NICE 2011 Guideline Update, UK
TIMELINE

The organization "electivecesarean.com" registered as a Stakeholder for the NICE Caesarean Section Guideline (Update) in July 2009, and as such, its founder Pauline Hull was involved in agreeing the final scope of the guideline update (maternal request was not included in the original scope draft), and submitted evidence and proposed changes to the text of each Guideline draft. In fact it was the publication of the 2004 Caesarean Guideline, and its inclusion of the statement "maternal request is not on its own an indication for CS", that was the catalyst for this website and its campaign for change.

The Timeline below provides information and links relating to the guideline update process, changes to recommendations and NICE's final published documents.


*23 November 2011

CG132 Caesarean section: full guideline published (read the NICE version here, the PATIENT VERSION (view and print here), and the Appendicies and Evidence tables here)

Important updates to "Key priorities for implementation" include:


Maternal request for CS

*When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.

*For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.

*An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.


Morbidly adherent placenta

*Offer MRI if acceptable to the woman.


Timing of antibiotic administration

*Offer women prophylactic antibiotics at CS before skin incision. Inform them that this reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision, and that no effect on the baby has been demonstrated

*Offer women prophylactic antibiotics at CS to reduce the risk of postoperative infections. Choose antibiotics effective against endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a CS.

*Do not use co-amoxiclav when giving antibiotics before skin incision.


Recovery following CS

*While women are in hospital after having a CS, give them the opportunity to discuss with healthcare professionals the reasons for the CS and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date.


Pregnancy and childbirth after CS

*Inform women who have had up to and including four CS that the risk of fever, bladder injuries and surgical injuries does not vary with planned mode of birth and that the risk of uterine rupture, although higher for planned vaginal birth, is rare.


Mother-to-child transmission of HIV

*Inform women that in these circumstances the risk of HIV transmission is the same for a CS and a vaginal birth.


Decision-to-delivery interval for unplanned CS

*Use these as audit standards only and not to judge multidisciplinary team performance for any individual CS.

Important updates to Recommendations include:

34. When a woman requests a CS explore, discuss and record the specific reasons for the request.
35. If a woman requests a CS when there is no other indication, discuss the overall risks and benefits of CS compared with vaginal birth (see tables 4.5 and 4.6) and record that this discussion has taken place. Include a discussion with other members of the obstetric team (including the obstetrician, midwife and anaesthetist) if necessary to explore the reasons for the request, and to ensure the woman has accurate information.
36. When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.
37. Ensure the healthcare professional providing perinatal mental health support has access to the planned place of birth during the antenatal period in order to provide care.
38. For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.
39. An obstetrician unwilling to perform a CS should refer the woman to an obstetrician who will carry out the CS.

Important update to Health Economics:

An economic model developed for this guideline suggested that planned vaginal birth was cost effective compared to a maternal request CS. However, this finding was limited to outcomes that were reported in the included studies for the clinical review undertaken for this guideline (see Section 4.2). A sensitivity analysis suggested that the inclusion of adverse outcomes not reported, such as urinary incontinence, could make the conclusion regarding cost effectiveness less certain. On balance, this model does not provide strong evidence to refuse a woman's request for CS on cost effectiveness grounds. (pages 100-101 of Full version)

*05 September 2011

Final draft of the guideline out for pre-publication check for factual inaccuracies by Stakeholders (together with Consultation Comments Table)
Read factual inaccuracies submitted by Pauline Hull - numbers 19-24 on pages 8-11

Important updates to Recommendations:

36. When a woman requests a CS because she has anxiety about childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her anxiety in a supportive manner.

38. For all women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS.

39. An obstetrician has the right to decline a woman's request for a CS. If this happens, they should refer the woman to an NHS obstetrician in the same
unit who will carry out the CS.

Evidence to Recommendations (page 101):

On balance this model [including the "downstream" cost of urinary incontinence alone] does not provide strong evidence to refuse a woman's request for CS on cost-effectiveness grounds.

*23 May 2011 - 22 June 2011

First draft of the guideline out for consultation with Stakeholders
Read comments/ evidence submitted by Pauline Hull on pages 187-265

Important updates to Recommendations:

36. When a woman requests a CS because she has a fear of childbirth, offer referral to a healthcare professional with expertise in providing perinatal mental health support to help her address her fears in a supportive manner.

38. If after providing support, a vaginal birth is still not an acceptable option to the woman, offer a planned CS.

39. An obstetrician has the right to decline a woman's request for a CS. If this happens, they should refer the woman to an obstetrician who will carry out the CS.


*08 July 2010

Final scope
, workshop notes and consultation table with responses published online
Read comments/evidence provided by Pauline Hull on pages 22-36

Important update to Scope:

Following stakeholder consultation we now plan to include an update of the section on maternal request.

*24 February 2010 - 24 March 2010
Draft scope of the guideline out for consultation with Stakeholders

*25 January 2010
Workshop for Stakeholders to discuss scope of the guideline update (maternal request is not listed in the draft scope)

*22 July 2009
Organization electivecesarean.com registered as a Stakeholder for the guideline