New Caesarean section guidelines from the Royal College of Obstetricians and Gynaecologists

Caesarean section (CS) is the end point of a number of care pathways hence it is not possible to cover all the clinical decisions and pathways which may lead to a CS in one guideline. This evidence based guideline has been developed to help ensure consistency of quality of care experienced by women having CS. It provides 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 and
• aspects of organisation and environment which affect CS rates.

This guideline draws together and builds on work from other relevant NICE guidelines (such as Antenatal Care, Electronic Fetal Monitoring and Induction of Labour), the findings of the NSCSA and the Children’s National Service Frameworks (England and Wales).

The NSF is in development and 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.doh.gov.uk/nsf/children.htm for England and www.wales.nhs.uk/sites/page.cfm?orgid= 334&pid = 934 for Wales).

In England, CS rates have increased from 9% of deliveries in 1980 to 21% in 2001 therefore about 120,000 caesarean sections are performed annually in England and Wales.

A similar increase in CS rates has been seen in many developed countries. Evaluation of factors associated with the increase in CS rates has been carried out in several countries. These studies have demonstrated that some of the difference in CS rates observed can be explained by changes in the demographic characteristics of the childbearing population.

For example where women are delaying childbirth and having fewer children the average age of women giving birth and the proportion having their first pregnancy has increased. CS rates increase with maternal age and this association persists after adjustment for other factors.

The overall CS rate for women in their first pregnancy is increased (24%). For women who have had a baby before but who have not had a CS, the rate of CS is reduced (10%) and for women who have had a baby before but who have had at least one previous CS the CS rate is markedly increased (67%).

The CS rate also varies in the UK according to ethnic group with higher CS rates reported in women who are black African or black Caribbean. This association persists after adjustment for other demographic or clinical differences. However these factors only explain part of the variation observed between regions and maternity units.

Although CS rates have increased over the last ten to fifteen years, the four major clinical determinants of the CS rate have not changed.

These remain fetal compromise (22%), “failure to progress” in labour (20%), repeat CS (14%) and breech (11%). The fifth most common reason given for performing a CS has changed and is now reported to be “maternal request” (7%).

Variation in clinical practice contributes to variation in CS rate. For example, the use of continuous electronic fetal monitoring in labour is associated with increases in CS rates but not with a reduction in perinatal mortality rate.

A national clinical standard recommends that fetal blood sampling is undertaken to assess whether there is fetal compromise in labour prior to the decision to perform a CS. Concordance with this standard was assessed in the NSCSA which demonstrated that maternity services meeting the standard had lower CS rates.

If this standard was met throughout maternity services it is likely the CS rate would be reduced by 1%. A clinical unit’s CS rate is also affected by organisational factors (such as being a tertiary referral centre or the presence of a neonatal intensive care unit).

A review of Canadian hospitals with low CS rates suggested that achievement and attainment of a low CS rate was associated with a range of factors including attitudinal factors (such as pride in a low CS rate, a ‘culture’ of birth as a normal physiological process, a commitment to one-to-one supportive care in labour), organisation of care (such as strong leadership, effective multidisciplinary teams, timely access to skilled professionals), clinicians application of knowledge and information (such as a strong commitment to evidence based practice and programmes to ensure continuous quality improvement).