Caesarean birth

Resource impact statement

The NICE guideline on caesarean birth originally published in March 2021 and was partially updated in the areas of placenta accreta spectrum (January 2024), diamorphine for spinal analgesia (September 2023), surgical opening technique (August 2023) and maternal request for caesarean birth (June 2023). The updates replace the relevant parts from the original guideline.

Placenta accreta spectrum (January 2024 update)

The guideline update sets out recommendations for the diagnosis and management of placenta accreta.

We expect that the resource impact of this update:

• for any single guideline recommendation in England will be less than £1 million per year (or approximately £1,800 per 100,000 population, based on a population for England of 56.6 million people) and
• for implementing the whole guideline in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 56.6 million people).

The guideline states that a greyscale ultrasound scan is conducted at 28 weeks by a senior clinician with expertise in the diagnosis of placenta accreta if a 20‑week ultrasound scan shows placenta praevia or low-lying placenta in a woman or pregnant person with a previous caesarean scar (or uterine scar from other surgery). We do not anticipate that this will have a significant resource impact because these scans are ordinarily performed by a consultant.

The number of MRI scans conducted for this population may reduce as previous guidance assumed that an MRI scan would be offered when placenta accreta was suspected. MRI scans should no longer be routinely offered because evidence suggests that they are no better at diagnosing placenta accreta than the greyscale ultrasound scan with colour Doppler. However, MRI scans may continue to have a role in some cases as they can be a useful aid in surgical planning. 

Diamorphine for spinal analgesia (September 2023 update)

The guideline update sets out recommendations on the use of neuraxial diamorphine, neuraxial morphine and the postoperative monitoring requirements following a caesarean birth.

We expect that the resource impact of this update:

• for any single guideline recommendation in England will be less than £1 million per year (or approximately £1,800 per 100,000 population, based on a population for England of 56.6 million people) and
• for implementing the whole guideline in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 56.6 million people).

The guideline recommends morphine as the preferred alternative when diamorphine is not available. Compared to neuraxial diamorphine, neuraxial morphine may be associated with an increased risk of respiratory depression over a longer period. Additional monitoring may therefore be required when morphine is used, and this should be determined by clinical assessment of individual cases. The impact of the requirement for any increased monitoring will be dependent on the setting in which any additional monitoring takes place and the resources used to do this.

Surgical opening technique (August 2023 update)

The guideline update sets out recommendations for surgical techniques for caesarean birth.

We expect that the resource impact of this update:

• for any single guideline recommendation in England will be less than £1 million per year (or approximately £1,800 per 100,000 population, based on a population for England of 56.6 million people) and
• for implementing the whole guideline in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 56.6 million people).

A significant change in clinical practice is not expected because of the updated recommendation 1.4.28. The updated guideline advises obstetric surgeons of the best surgical opening technique when performing caesarean births yet allows room for surgeon modification on a case-by-case basis. Use of a technique which reduces operating time, blood loss, pain and infections may lead to savings in resources to treat these complications.

Maternal request for caesarean birth (June 2023 update)

The guideline update sets out recommendations for women and pregnant people who request a caesarean birth in the absence of a medical indication for one.

We expect that the resource impact of this update:

• for any single guideline recommendation in England will be less than £1 million per year (or approximately £1,800 per 100,000 population, based on a population for England of 56.6 million people) and
• for implementing the whole guideline in England will be less than £5 million per year (or approximately £8,800 per 100,000 population, based on a population for England of 56.6 million people).

The recommendations have not changed significantly from the previous NICE guideline and we do not think practice will change substantially as a result of this guideline update. This is because conversations around choice of birth already happen during midwife appointments and the existing NICE guideline allowed people with no medical indication for a caesarean birth to choose to have a caesarean birth. No impact on capacity is anticipated as discussions with the same level of clinical staff are recommended following a request for a caesarean birth.

Maternity services and transitional care are commissioned by integrated care boards. Providers are NHS hospital trusts, primary care, and community services.