The prevalence of caesarean section (CS) has increased as a mode of delivery. Rates have steadily risen from 10% of all deliveries in the 1980s¹ to a current figure of around 23.8%.² Approximately 75% of CS are emergency procedures and only 25% are elective planned deliveries.

According to the Office for National Statistics there were more than 720,000 live births in 2010 in England and Wales.³

The implications of delivery by CS are far reaching. When deciding whether to offer CS, it is important to consider the psychological implications for the patient as well as the physical and mental sequelae in future pregnancies.

In a wider context, it is also important to consider the impact that CS has on the provision of care and services for patients in general and the economic costs tothe NHS.⁴

Finally, there should not be an underestimate of the time and costs related to the appropriate counselling of women in providing support for patients undergoing their first CS or when they are considering a repeat CS.

In recent years, there has been an increase in the evidence and knowledge of the implications and repercussions of CS, and as a result in November 2011 NICE5 updated its earlier guidance.⁶

The ultimate aim of the updated guideline 5 is to ensure consistency in the quality of care for patients undergoing CS and to provide clinicians with the best available evidence regarding delivery.

It also reinforces a patient-centred approach to care and the need to take into account individual women’s wishes.

The new key recommendations are listed in box 1.

Informed decisions

Clinicians should provide pregnant women with evidence-based information and support. Information should include details about the true indication(s) for the CS and what it implies, including its risks and benefits, see table 1.

The potential repercussions and complications for future pregnancies should be highlighted and clinicians should also take into account the woman’s concerns and priorities. We must remember that a pregnant woman is entitled to decline the offer of a CS.

When a decision is reached to perform a CS the clinician must record all the factors that have influenced the decision-making process, and which of these is the key one.⁵

Planned elective CS

The guideline covers pregnant women who have had a previous CS, those with a clinical indication for CS and women who are considering a CS when there are no other indications.

The guideline does not advocate CS in uncomplicated pregnancies. However, it supports CS on maternal request when attempts to empower the mother to have a vaginal birth have not been successful, see box 1.

The aim is to help women to overcome their fears and anxiety about labour and this is assisted by using a multidisciplinary approach. This multidisciplinary team could include a midwife, obstetrician, and a GP with a special interest and expertise in this type of counselling. It might also involve a psychologist or psychiatrist.

Conductive therapy has been found to be the most useful form of treatment, especially for those patients who have had a traumatic experience. For cases where pain is the fear, a discussion with an anaesthetist can help patients overcome their fear.

GPs should be aware that a woman may be fearful of vaginal birth. They may see a postpartum patient who refers to her delivery as a traumatic experience or a patient who has had a complicated delivery. (They may also come across a patient who expresses her fear of labour before conception.)

Commonly these fears grow during the pregnancy. Organising appropriate early referral and support can make a big difference to the patient.

GPs can help the patient understand that the aim of the referral is not to change her mind, but to allow her to make an informed decision.

CS on maternal request in fact only represented 1.4% of all CS in 20016 but it is an issue that has raised much media attention and debate.

The following patients should be offered a planned elective CS:

• singleton breech presentation at term, after external cephalic version (ECV) has failed, has been declined or is contraindicated. CS has been shown to improve fetal outcome (this accounts for 4% of all singleton pregnancies and 10% of all CS5)

• multiple pregnancies (when the first twin is not cephalic)

• placenta praevia, minor or major, (close to or covering the os)

• HIV-positive women when:

- not on any antiretroviral therapy, or the viral load is ≥ 400 copies/ml

- there is co-infection with hepatitis C virus, regardless of the viral count

• primary genital herpes simplex virus (HSV) infection only when occurring in the third trimester. The mother to child transmission rate is higher in vaginal birth, and despite the limited evidence there is consensus about offering CS to these patients.

Factors affecting the likelihood of CS

Reduced likelihood

• induction of labour for prolonged pregnancy after 41 weeks. So-called post-dates induction reduces the risk

of perinatal mortality and also the likelihood of CS

• ECV for breech presentation

• during labour:

- continuous support

- assessing the progress with a partogram with a 4-hour action line

- consultant obstetrician making the decision re CS

• home birth in uncomplicated pregnancy

Increased likelihood

Electronic fetal monitoring during labour is associated with an increased likelihood of CS. When fetal compromise is suspected, fetal blood sampling should be offered to assess wellbeing prior to deciding to carry out emergency CS.

No effect

The following factors have been shown not to influence the chances of having a CS: walking in labour; standing or squatting in the second stage of labour; water labour/birth; delivery in a midwifery-led unit; epidural analgesia; active management of labour; early amniotomy to augment the progress of labour; use of raspberry leaves.

Cost effectiveness

A vaginal birth costs £700 less than a CS. This would represent £4.9 million saved for every 1% reduction in the yearly CS rate (based on an annual birth rate of 706,000).5 If we incorporate the cost of postpartum and lifelong urinary incontinence into the adverse outcomes and the quality adjusted life years (QALY), then CS becomes a cost-effective alternative to vaginal birth.⁵

Therefore CS following maternal request could be considered to be actually cost effective in economic terms. We must also, however, remember that cost analysis could change, as the true impact of the long-term consequences of CS may unfold in future years.

Pregnancy and childbirth after one previous CS

The advice regarding the mode of delivery must consider maternal preferences and priorities, and it should also inform women about:

• A safe place of birth that can offer:

continuous fetal monitoring in labour;

facilities for emergency CS and blood transfusion

• The risk of uterine rupture increases if labour is induced or augmented

In women with up to four CS, the risk of fever, bladder injuries and surgical injuries is not affected by the planned mode of delivery. Uterine rupture is higher in vaginal birth after caesarean section (VBAC), but is rare. Planned VBAC also has a risk of emergency CS.

Economic analysis modelling suggests that the cost of VBAC is £2,205 and planned CS is £2,512, when considering the incremental cost-effectiveness ratio and the QALY, planned CS becomes cost effective. Special consideration should be given if further pregnancies are planned because the costs of increased complications associated with more pregnancies have not been calculated.

Women who have had a successful previous VBAC have an increased probability of vaginal birth.

Conclusions

The updated NICE guideline helps clinicians to be consistent in the management of patients requesting and having a CS, while also providing the best available up-to-date information.

The advice on best practice with regard to both procedural aspects of CS and post-CS care should raise standards in everyday practice.

The extensive recommendations for research are very important for the future of evidence-based CS to improve the quality of our knowledge.