Caesarean birth

Offer all pregnant women information and support to enable them to make informed decisions about childbirth. Make sure that:

• the information is evidence based

• any information provided is accessible, ideally with a choice of formats to suit different women's needs

• the language used in any information (written or oral) is respectful and suitable for the woman, taking into account any personal, cultural or religious factors that could form part of the woman's choices

• the women's preferences and concerns are central to the decision-making process. [2004, amended 2021]

Discuss mode of birth with all pregnant women early in their pregnancy. Cover information such as:

• around 25% to 30% of women have a caesarean birth

• factors that mean women may need a caesarean birth (for example, increased maternal age and body mass index [BMI])

• common indications for emergency caesarean birth include slow progression of labour or concern about fetal condition

• planned place of birth may affect the mode of birth (see planning place of birth in the NICE guideline on intrapartum care)

• what the caesarean birth procedure involves

• how a caesarean birth may impact on the postnatal period (for example, need for pain relief)

• implications for future pregnancies and birth after caesarean birth or vaginal birth (for example, after a caesarean birth the chances of caesarean birth in a future pregnancy may be increased). [2011, amended 2021]

Discuss the benefits and risks of both caesarean and vaginal birth with women, taking into account their circumstances, concerns, priorities and plans for future pregnancies. [2021]

Using the information in appendix A, explain to women that:

• there are benefits and risks associated with both vaginal and caesarean birth, some of which are very small absolute risks and some are greater absolute risks, and they will need to decide which risks are more (or less) acceptable to them

• there are other risks not included in these tables that might be relevant to their individual circumstances (for example, placental adherence problems from multiple caesarean births, fetal lacerations in caesarean birth, term birth injuries with vaginal birth or caesarean birth)

• these tables give summary estimates only and are intended to help discussions, but precise numerical risk estimates cannot be given for individual women. [2021]

Discuss with women the benefits and risks of planned vaginal birth versus planned caesarean birth for breech presentation, and the option of external cephalic version. [2004, amended 2021]

Offer women who have an uncomplicated singleton breech pregnancy after 36+0 weeks, external cephalic version, unless:

• the woman is in established labour

• there is fetal compromise

• the woman has ruptured membranes or vaginal bleeding

• the woman has any other medical conditions (for example, severe hypertension) that would make external cephalic version inadvisable. [2004, amended 2021]

Before carrying out a caesarean birth for an uncomplicated singleton breech pregnancy, carry out an ultrasound scan to check that the baby is in the breech position. Do this as late as possible before the caesarean birth procedure. [2021]

For recommendations on mode of birth in multiple pregnancy, see mode of birth in the NICE guideline on twin and triplet pregnancy. [2021]

For recommendations on mode of birth in preterm labour and birth, see mode of birth in the NICE guideline on preterm labour and birth. [2021]

Offer caesarean birth to women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia). [2004, amended 2011]

If the routine 20-week ultrasound scan shows placenta praevia or low-lying placenta in a woman or pregnant person with a previous caesarean scar (or a uterine scar from other surgery), refer for a greyscale ultrasound scan with colour doppler to assess for placenta accreta. This scan should be done around 28 weeks, but no later than 29 weeks, by a senior clinician with expertise in the diagnosis of placenta accreta. [2024]

(See the section on routine antenatal clinical care in the NICE guideline on antenatal care for more information on routine scans.)

If placenta accreta is suspected following the greyscale ultrasound scan with colour doppler (see recommendation 1.2.7), refer the woman or pregnant person to a specialist placenta accreta spectrum centre for care and ongoing management. [2024]

Consider an MRI scan to complement ultrasound findings when planning ongoing surgical management of placenta accreta spectrum. Discuss the following with the woman or pregnant person:

• what to expect during an MRI procedure

• that MRI can help clarify the degree of invasion, particularly with a posterior placenta

• that current experience suggests that MRI is safe, but that there is a lack of evidence about any long-term risks to the baby. [2024]

Discuss birth options (for example, timing of birth, operative interventions including possibility of hysterectomy, need for blood transfusion) with a woman or pregnant person suspected to have placenta accreta spectrum. This discussion should be carried out by a senior obstetrician. [2011, amended 2024]

When planning a caesarean birth for women or pregnant people suspected to have placenta accreta spectrum, the multidisciplinary team should:

• agree which other healthcare professionals need to be consulted or present (for example, specialists in gynaecological surgery, interventional radiology, colorectal surgery, urology or vascular surgery, depending on the nature of the placenta accreta spectrum) and

• the responsibilities of each team member. [2011, amended 2024]

When performing a planned caesarean birth for a woman or pregnant person suspected to have placenta accreta spectrum, ensure that:

• a consultant obstetrician, a consultant gynaecologist and a consultant anaesthetist are present in the operating theatre

• a paediatric or neonatal registrar or consultant is present to provide immediate care for the baby as soon as it is born

• a haematology registrar or consultant is available to contact for advice

• a critical care bed is available for the woman or pregnant person, and a critical care neonatal cot is available for the baby (although emergency surgery should not be delayed while waiting for a bed)

• sufficient cross-matched blood and blood products are readily available (if blood transfusions are acceptable to the woman or pregnant person). See the NICE guideline on blood transfusion. [2011, amended 2024]

Specialist placenta accreta spectrum centres and the local maternity units they support should develop protocols covering how placenta accreta spectrum should be diagnosed, assessed and managed across their network. The protocol should include the care and management of placenta accreta spectrum identified late in pregnancy or in labour, including how specialist units can support emergency care in local maternity units. [2024]

Do not use pelvimetry for decision making about mode of birth. [2004, amended 2021]

Do not use the following for decision making about mode of birth, as they do not accurately predict cephalopelvic disproportion:

• maternal shoe size

• maternal height

• estimations of fetal size (ultrasound or clinical examination). [2004, amended 2021]

Do not use a BMI of over 50 kg/m² alone as an indication for planned caesarean birth. [2011]

Ask for consent for caesarean birth only after providing pregnant women with evidence-based information. Ensure the woman's dignity, privacy, views and culture are respected, while taking the woman's clinical situation into account. [2004, amended 2021]

Advise women that they are entitled to decline the offer of treatment such as caesarean birth, even when it would benefit their or their baby's health. [2004, amended 2021]

When a woman decides on or declines a caesarean birth, document the factors that that are important to the woman when making her decision. [2004, amended 2021]

When a woman or pregnant person with no medical indication for a caesarean birth requests a caesarean birth:

• offer to discuss and explore the reasons for the request

• ensure they have balanced and accurate information

• offer to discuss alternative birth options (for example, place of birth, continuity of midwifery care where available, pain relief options), which may help address concerns they have about the birth

• offer discussions with a consultant midwife or senior midwife, ideally in a birth options clinic or at a birth options appointment

• offer discussions with a consultant or senior obstetrician and other members of the team (for example, an anaesthetist) if necessary or requested by the woman or pregnant person

• record the discussions and decisions. [2011, amended 2023]

If a woman or pregnant person requests a caesarean birth, discuss the overall benefits and risks of caesarean birth compared with vaginal birth (see the section on planning mode of birth) and record that this discussion has taken place. [2011]

If a woman or pregnant person requests a caesarean birth because they have tokophobia or other severe anxiety about childbirth (for example, following abuse or a previous traumatic event), offer referral to a healthcare professional with expertise in providing perinatal mental health support to help with their anxiety. See the NICE guideline on antenatal and postnatal mental health for more detailed advice on providing mental health services during pregnancy. [2011, amended 2021]

Ensure healthcare professionals providing perinatal mental health support for women or pregnant people with tokophobia or other severe anxiety about childbirth are able to access the planned place of birth with the woman or pregnant person during the antenatal period, as part of the support offered to help them overcome fears and concerns about the labour and birth. [2011, amended 2023]

If, after an informed discussion about the options for birth (including the offer of perinatal mental health support if appropriate; see recommendation 1.2.27), the woman or pregnant person requests a caesarean birth, support their choice. [2011, amended 2023]

If a woman or pregnant person requests a caesarean birth this should be offered within their obstetric unit. [2011, amended 2023]

Inform women that continuous support during labour from women, with or without prior training, reduces the likelihood of caesarean birth. [2004]

Use a partogram with a 4‑hour action line to monitor progress of women in spontaneous labour with an uncomplicated singleton pregnancy at term to reduce the likelihood of caesarean birth. [2004]

Involve a consultant obstetrician in decision-making for caesarean birth. [2004, amended 2021]

Inform women that the following interventions during intrapartum care have not been shown to influence the likelihood of caesarean birth, although they can affect other outcomes:

• walking in labour

• non-supine position during the second stage of labour

• immersion in water during labour

• epidural analgesia during labour

• the use of raspberry leaves. [2004, amended 2021]

Inform women that the effects on the likelihood of caesarean birth of complementary therapies used during labour (such as acupuncture, aromatherapy, hypnosis, herbal products, nutritional supplements, homeopathic medicines, and Chinese medicines) are uncertain. [2004, amended 2021]

Do not offer the following as they do not influence the likelihood of caesarean birth for slow progression in labour, although they can affect other outcomes:

• active management of labour (comprising a strict definition of established labour, early routine amniotomy, routine 2‑hourly vaginal examination, oxytocin if labour becomes slow)

• early amniotomy. [2004, amended 2021]

Inform women 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 needed is uncertain. [2004]

Inform women that having isotonic drinks during labour prevents ketosis without a concomitant increase in gastric volume. [2004]

Do not routinely carry out planned caesarean birth before 39 weeks, as this can increase the risk of respiratory morbidity in babies. [2004]

Use the following standardised scheme to document the urgency of caesarean birth and aid clear communication between healthcare professionals:

• Category 1. Immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia).

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

• Category 3. No maternal or fetal compromise but needs early birth.

• Category 4. Birth timed to suit woman or healthcare provider. [2004, amended 2021]

Perform category 1 caesarean birth as soon as possible, and in most situations within 30 minutes of making the decision. [2011, amended 2021]

Perform category 2 caesarean birth as soon as possible, and in most situations within 75 minutes of making the decision. [2011, amended 2021]

Take into account the condition of the woman and the unborn baby when making decisions about rapid birth. Be aware that rapid birth can be harmful in certain circumstances. [2011]

Before caesarean birth, carry out a full blood count to identify anaemia, antibody screening, and blood grouping with saving of serum. [2004, amended 2021]

Do not routinely carry out the following tests before caesarean birth:

• cross-matching of blood

• a clotting screen

• preoperative ultrasound for localisation of the placenta. [2004, amended 2021]

Carry out caesarean birth for pregnant women with antepartum haemorrhage, abruption or placenta praevia at a maternity unit with on-site blood transfusion services, as they are at increased risk of blood loss of more than 1,000 ml. [2004, amended 2021]

Give women having caesarean birth with regional anaesthesia an indwelling urinary catheter to prevent over-distension of the bladder. [2004, amended 2021]

Provide pregnant women having a caesarean birth with information on the different types of post‑caesarean birth analgesia, so that they can make an informed choice (see recommendation 1.6.11). [2004]

Offer women who are having a caesarean birth regional anaesthesia in preference to general anaesthesia, including women who have a diagnosis of placenta praevia. [2004, amended 2021]

Carry out induction of anaesthesia, including regional anaesthesia, for caesarean birth in theatre. [2004, amended 2021]

Apply a left lateral tilt of up to 15 degrees or appropriate uterine displacement once the woman is in a supine position on the operating table to reduce maternal hypotension. [2004, amended 2021]

Offer women who are having a caesarean birth under spinal anaesthesia a prophylactic intravenous infusion of phenylephrine, started immediately after the spinal injection. Adjust the rate of infusion to keep maternal blood pressure at 90% or more of baseline value and avoid decreases to less than 80% of baseline. [2004, amended 2021]

When using phenylephrine infusion, give intravenous ephedrine boluses to manage hypotension during caesarean birth, for example, if the heart rate is low and blood pressure is less than 90% of baseline. [2004, amended 2021]

Use intravenous crystalloid co-loading in addition to vasopressors to reduce the risk of hypotension occurring during caesarean birth. [2004, amended 2021]

Ensure each maternity unit has a set of procedures for failed intubation during obstetric anaesthesia. [2004]

Offer women antacids and drugs (such as H₂‑receptor antagonists or proton pump inhibitors) to reduce gastric volumes and acidity before caesarean birth.

In March 2021, this was an off-label use of proton pump inhibitors. See NICE's information on prescribing medicines. [2004, amended 2021]

Offer women having a caesarean birth anti-emetics (either pharmacological or acupressure) to reduce nausea and vomiting during caesarean birth. [2004]

Include pre-oxygenation, cricoid pressure and rapid sequence induction in general anaesthesia for caesarean birth to reduce the risk of aspiration. [2004, amended 2011]

Warm IV fluids (500 ml or more) and blood products used during caesarean birth to 37 degrees Celsius using a fluid warming device. [2021]

Warm all irrigation fluids used during caesarean birth to 38 to 40 degrees Celsius in a thermostatically controlled cabinet. [2021]

Consider forced air warming for women who shiver, feel cold, or have a temperature of less than 36 degrees Celsius during caesarean birth. [2021]

Ensure an appropriately trained practitioner skilled in the resuscitation of newborn babies is present for caesarean birth performed under general anaesthesia, or if there is evidence of fetal compromise. [2004]

As babies born by caesarean birth are more likely to have a lower temperature, ensure thermal care is in accordance with good practice for thermal care of newborn babies. [2004]

Offer and facilitate early skin-to-skin contact between the woman and her baby. [2004, amended 2021]

Offer women who have had a caesarean birth and who wish to breastfeed support to help them to start breastfeeding as soon as possible after the birth of their baby. [2004, amended 2021]

Be aware that, although it is rare for women to need intensive care after childbirth, this may occur after caesarean birth. [2004, amended 2021]

Offer intrathecal diamorphine (up to 300 micrograms) to reduce the need for supplemental analgesia after a caesarean birth. Use epidural diamorphine (up to 3 mg) as an alternative if intrathecal diamorphine has not been given.

In September 2023, this was an off-label use of diamorphine (both intrathecal and epidural). See NICE's information on prescribing medicines. [2004, amended 2023]

If diamorphine is unavailable, offer intrathecal preservative-free morphine (up to 100 micrograms) plus intrathecal fentanyl (up to 15 micrograms). Use epidural preservative-free morphine (up to 3 mg) as an alternative if intrathecal morphine has not been used.

Take into account that neuraxial morphine increases the risk of nausea, vomiting and itching compared with diamorphine, and that these side effects may need treatment.

In September 2023, this was an off-label use of fentanyl (intrathecal). See NICE's information on prescribing medicines. [2023]

When using neuraxial morphine in place of diamorphine, ensure that:

• only preservative-free morphine is used

• that preservative-containing and preservative-free morphine are stored separately

• that in settings where both types of morphine injection are kept, preservative-containing morphine is clearly identified as 'not for neuraxial administration'. [2023]

Discuss options with women for pain relief after caesarean birth and explain that:

• pain after caesarean birth can be controlled using oral or injectable medicines

• their choice of pain relief medicines after caesarean birth will depend on:

  • the severity of pain

  • whether they had spinal or epidural anaesthesia, or general anaesthesia

• if they wish to breastfeed, they will usually be able to do this and care for their baby while taking pain relief medicines. [2021]

Offer oral morphine sulfate to women who have received spinal or epidural anaesthesia for caesarean birth. If the woman cannot take oral medication (for example, because of nausea or vomiting), offer intravenous, intramuscular or subcutaneous morphine. [2021]

Consider intravenous patient-controlled analgesia (PCA) using morphine for women and people who have given birth who have had a general anaesthetic for caesarean birth. If intravenous PCA is not acceptable to the woman or person who has given birth, or the pain is less severe, consider oral morphine sulfate. [2021]

Ensure women and people who have had PCA with opioids after caesarean birth have routine hourly monitoring of oxygen saturations, respiratory rate, sedation and pain scores throughout treatment, and for at least 2 hours after discontinuation of treatment. [2004, amended 2023]

Use paracetamol and, unless contraindicated, a non-steroidal anti-inflammatory drug (for example, ibuprofen) in combination after caesarean birth, to reduce the need for opioids and to allow them to be stepped down and stopped as early as possible. [2004, amended 2021]

If paracetamol does not provide sufficient pain relief after caesarean birth, or non-steroidal anti‑inflammatory drugs cannot be taken, consider adding dihydrocodeine to paracetamol, or changing to co-dydramol (combination preparation of paracetamol and dihydrocodeine) as an alternative to paracetamol. [2021]

Do not offer codeine or co‑codamol (combination preparation of paracetamol and codeine) to women who are currently breastfeeding, because this can lead to serious neonatal sedation and respiratory depression. Follow the MHRA safety advice on codeine for analgesia: restricted use in children because of reports of morphine toxicity. [2021]

When using paracetamol, dihydrocodeine, co-dydramol or a non-steroidal anti-inflammatory drug after caesarean birth, prescribe them to be taken regularly and not just when needed for pain relief. [2021]

For women with severe pain after caesarean birth, when other pain relief is not sufficient:

• perform a full assessment to exclude other causes for the pain (for example, sepsis, haemorrhage, urinary retention)

• discuss with the woman that stronger pain relief medicines are available

• make sure the woman is aware that, if taken while breastfeeding, these medicines could increase the risk of neonatal sedation and respiratory depression.
  
  If the woman chooses to take stronger medicines, consider a short course of tramadol or oxycodone at the lowest effective dose. [2021]

In breastfeeding women, use opioid analgesics (for example, morphine, dihydrocodeine, tramadol or oxycodone) at the lowest effective dose and for the shortest duration, and not for more than 3 days without close supervision. [2021]

If, after a caesarean birth, a woman is discharged home on opioids, advise the woman to contact their healthcare provider if they are concerned about their baby (for example, drowsiness, breathing difficulties, constipation or difficulty feeding). [2021]

Consider laxatives for women taking opioids, for the prevention of constipation. [2021]

Consider anti-emetics for women taking opioids, if needed for nausea and vomiting. [2021]

Advise women that some over-the-counter medicines contain codeine, and should not be taken while breastfeeding because this can lead to serious neonatal sedation and respiratory depression. [2021]

If women are recovering well after caesarean birth and do not have complications, they can eat and drink as normal. [2004]

Offer removal of the urinary bladder catheter once a woman is mobile after a regional anaesthetic for caesarean birth, but no sooner than 12 hours after the last 'top-up' dose. [2004, amended 2021]

Do not offer routine respiratory physiotherapy to women after a caesarean birth under general anaesthesia as it does not improve respiratory outcomes (for example, coughing, phlegm, body temperature, chest palpation or auscultatory changes). [2004]

Inform women that length of hospital stay is likely to be longer after caesarean birth than after a vaginal birth. [2004, amended 2021]

Offer women who are recovering well, are apyrexial and do not have complications after caesarean birth, discharge from hospital after 24 hours and follow up at home, as this is not associated with more readmissions for babies or mothers. [2004, amended 2021]

Consider negative pressure wound therapy after caesarean birth for women with a BMI of 35 kg/m² or more to reduce the risk of wound infections. [2021]

When using standard (not negative pressure) wound dressings after caesarean birth take into account that:

• no type of wound dressing has been shown to be better than another at reducing the risk of wound infections

• there is no difference in the risk of wound infection when dressings are removed 6 hours postoperatively, compared with 24 hours postoperatively. [2021]

Ensure caesarean birth wound care includes:

• removing standard dressings 6 to 24 hours after the caesarean birth

• 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.
  
  Follow the recommendations in the NICE guideline on surgical site infections. [2004, amended 2021]

When caring for women who have had a caesarean birth who have urinary symptoms, consider possible diagnoses of:

• urinary tract infection

• stress incontinence (occurs in about 4% of women after caesarean birth)

• urinary tract injury (occurs in about 1 per 1,000 caesarean births)

• urinary retention. [2004, amended 2021]

When caring for women who have had a caesarean birth who have heavy and/or irregular vaginal bleeding, consider whether this is more likely to be because of endometritis than retained products of conception, and manage accordingly. [2004, amended 2021]

Pay particular attention to women who have respiratory symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf), as women who have had a caesarean birth may be at increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism). [2004, amended 2021]

Inform women who have had a caesarean birth that they can resume activities such as driving a vehicle, carrying heavy items, formal exercise and sexual intercourse when they feel they have fully recovered from the caesarean birth (including any physical restrictions or pain). [2004, amended 2021]

When caring for women who have had a caesarean birth, discuss that after a caesarean birth they are not at increased risk of depression, post-traumatic stress symptoms, pain on sexual intercourse, faecal incontinence or difficulties with breastfeeding. [2004, amended 2021]

While women are in hospital after having an emergency or unplanned caesarean birth, give them the opportunity to discuss with healthcare professionals the reasons for the caesarean birth, and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date. [2011, amended 2021]

Inform the woman's GP if follow-up investigations are needed after discharge from hospital (for example, a repeat full blood count if there has been a large amount of blood loss), and include details of the plan or course of action if the results are abnormal. [2021]