

    -   Use of controlled cord traction for removal of the placenta

    -   Closure of incision with two suture layers

    -   Checking of umbilical artery pH

    -   Considering woman\'s preference for birth environment and
        facilitating skin-to-skin contact for mother and baby

> Note: The following interventions and procedures are not recommended:
> closure of the subcutaneous space (unless \>2 cm fat); use of
> superficial wound drains; use of separate surgical knives for skin and
> deeper tissues; use of forceps routinely to deliver baby\'s head;
> suturing either the visceral or the parietal peritoneum; exteriorising
> the uterus; manual removal of the placenta

4.  Postoperative monitoring, including monitoring of cardiorespiratory
    stability, degree of sedation, and pain control

5.  The resuscitation of the newborn at CS with a general anaesthetic or
    with presumed fetal compromise

6.  Care of women and baby after CS, including support for
    breastfeeding, supplemental analgesia, wound care, discharge options

7.  Monitoring of recovery following CS, including wound care and
    maintaining vigilance for complications

8.  Discussion of implications for future vaginal births

#### MAJOR OUTCOMES CONSIDERED

-   Caesarean section (CS) rate

-   Perinatal mortality

-   Neonatal morbidity and mortality

-   Maternal morbidity and mortality

-   Mother-to-child viral transmission (human immunodeficiency virus,
    hepatitis B, hepatitis C, and genital herpes simplex virus)

-   Respiratory morbidity

-   Operating time

-   Length of hospital stay and readmission to hospital

-   Overall benefits and risks

-   Wound infection

-   Pain

-   Breastfeeding rate

-   Cost-effectiveness of vaginal birth after CS versus repeat CS

-   Costs of maternal request for CS

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Literature Search Strategy**

The aim of the literature review was to identify and synthesize relevant
evidence within the published literature, in order to answer specific
clinical questions. Searches were performed using generic and specially
developed filters, relevant medical subject heading terms, and free-text
terms. Details of all literature searches are available on application
to the National Collaborating Centre for Women\'s and Children\'s
Health.

The National Guidelines Clearinghouse database, the Turning Research
into Practice database, and the Organising Medical Networked Information
service on the Internet were searched for guidelines produced by other
development groups. The reference lists in these guidelines were checked
against the Guideline Development Group\'s searches to identify any
missing evidence.

Searches were carried out for each topic of interest. The Cochrane
Library (up to Issue 4, 2003) was searched to identify systematic
reviews (with or without meta-analyses) of randomised controlled
(clinical) trials (RCTs) and individual RCTs. The electronic databases
MEDLINE (Ovid version for the period January 1966 to January 2004),
EMBASE (Ovid version for the period between 1988 to January 2004), the
Cumulative Index to Nursing and Allied Health Literature, the British
Nursing Index, and PsychInfo were also searched, as was the Database of
Abstracts and Reviews of Effectiveness.

There was no systematic attempt to search the grey literature
(conferences, abstracts, theses and unpublished trials).

A preliminary scrutiny of titles and abstracts was undertaken and full
papers were obtained if the research question addressed the Guideline
Development Groups question relevant to the topic. Following a further
review of the full version of the study, articles that did not address
the Groups question were excluded. Studies that did not report relevant
outcomes were also excluded. Submitted evidence from stakeholders was
included where the evidence was relevant to the Groups clinical question
and was of equivalent or better quality than the research identified in
the literature searches.

The economic evidence presented in this guideline is not a systematic
review of all the economic evidence around CS, but a review of evidence
relating to specific aspects of CS. In addition to the databases listed
above, the Health Economic Evaluations Database and the NHS Economic
Evaluations Database were searched for relevant economic studies.

The search strategies were designed to find any economic study related
to CS. Relevant references in the bibliographies of reviewed papers were
also identified. Abstracts and database reviews of papers found were
reviewed by the health economists and were excluded if they appeared not
to contain any cost data relevant to the UK setting or did not relate to
the precise topic or question being considered. Studies were included if
they focused on the appropriate clinical question and were generalisable
to the England and Wales setting. The review of the evidence included
cost-effectiveness studies, cost-consequence studies (cost of present
and future costs only) and high quality systematic reviews of the
evidence.

For all subject areas, evidence from the study designs least subject to
bias was included. Where possible, the highest levels of evidence were
used, but all papers were reviewed using established guides. Published
systematic reviews or meta-analyses were used where available. For
subject areas where neither was available, other appropriate
experimental or observational studies were sought.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**1a**: Evidence obtained from systematic review or meta-analysis of
randomised controlled trials

**1b**: Evidence obtained from at least one randomised controlled trial

**2a**: Evidence obtained from at least one well-designed controlled
study without randomisation

**2b**: Evidence obtained from at least one well-designed
quasi-experimental study, such as a cohort study

**3**: Evidence obtained from well-designed nonexperimental descriptive
studies, such as comparative studies, correlation studies, case-control
studies, and case series

**4**: Evidence obtained from expert committee reports or opinions
and/or clinical experience of respected authorities

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Review of Published Meta-Analyses\
Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Identified articles were assessed methodologically and the best
available evidence was used to form and support the recommendations. The
highest level of evidence was selected for each clinical question. The
retrieved evidence was graded according to the evidence-level structure
shown in the field \"Rating Scheme for the Strength of the Evidence\" in
the complete summary. The clinical question dictated the highest level
of evidence that could be sought. For issues of therapy or treatment the
highest possible level of evidence was a meta-analysis of randomised
controlled trials (RCT) or an individual RCT.

For issues of prognosis, a cohort study was the best possible level of
evidence. This equates to a grade B recommendation. However, this should
not be interpreted as an inferior grade of recommendation because it
represents the highest level of evidence attainable for that type of
clinical question.

For diagnostic tests, test evaluation studies examining the performance
of the test were used if the efficacy of the test was required, but
where an evaluation of the effectiveness of the test in the management
and outcome was required, evidence from RCTs or cohort studies was
sought. For questions about women\'s beliefs, attitudes, and experiences
of childbirth and CS, qualitative research was reviewed.

All retrieved articles were appraised methodologically using established
guides. Where appropriate, if a systematic review, meta-analysis, or RCT
existed in relation to a topic, studies of a weaker design were
excluded. The evidence was synthesised using qualitative methods. These
involved summarising the content of identified papers in the form of
evidence tables and agreeing brief statements that accurately reflected
the relevant evidence. Quantitative synthesis (meta-analysis) was
performed where appropriate. Meta-analyses based on dichotomous outcomes
are presented as relative risks with 95% confidence intervals.

For the purposes of this guideline, data are presented as absolute
risks, relative risks, or odds ratios where relevant (i.e., in RCTs and
cohort studies). Where the data are statistically significant, they are
also presented as numbers needed to treat (for beneficial outcomes) or
numbers need to harm (for adverse effects of treatment) if relevant.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Nominal Group Technique)\
Informal Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The guideline was developed by a multi-professional and lay working
group (the Guideline Development Group \[GDG\]) convened by the National
Collaborating Centre for Women\'s and Children\'s Health (NCC-WCH).

Staff from the NCC-WCH provided methodological support for the guideline
development process, undertook systematic searches, retrieval, and
appraisal of the evidence, and wrote successive drafts of the document.

The Guideline Development Group was presented with the summaries (text
and evidence tables) of the best available research evidence to answer
each clinical question.

Recommendations were based on, and explicitly linked to, the evidence
that supported them. Where possible, the Group worked on an informal
consensus basis. Formal consensus methods (the nominal group technique)
were employed when required (e.g., grading recommendations and agreeing
audit criteria).

Summary results are presented in the original guideline document. More
detailed results and other data are presented in the relevant evidence
tables accompanying the original guideline document.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The grading of recommendations follows that outlined in the Health
Technology Assessment How to Develop Cost-Conscious Guidelines:

**Grade A** Based directly on level 1 evidence

**Grade B** Based directly on level 2 evidence or extrapolated from
level 1 evidence

**Grade C** Based directly on level 3 evidence or extrapolated from
level 1 or level 2 evidence

**Grade D** Based directly on level 4 evidence or extrapolated from
level 1, level 2, or level 3 evidence

**GPP** Good Practice Point based on the view of the Guideline
Development Group

#### COST ANALYSIS

The purpose of including economic evidence in a clinical guideline is to
allow recommendations to be made not just on the clinical effectiveness
of different forms of care, but also on their cost effectiveness. The
aim is to produce guidance that uses scarce health service resources
efficiently, that is providing the best possible care within resource
constraints.

There is economic literature that has considered the economic costs and
consequences of different modes of birth. The economic evidence is
focused around the cost of Caesarean section (CS) compared to vaginal
birth. The economic evidence presented in this guideline is not a
systematic review of all the economic evidence around CS. Specific
topics were considered where it was thought that economic evidence would
help them to inform decision making.

Topics for economic analysis were selected on the following basis by the
guideline development group:

-   Does the proposed topic have major resource implications?

-   Is there a change of policy involved?

-   Are there sufficient data of adequate quality to allow useful review
    or modelling?

-   Is there a lack of consensus amongst clinicians?

-   Is there a particular area with a large amount of uncertainty?

Where the above answers are yes, this indicated that further economic
analysis including modelling was more likely to be useful.

A simple economic model was developed for each of the specific topic
areas for which the economic evidence was reviewed, in order to present
the guideline development group with a coherent picture of the costs and
consequences of the decisions based on the clinical and economic
evidence. The health economist undertook the literature review in these
specific areas and obtained cost data considered to be the closest to
current UK opportunity cost (the value of the resources used, rather
than the price or charge). The criteria for assessing the economic
papers was based on that developed by Drummond et al (1997) and the
format of the abstract follows that of the National Health Service
Economic Evaluation Database (NHS EED) managed by the NHS Centre for
Reviews and Dissemination
(<http://www.york.ac.uk/inst/crd/crddatabases.htm>)

Health economics evidence was available for the following areas:

-   External cephalic version for breech presentation at term

-   CS in the management of women with breech presentation

-   Human immunodeficiency virus/acquired immune deficiency syndrome
    (HIV/AIDS)

-   Herpes simplex virus

-   Vaginal birth after CS

-   Maternal request for CS

-   Use of antibiotics at CS

-   Intrathecal diamorphine

The economic evidence is based not only on the economic literature, but
is also consistent with the clinical effectiveness evidence presented in
the guideline.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guideline has been developed in accordance with the National
Institute for Clinical Excellence (NICE) guideline development process.
This has included the opportunity for registered stakeholders to comment
on the scope of the guideline, the first draft of the full and summary
guidelines and the second draft of all versions of the guideline. In
addition the drafts were reviewed by an independent Guideline Review
Panel and the Patient Involvement Unit established by NICE. The summary
of recommendations was reviewed by the NICE Executive.

The comments made by the stakeholders, peer reviewers, the Guideline
Review Panel, and NICE were collated and presented anonymously for
consideration by the Guideline Development Group. All comments were
considered systematically by the Guideline Development Group and the
resulting actions and responses were recorded.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

Levels of evidence (1a-4) and grading of recommendations (A-D) are
defined at the end of the Major Recommendations field.

In addition to the evidence-based recommendations, the guideline
development group also identifies points of good clinical practice
(GPP).

**Woman-centered Care**

**Provision of Information**

**C** - Pregnant women should be offered evidence-based information and
support to enable them to make informed decisions about childbirth.
Addressing women\'s views and concerns should be recognised as being
integral to the decision-making process.

**GPP** - Pregnant women should be given evidence-based information
about caesarean section (CS) during the antenatal period, because about
1 in 5 women will have a CS. This should include information about CS
such as:

-   indications for CS (such as presumed fetal compromise, failure to
    progress in labour, breech presentation)

-   what the procedure involves

-   associated risks and benefits

-   implications for future pregnancies and birth after CS

**GPP** - Communication and information should be provided in a form
that is accessible to pregnant women, taking into account the
information and cultural needs of minority communities and women whose
first language is not English or who cannot read, together with the
needs of women with disabilities or learning difficulties.

Information summarising the likely effect of CS on women\'s and
children\'s health can be found in Appendix A of the original guideline
document.

**Consent for Caesarean Section (CS)**

**C** - Consent for CS should be requested after providing pregnant
women with evidence-based information and in a manner that respects the
woman\'s dignity, privacy, views, and culture, while taking into
consideration the clinical situation.

**D** - A competent pregnant woman is entitled to refuse the offer of
treatment such as CS, even when the treatment would clearly benefit her
or her baby\'s health. Refusal of treatment needs to be one of the
patient\'s options.

**GPP** - When considering a CS, there should be discussion on the
benefits and risks of CS compared with vaginal birth specific to the
woman and her pregnancy.

**GPP** - When the decision is made to perform a CS, a record should be
made of all the factors that influence the decision, and which of these
is the most influential.

**Classification of Urgency**

**C** - The urgency of CS should be documented using the following
standardised scheme in order to aid clear communication between
health-care professionals about the urgency of a CS:

1.  Immediate threat to the life of the woman or fetus

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

3.  No maternal or fetal compromise but needs early delivery

4.  Delivery timed to suit woman or staff

**Planned CS**

Planned CS refers to a CS that is scheduled before the onset of labour
for a specific clinical indication. This section deals only with
decisions about the mode of delivery. Other aspects of management of
specific conditions or complications of pregnancy are outside the scope
of this guideline.

**Breech Presentation**

**A** - Women who have an uncomplicated singleton breech pregnancy at 36
weeks gestation should be offered external cephalic version. Exceptions
include women in labour and women with a uterine scar or abnormality,
fetal compromise, ruptured membranes, vaginal bleeding, or medical
conditions.

**A** - Pregnant women with a singleton breech presentation at term for
whom external cephalic version is contraindicated or has been
unsuccessful should be offered CS because it reduces perinatal mortality
and neonatal morbidity.

**Multiple Pregnancy**

**C** - 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 CS in improving outcome for the second twin remains uncertain
and therefore CS should not routinely be offered outside a research
context.

**GPP** - In twin pregnancies where the first twin is not cephalic, the
effect of CS in improving outcome is uncertain, but current practice is
to offer a planned CS.

**B** - Planned CS for uncomplicated twin pregnancy should not be
carried out before 38 weeks because this increases the risk of
respiratory problems in these babies.

**Preterm Birth and CS**

**C** - Preterm birth is associated with higher neonatal morbidity and
mortality. However, the effect of planned CS in improving these outcomes
remains uncertain and therefore CS should not routinely be offered
outside a research context.

**Small for Gestational Age and CS**

**C** - The risk of neonatal morbidity and mortality is higher with
\"small for gestational age\" babies. However, the effect of planned CS
in improving these outcomes remains uncertain, and therefore CS should
not routinely be offered outside a research context.

**Placenta Praevia**

**D** - Women with a placenta that partly or completely covers the
internal cervical os (grade 3 or 4 placenta praevia) should be offered
CS.

**Predicting CS for Cephalopelvic Disproportion in Labour**

**A** - Pelvimetry is not useful in predicting \"failure to progress\"
in labour and should not be used in decision making about mode of birth.

**B** - Shoe size, maternal height, and estimations of fetal size
(ultrasound or clinical examination) do not accurately predict
cephalopelvic disproportion and should not be used to predict \"failure
to progress\" during labour.

**Mother-to-Child Transmission of Maternal Infections**

This section exclusively addresses CS as an intervention to reduce
mother-to-child transmission of infections. Other interventions to
reduce transmission of these infections to the baby are available but
are outside the scope of this guideline.

**A** - Human immunodeficiency virus (HIV)-positive women who are
pregnant should be offered a planned CS because it reduces the risk of
mother-to-child transmission of HIV.

**B** - Mother-to-child transmission of hepatitis B can be reduced if
the baby receives immunoglobulin and vaccination. In these situations
pregnant women with hepatitis B should not be offered a planned CS,
because there is insufficient evidence that this reduces mother-to-child
transmission of hepatitis B virus.

**C** - Women who are infected with hepatitis C should not be offered a
planned CS because this does not reduce mother-to-child transmission of
the virus.

**C** - Pregnant women who are coinfected with hepatitis C virus and HIV
should be offered planned CS because it reduces mother-to-child
transmission of both hepatitis C virus and HIV.

**C** - Women with primary genital herpes simplex virus (HSV) infection
occurring in the third trimester of pregnancy should be offered planned
CS because it decreases the risk of neonatal HSV infection.

**C** - Pregnant women with a recurrence of HSV at birth should be
informed that there is uncertainty about the effect of planned CS in
reducing the risk of neonatal HSV infection. Therefore, CS should not
routinely be offered outside a research context.

**Maternal Request for CS**

**GPP** - Maternal request is not on its own an indication for CS, and
specific reasons for the request should be explored, discussed, and
recorded.

**GPP** - When a woman requests a CS in the absence of an identifiable
reason, the overall benefits and risks of CS compared with vaginal birth
should be discussed and recorded.

**A** - When a woman requests a CS because she has a fear of childbirth,
she should be offered counselling (such as cognitive behavioural
therapy) to help her to address her fears in a supportive manner,
because this results in reduced fear of pain in labour and shorter
labour.

**GPP** - An individual clinician has the right to decline a request for
CS in the absence of an identifiable reason. However the woman\'s
decision should be respected, and she should be offered referral for a
second opinion.

**Factors Affecting Likelihood of CS During Intrapartum Care**

**Place of Birth**

**B** - During their discussions about options for birth, healthy
pregnant women with anticipated uncomplicated pregnancies should be
informed that delivering at home reduces the likelihood of CS.

**A** - During their discussions about options for birth, healthy
pregnant women with anticipated uncomplicated pregnancies should be
informed that planned childbirth in a \"midwifery-led unit\" does not
reduce the likelihood of CS.

**Reducing Likelihood of CS**

The following interventions during intrapartum care have been shown to
decrease the likelihood of CS:

**A** - Women should be informed that continuous support during labour
from women with or without prior training reduces the likelihood of CS.

**A** - Women with an uncomplicated pregnancy should be offered
induction of labour beyond 41 weeks because this reduces the risk of
perinatal mortality and the likelihood of CS (see also the NICE Clinical
Guideline on induction of labour; details in Section 6 of that
document).

**A** - A partogram with a 4-hour action line should be used to monitor
progress of labour of women in spontaneous labour with an uncomplicated
singleton pregnancy at term, because it reduces the likelihood of CS.

**C** - Consultant obstetricians should be involved in the decision
making for CS, because this reduces the likelihood of CS.

**B** - Electronic fetal monitoring is associated with an increased
likelihood of CS. When CS is contemplated because of an abnormal fetal
heart rate pattern, in cases of suspected fetal acidosis, fetal blood
sampling should be offered if it is technically possible and there are
no contraindications (see also the NICE Clinical Guideline on electronic
fetal monitoring; details in Section 6 of that document).

**No Influence on Likelihood of CS**

**A** - Women should be informed that the following interventions during
intrapartum care have not been shown to influence the likelihood of CS,
although they may affect other outcomes that are outside the scope of
this guideline:

-   Walking in labour

-   Nonsupine position during the second stage of labour

-   Immersion in water during labour

-   Epidural analgesia during labour

-   Use of raspberry leaf

**D** - Women should be informed that the effects on the likelihood of
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.

**\"Failure to Progress\" in Labour and CS**

**A** - The following aspects of intrapartum care have not been shown to
influence the likelihood of CS for \"failure to progress\" and should
not be offered for this reason, although they may affect other outcomes
which are outside the scope of this guideline:

-   Active management of labour

-   Early amniotomy

**Eating during Labour**

**A** - Women should be informed 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
required is uncertain.

**A** - Women should be informed that having isotonic drinks during
labour prevents ketosis without a concomitant increase in gastric
volume.

**Procedural Aspects of CS**

**Timing of CS**

**B** - The risk of respiratory morbidity is increased in babies born by
CS before labour, but this risk decreases significantly after 39 weeks.
Therefore planned CS should not routinely be carried out before 39
weeks.

**Decision-to-Delivery Interval for Emergency CS**

**C** - Delivery at emergency CS for maternal or fetal compromise should
be accomplished as quickly as possible, taking into account that rapid
delivery has the potential to do harm. A decision-to-delivery interval
of less than 30 minutes is not in itself critical in influencing baby
outcome, but has been an accepted audit standard for response to
emergencies within maternity services.

**Preoperative Testing Before CS**

**C** - Pregnant women should be offered a haemoglobin assessment before
CS to identify those who have anaemia. Although blood loss of more than
1,000 ml is infrequent after CS (it occurs in 4-8% of CS), it is a
potentially serious complication.

**C** - Pregnant women having CS for antepartum haemorrhage, abruption,
uterine rupture, and placenta praevia are at increased risk of blood
loss of more than 1,000 ml and should have the CS carried out at a
maternity unit with on-site blood transfusion services.

**C** - Pregnant women who are healthy and who have otherwise
uncomplicated pregnancies should not routinely be offered the following
tests before CS:

-   Grouping and saving of serum

-   Cross-matching of blood

-   A clotting screen

-   Preoperative ultrasound for localisation of the placenta, because
    this does not improve CS morbidity outcomes (such as blood loss of
    more than 1,000 ml, injury of the infant, and injury to the cord or
    to other adjacent structures).

**GPP** - Women having CS with regional anaesthesia require an
indwelling urinary catheter to prevent over-distension of the bladder,
because the anaesthetic block interferes with normal bladder function.

**Anaesthesia for CS**

**GPP** - Pregnant women having a CS should be given information on
different types of post-CS analgesia so that analgesia best suited to
their needs can be offered (see recommendation below under \"Care of the
Woman after CS\").

**A** - Women who are having a CS should be offered regional anaesthesia
because it is safer and results in less maternal and neonatal morbidity
than general anaesthesia. This includes women who have a diagnosis of
placenta praevia.

**B** - Women who are having induction of regional anaesthesia for CS
should be cared for in theatre because this does not increase patient
anxiety.

**A** - Women who are having a CS under regional anaesthesia should be
offered intravenous ephedrine or phenylephrine, and volume preloading
with crystalloid or colloid to reduce the risk of hypotension occurring
during CS.

**D** - Each maternity unit should have a drill for failed intubation
during obstetric anaesthesia.

**B** - To reduce the risk of aspiration pneumonitis, women should be
offered antacids and drugs (such as H~2~ receptor antagonists or proton
pump inhibitors) to reduce gastric volumes and acidity before CS.

**A** - Women having a CS should be offered antiemetics (either
pharmacological or acupressure) to reduce nausea and vomiting during CS.

**GPP** - General anaesthesia for emergency CS should include
preoxygenation, cricoid pressure, and rapid sequence induction to reduce
the risk of aspiration.

**A** - Intravenous ephedrine or phenylephrine should be used in the
management of hypotension during CS.

**A** - The operating table for CS should have a lateral tilt of 15°,
because this reduces maternal hypotension.

**Surgical Techniques for CS**

The following recommendations for surgical techniques apply to
pregnancies at term where there is a lower uterine segment. Techniques
may need modification in situations such as repeat CS or placenta
praevia.

**A** - Health-care professionals should wear double gloves when
performing or assisting at CS on women who have tested positive for HIV,
to reduce the risk of HIV infection of health-care professionals during
surgery.

**C** - General recommendations for safe surgical practice should be
followed at CS to reduce the risk of HIV infection of staff.

**B** - CS should be performed using a transverse abdominal incision
because this is associated with less postoperative pain and an improved
cosmetic effect compared with a midline incision.

**A** - The transverse incision of choice should be the Joel Cohen
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), because it is associated with shorter
operating times and reduced postoperative febrile morbidity.

**B** - The use of separate surgical knives to incise the skin and the
deeper tissues at CS is not recommended because it does not decrease
wound infection.

**A** - When there is a well formed lower uterine segment, blunt rather
than sharp extension of the uterine incision should be used because it
reduces blood loss, incidence of postpartum haemorrhage, and the need
for transfusion at CS.

**C** - Women who are having a CS birth should be informed that the risk
of fetal lacerations is about 2%.

**C** - Forceps should only be used at CS if there is difficulty
delivering the baby\'s head. The effect on neonatal morbidity of the
routine use of forceps at CS remains uncertain.

**C** - Oxytocin 5 IU by slow intravenous injection should be used at CS
to encourage contraction of the uterus and to decrease blood loss.

**A** - At CS, the placenta should be removed using controlled cord
traction and not manual removal as this reduces the risk of
endometritis.

**A** - Intraperitoneal repair of the uterus at CS should be undertaken.
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.

**B** - 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.

**A** - Neither the visceral nor the parietal peritoneum should be
sutured at CS because this reduces operating time and the need for
postoperative analgesia and improves maternal satisfaction.

**B** - In the rare circumstances that a midline abdominal incision is
used at CS, mass closure with slowly absorbable continuous sutures
should be used because this results in fewer incisional hernias and less
dehiscence than layered closure.

**A** - Routine closure of the subcutaneous tissue space should not be
used, unless the woman has more than 2 cm subcutaneous fat, because it
does not reduce the incidence of wound infection.

**A** - Superficial wound drains should not be used at CS because they
do not decrease the incidence of wound infection or wound haematoma.

**C** - Obstetricians should be aware that the effects of different
suture materials or methods of skin closure at CS are not certain.

**B** - Umbilical artery pH should be performed after all CS for
suspected fetal compromise, to allow review of fetal well-being and
guide ongoing care of the baby.

**A** - Women having a CS should be offered prophylactic antibiotics,
such as a single dose of first-generation cephalosporin or ampicillin,
to reduce the risk of postoperative infections (such as endometritis,
urinary tract and wound infection), which occur in about 8% of women who
have had a CS.

**D** - Women having a CS should be offered thromboprophylaxis because
they are at increased risk of venous thromboembolism. The choice of
method of prophylaxis (for example, graduated stockings, hydration,
early mobilisation, low molecular weight heparin) should take into
account risk of thromboembolic disease and follow existing guidelines.

**GPP** - Women\'s preferences for the birth, such as music playing in
theatre, lowering the screen to see the baby born, or silence so that
the mothers voice is the first the baby hears, should be accommodated
where possible.

**Care of the Baby Born by CS**

**C** - An appropriately trained practitioner skilled in the
resuscitation of the newborn should be present at CS performed under
general anaesthesia or where there is evidence of fetal compromise.

**GPP** - Babies born by CS are more likely to have a lower temperature,
and thermal care should be in accordance with good practice for thermal
care of the newborn baby.

**A** - Early skin-to-skin contact between the woman and her baby should
be encouraged and facilitated because it improves maternal perceptions
of the infant, mothering skills, maternal behaviour, and breastfeeding
outcomes, and reduces infant crying.

**A** - Women who have had a CS should be offered additional support to
help them to start breastfeeding as soon as possible after the birth of
their baby. This is because women who have had a CS are less likely to
start breastfeeding in the first few hours after the birth, but, when
breastfeeding is established, they are as likely to continue as women
who have a vaginal birth.

**Care of the Woman after CS**

**D** - After CS, women should be observed on a one-to-one basis by a
properly trained member of staff until they have regained airway control
and cardiorespiratory stability and are able to communicate.

**B** - Health-care professionals caring for women after CS should be
aware that, although it is rare for women to need intensive care
following childbirth, this occurs more frequently after CS (about 9 per
1,000).

**GPP** - After recovery from anaesthesia, observations (respiratory
rate, heart rate, blood pressure, pain, and sedation) should be
continued every half hour for 2 hours, and hourly thereafter provided
that the observations are stable or satisfactory. If these observations
are not stable, more frequent observations and medical review are
recommended.

**GPP** - For women who have had intrathecal opioids, there should be a
minimum hourly observation of respiratory rate, sedation, and pain
scores for at least 12 hours for diamorphine and 24 hours for morphine.

**GPP** - For women who have epidural opioids or patient-controlled
analgesia with opioids, there should be routine hourly monitoring of
respiratory rate, sedation, and pain scores throughout treatment and for
at least 2 hours after discontinuation of treatment.

**A** - Women should be offered diamorphine (0.3-0.4 mg intrathecally)
for intra- and postoperative analgesia because it reduces the need for
supplemental analgesia after a CS. Epidural diamorphine (2.5-5 mg) is a
suitable alternative.

**GPP** - Patient-controlled analgesia using opioid analgesics should be
offered after CS because it improves pain relief.

**A** - Providing there is no contraindication, nonsteroidal
anti-inflammatory drugs should be offered post-CS as an adjunct to other
analgesics, because they reduce the need for opioids.

**A** - Women who are recovering well after CS and do not have
complications can eat and drink when they feel hungry or thirsty.

**D** - Removal of the urinary bladder catheter should be carried out
once a woman is mobile after a regional anaesthetic and not sooner than
12 hours after the last \"top up\" dose.

**A** - Routine respiratory physiotherapy does not need to be offered to
women after a CS under general anaesthesia, because it does not improve
respiratory outcomes such as coughing, phlegm, body temperature, chest
palpation, and auscultatory changes.

**GPP** - Women who have had a CS should be offered the opportunity to
discuss with their health-care providers the reasons for the CS and
implications for the child or future pregnancies.

**A** - Length of hospital stay is likely to be longer after a CS (an
average of 3-4 days) than after a vaginal birth (average 1-2 days).
However, women who are recovering well, are apyrexial, and do not have
complications following CS should be offered early discharge (after 24
hours) from hospital and follow-up at home, because this is not
associated with more infant or maternal readmissions.

**Recovery Following CS**

**GPP** - In addition to general postnatal care, women who have had a CS
should be provided with:

-   Specific care related to recovery after CS

-   Care related to management of other complications during pregnancy
    or childbirth

**D** - Women who have a CS should be prescribed and encouraged to take
regular analgesia for postoperative pain, using:

-   For severe pain, co-codamol with added ibuprofen

-   For moderate pain, co-codamol

-   For mild pain, paracetamol

**D** - CS wound care should include:

-   Removing the dressing 24 hours after the CS

-   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

**D** - Health-care professionals caring for women who have had a CS and
who have urinary symptoms should consider the possible diagnosis of:

-   Urinary tract infection

-   Stress incontinence (occurs in about 4% of women after CS)

-   Urinary tract injury (occurs in about 1 per 1,000 CS)

**D** - Health-care professionals caring for women who have had a CS and
who have irregular vaginal bleeding should consider that this is more
likely to be due to endometritis than retained products of conception.

**D** - Women who have had a CS are at increased risk of thromboembolic
disease (both deep vein thrombosis and pulmonary embolism), so
health-care professionals need to pay particular attention to women who
have chest symptoms (such as cough or shortness of breath) or leg
symptoms (such as painful swollen calf).

**GPP** - Women who have had a CS should resume activities such as
driving a vehicle, carrying heavy items, formal exercise, and sexual
intercourse once they have fully recovered from the CS (including any
physical restrictions or distracting effect due to pain).

**D** - Health-care professionals caring for women who have had a CS
should inform women that after a CS they are not at increased risk of
difficulties with breastfeeding, depression, post-traumatic stress
symptoms, dyspareunia, and faecal incontinence.

**Pregnancy and Childbirth Following CS**

**GPP** - The risks and benefits of vaginal birth after CS compared with
repeat CS are uncertain. Therefore the decision about mode of birth
after a previous CS should take into consideration:

-   Maternal preferences and priorities

-   A general discussion of the overall risks and benefits of CS (see
    Appendix A of the original guideline document)

-   Risk of uterine rupture

-   Risk of perinatal mortality and morbidity

**B** - Pregnant women who have a previous CS and who want to have a
vaginal birth should be supported in this decision. They should be
informed that:

-   Uterine rupture is a very rare complication, but is increased in
    women having a planned vaginal birth (35 per 10,000 women compared
    with 12 per 10,000 women having planned repeat CS).

-   The risk of an intrapartum infant death is small for women who have
    a planned vaginal birth (about 10 per 10,000), but higher than for a
    planned repeat CS (about 1 per 10,000).

-   The effect of planned vaginal birth or planned repeat CS on cerebral
    palsy is uncertain.

**GPP** - Women who have had a previous CS should be offered:

-   Electronic fetal monitoring during labour

-   Care during labour in a unit where there is immediate access to CS
    and on-site blood transfusion services

**B** - Women who have had a previous CS can be offered induction of
labour, but both women and health-care professionals should be aware
that the likelihood of uterine rupture in these circumstances is
increased to:

-   80 per 10,000 when labour is induced with nonprostaglandin agents

-   240 per 10,000 when labour is induced using prostaglandins.

**GPP** - During induction of labour, women who have had a previous CS
should be monitored closely, with access to electronic fetal monitoring
and with immediate access to CS, because they are at increased risk of
uterine rupture.

**B** - Pregnant women with both previous CS and a previous vaginal
birth should be informed that they have an increased likelihood of a
vaginal birth than women who have had a previous CS but no previous
vaginal birth.

**Definitions**:

**Levels of Evidence**

**1a**: Evidence obtained from systematic review or meta-analysis of
randomised controlled trials

**1b**: Evidence obtained from at least one randomised controlled trial

**2a**: Evidence obtained from at least one well-designed controlled
study without randomisation

**2b**: Evidence obtained from at least one well-designed
quasi-experimental study, such as a cohort study

**3**: Evidence obtained from well-designed nonexperimental descriptive
studies, such as comparative studies, correlation studies, case-control
studies, and case series

**4**: Evidence obtained from expert committee reports, or opinions
and/or clinical experience of respected authorities

**Grading of Recommendations**

**Grade A** Based directly on level 1 evidence

**Grade B** Based directly on level 2 evidence or extrapolated from
level 1 evidence

**Grade C** Based directly on level 3 evidence or extrapolated from
level 1 or level 2 evidence

**Grade D** Based directly on level 4 evidence or extrapolated from
level 1, level 2, or level 3 evidence

**Good Practice Points (GPP)** The view of the Guideline Development
Group

#### CLINICAL ALGORITHM(S)

A practice algorithm is provided in the original guideline document for
caesarean section.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each
recommendation (see \"Major Recommendations\")

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

**General Benefits**

Consistent quality of care for women considering caesarean section

**Subgroups Most Likely to Benefit**

-   Pregnant women with a singleton breech presentation at term, for
    whom external cephalic version is contraindicated or has been
    unsuccessful, should be offered caesarean section (CS) because it
    reduces perinatal mortality and neonatal morbidity.

-   Human immunodeficiency virus (HIV)-positive women who are pregnant
    should be offered a planned CS because it reduces the risk of
    mother-to-child transmission of HIV.

-   Pregnant women who are coinfected with hepatitis C virus and HIV
    should be offered planned CS because it reduces mother-to-child
    transmission of both hepatitis C virus and HIV.

-   Women with primary genital herpes simplex virus infection occurring
    in the third trimester of pregnancy should be offered planned CS
    because it decreases the risk of neonatal herpes simplex virus
    infection.

#### POTENTIAL HARMS

-   Complications of caesarean section (CS) include anesthesia risks,
    blood loss during surgery, postoperative wound infections and
    endometritis, urinary and genital tract injury, fetal laceration,
    postoperative urinary tract infections, pain, and venous
    thromboembolism.

-   Women who have had a CS and have a subsequent vaginal birth are at
    higher risk for uterine rupture (35 per 10,000 women) and
    intrapartum infant death (10 per 10,000) than women who have a
    repeat CS.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Contraindications to fetal blood sampling include maternal infection
(such as human immunodeficiency virus \[HIV\], hepatitis viruses, or
herpes simplex virus); fetal bleeding disorders such as haemophilia, and
prematurity (less than 34 weeks). Where there is clear evidence of acute
fetal compromise (e.g., prolonged decelerations \[longer than 3
minutes\]), fetal blood sampling should not be undertaken and the baby
should be delivered urgently.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This guidance represents the view of the Institute, which was
    arrived at after careful consideration of the evidence available.
    Health professionals are expected to take it fully into account when
    exercising their clinical judgement. The guidance does not, however,
    override the individual responsibility of health professionals to
    make decisions appropriate to the circumstances of the individual
    patient, in consultation with the patient and/or guardian or carer.

-   This guideline focuses on cesarean section (CS), and factors that
    affect decisions about CS. It does not consider the effect these
    factors might have on other aspects of antenatal and intrapartum
    care.

-   CS is the end of a number of clinical pathways; therefore it is not
    possible to cover all the clinical decisions that may lead to a CS
    in one guideline. The guideline does not offer advice on the risks
    and benefits of CS for specific clinical conditions arising during
    pregnancy such as pre-eclampsia. Nor does it address the needs of
    pregnant women or babies with rare conditions such as maternal
    congenital heart disease or monozygotic twins.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

Local health communities should review their existing practice on
Caesarean section (CS) against this guideline as they develop their
Local Delivery Plans. The review should consider the resources required
to implement the recommendations set out in the original guideline
document (and in the \"Major Recommendations\" section of this summary),
the people and processes involved, and the timeline over which full
implementation is envisaged. It is in the interests of women that the
implementation timeline is as rapid as possible.

Relevant local clinical guidelines, care pathways, and protocols should
be reviewed in the light of this guidance and revised accordingly.

The guideline will complement the Children\'s National Service Framework
(England and Wales), which is in development and which will produce
standards for service configuration, with emphasis on how care is
delivered and by whom, including issues of ensuring equity of access to
care for disadvantaged women and women\'s views about service provision.
(For more information, see
[www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/ChildrenServicesInformation/fs/en](http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/ChildrenServices/ChildrenServicesInformation/fs/en)
for England and
[www.wales.nhs.uk/sites/page.cfm?orgid=334&pid=934](http://www.wales.nhs.uk/sites/page.cfm?orgid=334&pid=934)
for Wales.)

Further information on Caesarean section may be obtained from
evidence-based websites such as the Cochrane Library
([www.update-software.com/clibng/cliblogon.htm](http://www.update-software.com/clibng/cliblogon.htm))
and the National Electronic Library for Health
([www.nelh.nhs.uk/maternity](http://www.nelh.nhs.uk/maternity)).

*The Pregnancy Book* (published by health departments in England and
Wales) may also be a useful resource for parents.

Suggested audit criteria are listed in Section 11 of the original
guideline document. These can be used as the basis for local clinical
audit, at the discretion of those in practice.

**Key Priorities for Implementation**

**Making the Decision**

-   When considering a Caesarean section (CS), there should be
    discussion on the benefits and risks of CS compared with vaginal
    birth specific to the woman and her pregnancy.

-   Maternal request is not on its own an indication for CS, and
    specific reasons for the request should be explored, discussed, and
    recorded. When a woman requests a CS in the absence of an
    identifiable reason, the overall benefits and risks of CS compared
    with vaginal birth should be discussed and recorded.

**Carrying Out the Procedure**

-   The following interventions should be used to decrease morbidity
    from CS:

    -   regional anaesthesia

    -   antibiotic prophylaxis

    -   thromboprophylaxis

    -   antacids

    -   antiemetics

-   The risk of respiratory morbidity is increased in babies born by CS
    before labour but this risk decreases significantly after 39 weeks.
    Therefore, planned CS should not routinely be carried out before 39
    weeks.

**Reducing the Likelihood of CS**

-   Women who have an uncomplicated singleton breech pregnancy at 36
    weeks\' gestation should be offered external cephalic version.
    Exceptions include women in labour, and women with a uterine scar or
    abnormality, fetal compromise, ruptured membranes, vaginal bleeding,
    or medical conditions.

-   Women should be informed that continuous support during labour from
    women with or without prior training reduces the likelihood of CS.

-   Women with uncomplicated pregnancies should be offered induction of
    labour beyond 41 weeks, because this reduces the risk of perinatal
    mortality and the likelihood of CS.

-   A partogram with a 4-hour action line should be used to monitor
    progress of labour of women in spontaneous labour with an
    uncomplicated singleton pregnancy at term, because it reduces the
    likelihood of CS.

-   Consultant obstetricians should be involved in the decision making
    for CS, because this reduces the likelihood of CS.

-   Electronic fetal monitoring is associated with an increased
    likelihood of CS. When CS is contemplated because of an abnormal
    fetal heart rate pattern, in cases of suspected fetal acidosis,
    fetal blood sampling should be offered if it is technically possible
    and there are no contraindications.

#### IMPLEMENTATION TOOLS

Audit Criteria/Indicators\
Clinical Algorithm\
Foreign Language Translations\
Patient Resources\
Quick Reference Guides/Physician Guides

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

National Collaborating Centre for Women\'s and Children\'s Health.
Caesarean section. London (UK): National Institute for Clinical
Excellence (NICE); 2004 Apr. 142 p. \[688 references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Apr

#### GUIDELINE DEVELOPER(S)

National Collaborating Centre for Women\'s and Children\'s Health -
National Government Agency \[Non-U.S.\]

#### SOURCE(S) OF FUNDING

National Institute for Clinical Excellence (NICE)

#### GUIDELINE COMMITTEE

Guideline Development Group

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Dr John Sandars (Group Leader), General
Practitioner, Stockport, Cheshire, and Part-Time Lecturer, University of
Manchester; Mrs Debbie Chippington Derrick, Caesarean Birth and VBAC
Coordinator, National Childbirth Trust, London; Mrs Jill Demilew,
Consultant Midwife, Kings College Hospital, London; Mrs Christine Ruby,
Senior Lecturer in Midwifery and Women\'s Health, University College
Worcester, and Midwife, Powys Local Health Board; Dr Michael Wee, Lead
Consultant Obstetric Anaesthetist, Poole Hospital NHS Trust, Poole,
Dorset; Dr Bryan Beattie, Consultant Obstetrician and Fetal Medicine,
University Hospital of Wales, Cardiff; Mrs Shaheen Chaudhry, Freelance
Consultant, Facilitator and Trainer, Bristol; Dr John Madar, Consultant
Neonatologist, Derriford Hospital, Plymouth, Devon; Dr Gwyneth Lewis,
Director of the United Kingdom Confidential Enquiries into Maternal
Deaths; Professor David James, Professor of Fetomaternal Medicine and
Director of Medical Education, Queens Medical Centre, Nottingham; Ms
Jane Thomas, Director, National Collaborating Centre for Women\'s and
Children\'s Health (NCC-WCH), and Honorary Consultant Obstetrician and
Gynaecologist, Oxford; Dr Heather Brown, Research Fellow, NCC-WCH; Dr
Shantini Paranjothy, Research Fellow, NCC-WCH; Mr Alex McNeil,
Informatics Specialist, NCC-WCH; Miss Anna Bancsi, Work Programme
Co-ordinator, NCC-WCH, Dr Hannah-Rose Douglas, Health Economist, London
School of Hygiene Tropical Medicine

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

In accordance with guidance from the National Institute for Clinical
Excellence (NICE), all Guideline Development Group members\' interests
were recorded on a standard declaration form that covered consultancies,
fee-paid work, share-holdings, fellowships, and support from the
health-care industry.

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) format
from the [National Institute for Clinical Excellence (NICE) Web
site](http://www.nice.org.uk/page.aspx?o=114953).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   National Collaborating Centre for Women\'s and Children\'s Health.
    Caesarean section. NICE guideline. London (UK): National Institute
    for Clinical Excellence (NICE); 2004 Apr. 38 p. (Clinical guideline,
    no. 13). Available in Portable Document Format (PDF) from the
    [National Institute for Clinical Excellence (NICE) Web
    site](http://www.nice.org.uk/page.aspx?o=113192).

-   Caesarean section. Quick reference guide. National Collaborating
    Centre for Women\'s and Children\'s Health, 2004 Apr. 8 p. Available
    in Portable Document Format (PDF) from the [NICE Web
    site](http://www.nice.org.uk/page.aspx?o=113196).

-   Caesarean section. Evidence tables. National Collaborating Centre
    for Women\'s and Children\'s Health. Commissioned by the National
    Institute for Clinical Excellence, 2004 Apr. 153 p. Available in
    Portable Document Format (PDF) from the [NICE Web
    site](http://www.nice.org.uk/page.aspx?o=115078).

-   Caesarean section. Summary of effects and procedural aspects.
    National Collaborating Centre for Women\'s and Children\'s Health,
    2004 Apr. 4. p. Available in Portable Document Format (PDF) from the
    [NICE Web site](http://www.nice.org.uk/page.aspx?o=113194).

Print copies: Available from the National Health Service (NHS), 11
Strand, London, WC2N 5HR. Response Line 0870 1555 455.

Additionally, Audit Criteria can be found in Section 11 of the [original
guideline document](http://www.nice.org.uk/page.aspx?o=114953).

#### PATIENT RESOURCES

The following is available:

-   Caesarean section: Understanding NICE guidance - information for
    pregnant women, their partners and the public. National Institute
    for Clinical Excellence (NICE), 2004 Apr. 52 p.

Electronic copies: Available in English and Welsh from the [National
Institute for Clinical Excellence (NICE) Web
site](http://www.nice.org.uk/page.aspx?o=113198).

Print copies: Available from the National Health Service (NHS), 11
Strand, London, WC2N 5HR. Response Line 0870 1555 455, ref N0479.

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI on July 9, 2004. The information
was verified by the guideline developer on December 3, 2004. This
summary was updated on May 3, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration advisory
on COX-2 selective and non-selective non-steroidal anti-inflammatory
drugs (NSAIDs). This summary was updated by ECRI Institute on June 22,
2007 following the U.S. Food and Drug Administration (FDA) advisory on
heparin sodium injection. This summary was updated by ECRI Institute on
March 13, 2008 following the updated FDA advisory on heparin sodium
injection.

#### COPYRIGHT STATEMENT

This summary is based on the original guideline, which is subject to the
guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008