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New caesarean guidelines proposed

Several newspapers have reported that all pregnant women will “get the right to a caesarean”, regardless of whether there is a medical reason for having one. Currently, around one in four UK babies is delivered by caesarean.

The reports are based on new draft guidelines from the National Institute for Health and Clinical Excellence (NICE), the national body that evaluates which treatments should be available for specific conditions. The proposed guidelines are the first major update from NICE on caesarean sections since 2004, and take into account the latest research on the procedure.

 

What do the guidelines recommend?

Although newspapers focused on caesareans potentially being available to a wider range of women, the draft guidelines cover all aspects of caesarean sections, including planning, timing, the procedure itself and care after a caesarean. The guidelines include a number of new and updated recommendations about all these areas, but the ones relating to who should be offered a caesarean state that:

  • Pregnant women should be given evidence-based information about caesarean sections, including information about the reasons why a caesarean section might be used, what the procedure involves, associated risks and benefits, and implications for future pregnancies and birth.
  • The decision about whether to carry out a caesarean section should take into account the woman’s circumstances, concerns and priorities.  

Requested caesareans

In addition, the draft guidelines set out specific processes to follow if a woman asks for a caesarean:

  • If a woman requests a caesarean section, the reasons for this should be explored, discussed and recorded. If there are no medical reasons why the woman needs to have a caesarean, the risks and benefits of a caesarean compared to a vaginal birth should be discussed with her.
  • When a woman requests a caesarean section because of a fear of childbirth, she should be offered the chance to see a healthcare professional who has expertise in providing perinatal (around the time of birth) mental health support to help her address her fears in a supportive manner. If after receiving this support the woman still does not consider a vaginal birth to be an acceptable option, she should be offered a planned caesarean section.
  • An obstetrician can decline a women’s request for a caesarean. In this case, they should refer the woman to another NHS obstetrician in the same unit who will carry out the caesarean section.

Cases when a caesarean is recommended

The guidelines also recommend offering a planned caesarean to pregnant women under specific medical circumstances. Caesareans should be offered when a woman has:

  • a single baby who is in “breech position” at term (the time when it is due to be born). A breech position is when a baby has its bottom pointing downwards rather than its head, or less commonly one or both legs extending downwards and the feet presenting first. A caesarean should be offered if it has not been possible to turn the baby by manipulating it through the mother’s abdomen (a procedure known as external cephalic version, which is normally considered in suitable cases at around 36 weeks of pregnancy)
  • a twin pregnancy where the first twin is not positioned head down
  • a placenta that partly or completely covers the cervix (called minor or major placenta praevia)
  • HIV that is not being treated with anti-HIV (retroviral) therapy
  • HIV and 400 or more copies of the HIV virus per ml of blood (regardless of any anti-HIV treatment being received)
  • both HIV and the hepatitis C virus
  • a primary genital herpes simplex virus (HSV) infection that occurred in the third trimester of pregnancy (over 28 weeks)

 

Does NICE recommend offering caesareans for all?

No. The draft guidelines do not recommend that every woman should be routinely offered a caesarean. Rather, they state the medical circumstances where one is recommended and where one is not, and discuss the options that are available when a woman has a preference for a caesarean over a vaginal birth.

There are also several scenarios in which the guidelines say that women should not be routinely offered caesarean sections. These include women with:

  • a twin pregnancy that is uncomplicated at full term, where the first twin is presenting head downwards
  • a preterm birth
  • a baby that is small for its gestational age (how old the baby is based on when it was conceived)
  • HIV that is being treated with standard HIV treatment (anti-retroviral treatment called HAART therapy) and less than 400 copies of the HIV virus per ml of blood
  • HIV that is being treated with any anti-retroviral treatment (HAART or otherwise) and less than 50 copies of the HIV virus per ml of blood
  • hepatitis B or C viruses
  • a recurrent episode of genital herpes at full term
  • a body mass index of over 50 and no other risk factors that suggest a caesarean section would be appropriate

 

Why have the guidelines changed?

NICE’s existing caesarean guidance was issued in 2004. These new draft guidelines have take into account the evidence from newer research published since then. NICE’s system for updating its guidance is based on an in-depth, step-by-step process, involving:

  • reviewing the questions answered by the existing guidance and adding any important new questions that need to be addressed
  • carrying out systematic searches to identify all relevant high-quality research that addresses these questions
  • assessing the quality of these studies and extracting their findings
  • carrying out health-centred economic analyses where necessary
  • weighing up what this analysed evidence suggests, and assessing whether it suggests that existing recommendations need to change
  • adapting the recommendations in the guidelines as necessary, based on the updated evidence

Draft guidelines will then be published on the NICE website to allow interested parties to review the recommendations and suggest changes.

 

Are these guidelines official yet?

No. These guidelines are still undergoing pre-publication checks and may be subject to further changes before they are made official. However, any further changes are likely to be small as the guidelines have already been adapted to incorporate changes suggested in the commenting phase, which occurred in May and June 2011. It is expected that the final, official guidelines will be published in November.

 

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