Caesarean section
(update)
Implementing NICE guidance
November 2011
NICE clinical guideline 132
What this presentation covers
Updated guidance: scope
Epidemiology
Key priorities for implementation
Costs and savings
Discussion
NICE Pathway
NHS Evidence
Find out more
Updated guidance: scope
New and updated recommendations on:
•
the risks and benefits of caesarean section
•
care of women considered at risk of a morbidly adherent
placenta
•
care and choices for women who are HIV positive
•
care of women requesting caesarean section without a clinical
indication
•
decision-to-delivery intervals to be used as audit standards
•
timing of antibiotics
•
care and choices for women who have had a caesarean
section
Epidemiology
Caesarean section rate
•
Caesarean section
accounts for 20–25% of
births in the UK
40%
20%
0%
1980 1992 2000 2004 2009
•
40% of caesarean sections
are planned. The remaining
60% are unplanned procedures
•
70% of unplanned caesarean sections are a result of
dystocia (prolonged labour), suspected fetal compromise, fetal
malpresentation and previous caesarean birth
Epidemiology (2)
Morbidly adherent placenta
• Estimated incidence is 1.6 per 10,000 pregnancies*
• Risk increases with the number of previous caesarean sections
HIV
• Nationally around 1 in 450 pregnant women are HIV positive
* preliminary data from 2011 report, kindly provided by Dr Marian Knight, National
Perinatal Epidemiology Unit
Key priorities for implementation
The new key priorities for implementation cover:
• morbidly adherent placenta
• mother-to-child transmission of HIV
• maternal request for caesarean section
• decision-to-delivery intervals for unplanned caesarean section
• timing of antibiotic administration
• recovery following caesarean section
• pregnancy and childbirth after caesarean section
Morbidly adherent placenta
•
For women who have had a previous CS and have a low-lying
placenta confirmed at 32–34 weeks, offer colour-flow doppler
ultrasound as the first diagnostic test
•
If results suggest morbidly adherent placenta, discuss with the
woman the improved accuracy of magnetic resonance imaging
(MRI) in addition to ultrasound to help diagnose morbidly
adherent placenta and clarify the degree of invasion
•
Offer MRI if acceptable to the woman
Mother-to-child transmission
of HIV
•
Do not offer a caesarean section on the grounds of HIV status to
prevent mother-to-child transmission of HIV to women:
– on highly active anti-retroviral therapy (HAART) with a viral
load of < 400 copies per ml or
– on any anti-retroviral therapy with a viral load of < 50 copies
per ml
• Offer a caesarean section to women who:
– are not receiving any anti-retroviral therapy or
– are receiving any anti-retroviral therapy and have a
viral load of 400 copies per ml or more
Maternal request for caesarean
section
The guideline aims to ensure that:
• women who need a caesarean section are able to have one
• care is planned to support vaginal birth for women who do not need
a caesarean section
The guideline does not recommend that all women should be able to
have a caesarean section ‘on demand’
Women who still have a fear of vaginal birth after counselling,
information and support should be offered a caesarean section
Maternal request:
information on risks
FOR WOMEN –
REDUCED RISK
FOR BABIES –
INCREASED RISK
FOR WOMEN –
INCREASED RISK
perineal and abdominal
pain during birth and 3
days postpartum
neonatal intensive care
unit admission
longer hospital stay
injury to vagina
hysterectomy caused by
postpartum haemorrhage
early postpartum
haemorrhage
cardiac arrest
obstetric shock
Planned caesarean section compared with planned vaginal birth for women with
an uncomplicated pregnancy and no previous caesarean section
Decision-to-delivery interval for
unplanned caesarean section
Decision-to-delivery intervals should ONLY be used as audit
standards not to judge performance
Category 1
immediate threat to the life of the woman
or fetus
Audit standard
30 minutes
Category 2
maternal or fetal compromise which is
not immediately life-threatening
both 30
minutes and 75
minutes
Category 3
no maternal or fetal compromise but
needs early delivery
N/A
Category 4
delivery timed to suit woman or staff
N/A
Timing of antibiotic
administration
• Offer prophylactic antibiotics before skin incision
• Choose antibiotics effective against endometritis, urinary tract and
wound infections
• Do not use co-amoxiclav before skin incision
Recovery following caesarean
section
• While women are in hospital following a caesarean section:
– give them the opportunity to discuss with healthcare
professionals the reasons for the caesarean section
– provide verbal and printed information about birth options for
any future pregnancies
• If the women prefers, this can be done at a later date
Pregnancy and childbirth
after caesarean section
• When advising about the mode of birth after a previous caesarean
section, inform women who have had up to and including four
caesarean sections that:
– the risk of fever, bladder injuries and surgical injuries does
not vary with planned mode of birth
– the risk of uterine rupture, although higher with planned
vaginal birth, is rare
Costs and savings
per 100,000 population
Recommendations with significant costs
Mental health support for women with a fear of
childbirth
Diagnosis and preparation costs relating to
morbidly adherent placenta
Estimated cost of implementation
Recommendations with significant savings
Costs
(£ per year)
2056
77
2133
Savings
(£ per year)
Reduction in CS rate amongst HIV positive women
1473
Estimated saving of implementation
1473
Discussion
•
How will the changes to the recommendations in the updated
guideline affect our practice?
•
How do we currently deal with maternal requests for caesarean
section? What do we need to change?
•
What information, advice and support do we give to women who
have had a caesarean section?
NICE
Pathway
Click here to
go to NICE
Pathways
website
NHS Evidence
Visit NHS Evidence for the best available evidence on all
aspects of maternity care.
Click here to
go to the
NHS Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG132 for:
•
•
•
•
•
•
•
the guideline
‘Understanding NICE guidance’
costing report and template
baseline assessment
audit support
podcast
clinical case scenarios (available December 2011)
NB. Not part of presentation
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