Individual research recommendation details

Recommendation ID

NG121/5

Question

What is the clinical and cost effectiveness of intermittent auscultation compared with continuous cardiotocography for women in labour who have had a previous caesarean section?

Any explanatory notes
(if applicable)

No evidence was found for intravenous cannulation for women in labour with a previous caesarean section. The committee agreed that the chance of needing intravenous access for urgent blood transfusion was unlikely to be higher in these women, and so recommended that cannulation should not be routine.

The committee noted from the evidence and their expertise that the risk of uterine rupture with vaginal birth was small for women with a previous caesarean section. There was some evidence that performing an emergency caesarean section in labour is associated with an increased risk of heavy bleeding and the need for blood transfusion, infection and a longer hospital stay. The committee recommended that women should be told about this when making decisions about mode of birth.

The committee felt it was important that women should be made aware that there is no compelling evidence to recommend one mode of birth over another to improve outcomes for the baby.

Evidence indicated that women in labour with a previous caesarean section are likely to be at a lower risk of complications if they have also had a previous vaginal birth.

There was evidence that augmentation of labour with oxytocin and regional analgesia both reduced the chance of another caesarean section for women in labour who have had a caesarean section in the past. The likelihood of an instrumental vaginal birth (forceps or ventouse) was increased with both. The committee agreed that this should be explained to women so that they can make a fully informed decision.

No evidence was found to recommend one form of pain relief over another for women with a previous caesarean section. There was also no evidence that the use of the birthing pool for pain relief is contraindicated for these women. Therefore, the committee agreed to recommend that all forms of pain relief, including the birthing pool, should be offered.

No evidence was found for routine amniotomy in women in labour with previous caesarean section. The committee used their experience and expertise to recommend that this should not be offered.

The committee was aware that continuous cardiotocography is usually advised for women in labour who have had a previous caesarean section. However, it is uncertain whether continuous cardiotocography in these circumstances allows risk to be identified sooner than if intermittent auscultation is used. The committee made a research recommendation to inform future guidance.

How the recommendations might affect practice

The committee recognised there was variation in practice and inequity in the choices available to women in labour with a previous caesarean section. The committee wanted to ensure that these women would be offered comprehensive information so that they could make informed decisions about their care and wellbeing, and would not be subjected to unnecessary interventions that may not improve outcomes for the woman or her baby. They noted that the extent of change in practice arising from the recommendations would vary across the UK based on current practice and that the recommendations may result in specific changes in practice around supporting women's choice of place of birth and routine cannulation in labour, which may in turn lead to cost savings for the healthcare system.

Full details of the evidence and the committee's discussion are in evidence review S: previous caesarean section.

Source guidance details

Comes from guidance

Intrapartum care for women with existing medical conditions or obstetric complications and their babies

Number

NG121

Date issued

March 2019

Other details