COMMENTARY

The National Institute of Clinical Excellence (NICE) guide-

lines for caesarean sections: implications for the anaesthetist
M. Y. K Wee, H. Brown, F. Reynolds
Department of Anaesthesia, Poole Hospital, Dorset, Department of Obstetrics and Gynaecology,
Princess Anne Hospital, Southampton, Department of Anaesthesia, St. Thomass Hospital, London, UK
INTRODUCTION
The bodies involved; Background; Aims of the guidelines; Evidence and grading of recommendations
SUMMARY OF RECOMMENDATIONS AFFECTING ANAESTHETIC PRACTICE
Provision of information and consent
Classification of urgency of caesarean section
Planned caesarean section
Factors in intrapartum care affecting likelihood of caesarean section
Factors with no influence on caesarean section rates: Epidural analgesia; Eating in labour
Procedural aspects of caesarean section: Decision-to-delivery interval for emergency caesarean section; Pre-
operative testing and preparation for caesarean section; Urinary catheterisation at caesarean section
Aspects of anaesthesia for caesarean section: Antacids and antiemetics; General versus regional anaesthesia for
caesarean section; Converting epidural analgesia to anaesthesia for caesarean section; Place of induc-
tion and monitoring during caesarean section; Procedures to avoid hypotension; Failed intubation
Surgical techniques for caesarean section of relevance to the anaesthetist: Use of uterotonics; Uterine exteriorisation;
Use of antibiotics; Thromboprophylaxis for caesarean section
Care of the baby born by caesarean section
Care of the woman after caesarean section: High dependency and intensive care admission; Routine monitoring after
caesarean section
Pain management after caesarean section: Intrathecal and epidural analgesia; Patient controlled analgesia (PCA)
and non-steroidal anti-inflammatory analgesics; Other local anaesthetic techniques
Post partum care: Early eating and drinking after caesarean section; Urinary catheter removal after caesarean
section; Length of hospital stay
CONCLUSION
Keywords: NICE guidelines; Caesarean section; Anaesthesia
INTRODUCTION
The National Institute for Clinical Excellence (NICE)
is part of the National Health Service (NHS) in the
UK. It was established in 1999 as an independent
organisation to promote clinical excellence by provid-
ing guidance on treatments and care based on the
best available evidence and effective use of resources.
NICE has under its wing the Confidential Enquiries
into Maternal and Child Health (CEMACH). In April
2004, NICE published caesarean section guidelines;
International Journal of Obstetric Anesthesia (2005) 14, 147158
2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijoa.2004.09.008
Accepted September 2004
M.Y.K. Wee, Consultant Obstetric Anaesthetist, Department of
Anaesthesia, Poole Hospital NHS Trust, Longfleet Road, Poole, Dorset
BH 15 2JB, UK, H. Brown, Senior Specialist Registrar in Obstetrics
and Gynaecology, Princess Anne Hospital, Coxford Road,
Southampton SO16 5YA, F. Reynolds, Emeritus Professor of
Obstetric Anaesthesia, St. Thomass Hospital, Lambeth Palace Road,
London SE1 7EH, UK.
Correspondence to: M.Y.K Wee, Consultant Obstetric Anaesthetist,
Department of Anaesthesia, Poole Hospital NHS Trust, Longfleet
Road, Poole, Dorset BH 15 2JB, UK, Tel.: +44 120 244 2443;
fax: +44 120 244 2672;
E-mail: m.wee@virgin.net.
147
the aim of this review is to highlight aspects of these
guidelines that may have implications for anaes-
thetists.
Several versions of the guidelines are available and
can be downloaded from the web:
i. the full document
www.nice.org.uk/pdf/CG013fullguideline.pdf
ii. evidence tables
www.nice.org.uk/pdf/CG013evidencetables.pdf
iii. an algorithm
www.nice.org.uk/pdf/CG013algorithm.pdf
iv. recommendations for the NHS
www.nice.org.uk/pdf/CG013NICEguideline.pdf
v. the quick reference guide
www.nice.org.uk/pdf/CG013quickrefguide.pdf
vi. information for the public
www.nice.org.uk/pdf/CG013publicinfoenglish.pdf
(very large print)
The bodies involved
The National Collaborating Centre for Womens and
Childrens Health (NCC-WCH) was commissioned by
NICE to produce the guidelines. NICE and 60 registered
stakeholders including the Royal College of Anaesthe-
tists (RCA) and Obstetric Anaesthetists Association
(OAA) were involved in their development. An indepen-
dent Guideline Review Panel and Patient Involvement
Unit then reviewed the draft guidelines.
The NCC-WCH established the Guideline Develop-
ment Group (GDG) comprising a general practitioner
who chaired the group, two obstetricians, two midwives,
a neonatologist, an anaesthetist and two consumers.
Other members of the GDG included the director of
the NCC-WCH, chair of CEMACH, informatics special-
ist, health economist and several research fellows. The
anaesthetic representative was selected from nomina-
tions submitted by the RCA and the OAA and consulted
widely during development of the guidelines on issues
of anaesthetic interest from obstetric anaesthetist experts
within the UK.
Background
The National Sentinel Caesarean Section Audit
(NSCSA) reported that in England and Wales, caesarean
section rates increased from 9% of deliveries in 1980 to
21% in 2001, with similar increases in many developed
countries.
1
The average age of women giving birth has
increased and caesarean section rates increase with
maternal age. The caesarean section rate for women in
their first pregnancy is now 24% and for women who
have had a previous caesarean section, it is markedly in-
creased (67%). The caesarean section rate also varied in
the UK according to ethnicity, with higher rates reported
in black African and Caribbean ethnic groups.
The five major indications for caesarean section in
the UK are fetal compromise (22%), failure to progress
in labour (20%), repeat caesarean section (14%), breech
presentation (11%) and maternal request (7%).
1
The first
indication is influenced by the use of continuous elec-
tronic fetal monitoring, which may be associated with
increased caesarean section rate unless it is used in con-
junction with fetal blood sampling to assess fetal acid-
base balance before a decision is made for caesarean
section.
Aims of the guidelines
The guidelines aim to provide evidence-based informa-
tion in the following areas:
Risks and benefits of caesarean section
Certain specific indications for caesarean section
Effective management strategies to avoid caesarean
section
Anaesthetic and surgical aspects of care
Interventions to reduce morbidity from caesarean sec-
tion and
Aspects of organisation and environment that affect
caesarean section rates.
This does not cover all the clinical decisions and care
pathways that may lead to caesarean section. For exam-
ple, it omits advice on the risks and benefits of caesarean
section in specific conditions such as preeclampsia or
gestational diabetes or in rare diseases.
As well as clinical effectiveness, the guidelines were
concerned with cost-effectiveness of caesarean section
compared to vaginal birth.
Evidence and grading of recommendations
Evidence from studies that were least subject to bias and
published systematic reviews or meta-analyses were
used where available (Table 1). Data are presented as
absolute risks, relative risks or odds ratios where rele-
vant. Where data are statistically significant they are
also presented as numbers needed to treat for beneficial
outcomes or numbers needed to harm for adverse effects
as relevant. Recommendations are graded according to
the strength of the evidence that supports them
(Table 2).
SUMMARY OF RECOMMENDATIONS
AFFECTING ANAESTHETIC PRACTICE
Bullet-points below quote from, summarise or para-
phrase recommendations from the guidelines; the letter
following denotes their grading (Table 2).
148 International Journal of Obstetric Anesthesia
Provision of information and consent
Pregnant women should be given evidence-based
information and support to enable them to make
informed decisions about childbirth. [C]
Information about caesarean section should be given
during the antenatal period because about 1 in 5 preg-
nant women will have a caesarean section. [GPP]
The information should be in a form that is accessi-
ble taking into account cultural needs of ethnic
minority communities and those with disabilities.
[GPP]
In 1993, the Expert Maternity Group from the
Department of Health released the report Changing
Childbirth,
2
which made explicit the right of women
to be involved in decisions regarding all aspects of
their care during pregnancy and childbirth. In order
to discuss decisions with caregivers, women require
evidence-based information. Randomised trials (RCTs)
on antenatal education suggest that the provision of
information is often seen as inadequate by women.
3
The use of evidence-based information leaflets has
been shown to improve maternal satisfaction.
4
As
about one in five women in the UK are delivered by
caesarean section (the majority unplanned),
1
all of
them need information on both vaginal and caesarean
delivery. The Obstetric Anaesthetists Association has
produced evidence-based leaflets and a related video
on anaesthesia for caesarean section that can be used
to inform women.
5,6
Provision of information is a prerequisite to consent
and should cover the patients condition, possible inves-
tigations and treatment options, their risks and benefits
and the risk of refusing treatment.
710
Ideally, in the case
of caesarean section, such estimates should be derived
from intention to treat analysis of RCTs and systematic
reviews comparing planned caesarean section with
planned vaginal birth.
1113
Anaesthetists should give full
information including the material risks of anaesthesia
for caesarean section.
1415
Consent for caesarean section should be requested
after providing the pregnant woman with evi-
dence-based information and in a manner that
respects the womans dignity, privacy, views and
culture whilst taking into consideration the clinical
situation. [C]
A competent pregnant woman is entitled to refuse
treatment even when the treatment would clearly
benefit her or her babys health. Refusal of treatment
needs to be one of the womans options. [D]
Classification of urgency of caesarean section
Caesarean section has traditionally been classified as
elective and emergency. The emergency category,
however, does not differentiate between true emergen-
cies where the life of the woman or fetus is threatened,
and situations in which there is no imminent threat to
life. A four-point classification has been piloted, used
in a national survey and shown to predict baby out-
come.
1,16
Its adoption is recommended to aid clear com-
munication between healthcare professionals about the
urgency of caesarean section.
Category 1: immediate threat to the life of the woman or
fetus. This includes caesarean section for acute severe
fetal bradycardia, cord prolapse, uterine rupture, fetal
blood pH less than 7.2.
Table 1. Levels of evidence
Level Evidence
1a Systematic review or meta-analyses of randomised controlled trials
1b At least one randomised controlled trial
2a At least one well-designed controlled study without randomisation
2b At least one well-designed quasi-experimental study, such as a cohort study
3 Well-designed non-experimental descriptive studies, such as comparative studies,
correlation studies, case controlled studies and case series
4 Expert committee reports, or opinions and/or clinical experience of respected authorities
From www.nice.org.uk/pdf/CG013fullguideline.pdf.
Table 2. Grading of recommendations
Grade Strength of evidence
A Based on level 1 evidence
B Based on level 2 evidence or extrapolated from level 1 evidence
C Based on level 3 evidence or extrapolated from level 1 or 2 evidence
D Based on level 4 evidence or extrapolated from level 1, 2 or 3 evidence
GPP Group practice point based on the view of the guideline development group
NICE TA Recommendation taken from NICE Technology Appraisal
From www.nice.org.uk/pdf/CG013fullguideline.pdf.
The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections 149
Category 2: maternal or fetal compromise that is not
immediately life-threatening. There is a degree of
urgency to deliver the baby in order to prevent further
deterioration of either the mothers or the babys con-
dition. Examples include antepartum haemorrhage
and failure to progress in labour with maternal or
fetal compromise.
Category 3: no maternal or fetal compromise but needs
early delivery. Examples include a situation in which
caesarean section is planned but the woman is admit-
ted in early labour or with ruptured membranes.
Category 4: delivery timed to suit woman or staff. This
includes all planned elective caesarean sections.
Planned caesarean section
The guidelines recommend that planned caesarean sec-
tion should be offered:
with breech presentation at term if external cephalic
version has been unsuccessful or is contraindicated
[A]
to HIV-positive women at term [A].
to women with grade 3 or 4 placenta praevia [D]
The evidence for other indications is less sound, for
example it is uncertain whether caesarean section
confers any additional benefit in twin pregnancies
at term where the first twin is cephalic, preterm
babies or small for gestational age babies.
Maternal request is not on its own considered an
indication for caesarean section. Whether an indi-
vidual clinician has the right to decline a request
for a caesarean section is of concern to anaesthe-
tists. Individual women may request caesarean sec-
tion because of fear of pain in childbirth. The
guideline recommends counselling for this, but the
logical inference that a discussion with an anaesthe-
tist about epidural analgesia could form part of this
counselling is overlooked.
Factors in intrapartum care affecting likelihood of
caesarean section
The indications for emergency caesarean section should
surely feature prominently in the guidelines, as one of
the aims is to provide effective management strategies
to avoid caesarean section, and the majority of caesar-
ean sections are unplanned. Yet this topic is addressed
only under the heading Factors reducing the likelihood
of (caesarean section). The recommendations related
to care in labour are:
A partogram with a 4-h action line should be used to
monitor progress in women in spontaneous labour with
anuncomplicated singletonpregnancyat term, because
it reduces the likelihood of caesarean section. [A]
Consultant obstetricians should be involved in the
decision-making because this reduces the likeli-
hood of caesarean section. [C]
Electronic fetal monitoring is associated with an
increased likelihood of caesarean section. When cae-
sarean section is contemplated because of an abnor-
mal fetal heart rate pattern fetal blood
sampling should be offered if possible. [B]
Factors with no influence on caesarean section
rates
Epidural analgesia
A woman who mistakenly believes that epidural anal-
gesia increases the likelihood of caesarean section will
be prejudiced against it. Fortunately there is ample
evidence of the highest level (1a: RCTs and
meta-analyses
17,18
) that epidural analgesia during
labour does not influence the likelihood of caesarean
section.
Aspects of care in labour with no influence on the
likelihood of caesarean section include walking,
non-supine position during the second stage, immer-
sion in water, epidural analgesia and raspberry leaf
tea. [A]
Eating in labour
Eating in labour is an issue much debated between
healthcare professionals, some midwives believing it
will reduce the need for intervention. The debate is rel-
evant to obstetric anaesthesia. One RCT comparing a
group given a light diet in labour with a starved group
given water only (the guidelines erroneously state that
the starved group were given water, tea, coffee or co-
coa), showed that while maternal ketosis was improved,
gastric volume and vomiting were both increased by eat-
ing.
19
Another RCT substituted an isotonic sport drink
for solids and showed that it reduced ketosis without
increasing gastric volume.
20
Neither study was powered
to examine obstetric outcome, which is the subject of an
on-going study. The recommendation in the guidelines
states:
Women should be informed that eating a low residue
diet during labour results in larger gastric volumes,
but the effect on the risk of aspiration if anaesthesia is
required is uncertain having isotonic drinks during
labour prevents ketosis without a concomitant
increase in gastric volume. [A]
This surely misses the point; we know larger gastric
volumes are associated with increased likelihood of
vomiting, but not whether calorie intake affects the pro-
gress of labour.
150 International Journal of Obstetric Anesthesia
Procedural aspects of caesarean section
Decision-to-delivery interval for emergency caesarean
section
Earlier guidelines on electronic fetal heart monitoring
recommended that where acute fetal compromise was
suspected, delivery should occur as soon as possible,
ideally within 30 min, taking into account fetal and
maternal factors.
21
Research to underpin this 30-min
rule is limited.
2225
Poor outcome among babies deliv-
ered rapidly prompted the misapprehension that rapid
delivery may itself be causative, overlooking the fact
that the most compromised babies are commonly deliv-
ered with the least delay.
25,26
However, general anaes-
thesia to allow rapid delivery has been a cause of
maternal mortality.
27
The association between decision-to-delivery interval
and neonatal and maternal outcomes was examined
using data from NSCSA.
1
Babies who were delivered
with short (<30 min) or long (>75 min) decision-to-de-
livery intervals were more likely to require special care.
These findings are consistent with previous studies.
2224
A delay of more than 75 min, particularly of course in
the presence of fetal or maternal compromise, is associ-
ated with poorer outcomes.
28
The guidelines suggest that although 30 min is an
arbitrary limit, it remains important that the obstetric
team can respond safely within this time to Category
1 caesarean section. The 75-min decision-to-delivery
time should be added as a clinically important stan-
dard. [C]
Pre-operative testing and preparation for caesarean
section
Women who are anaemic are less able to tolerate blood
loss.
27
Recommendations for antenatal screening in-
clude measuring haemoglobin at booking and at 28
weeks.
29
It has been estimated that, of all women giving birth,
1.3% have blood loss >1000 mL while 0.7% have blood
loss >1500 mL.
30
Haemorrhage remains an important
cause of maternal mortality.
27
Although caesarean section
in labour is associated with greater blood loss than vaginal
or planned caesarean delivery,
30
there may be little differ-
ence in blood loss between planned caesarean section and
planned vaginal birth,
31,32
while factors such as placental
abruption or antepartumhaemorrhage contribute. Women
who have caesarean section for antepartum haemorrhage,
placenta praevia or uterine rupture account for 21% of
cases of blood loss >1000 mL in the UK.
1
Women should be offered a haemoglobin assessment
before caesarean section to identify those who have
anaemia. [C]
Women having caesarean section for antepartum
haemorrhage, placenta abruption, uterine rupture
and placenta praevia are at increased risk of blood
loss >1000 mL and should be delivered at a maternity
unit with on-site blood transfusion services. [C]
Grouping and saving of serum, cross-matching and a
clotting screen are unnecessary before caesarean sec-
tion in uncomplicated pregnancy. [C]
Urinary catheterisation at caesarean section
A survey of UK obstetricians reported that for caesarean
section under regional anaesthesia the majority (82%)
use an indwelling urinary catheter for both the procedure
and postoperatively, with a minority using the catheter
for the procedure only or an in-out catheter.
33
Women having caesarean section with regional
anaesthesia require an indwelling urinary catheter to
prevent over-distension of the bladder because the
anaesthetic block interferes with normal bladder
function. [GPP]
Aspects of anaesthesia for caesarean section
The options for anaesthesia and analgesia should be dis-
cussed with the woman before her caesarean section using
obstetric anaesthesia and analgesia information media.
5,6
Antacids and antiemetics
Aspiration pneumonitis is now a rare event associated
with general anaesthesia for caesarean section. In the
UK 99% of units routinely use drugs to reduce the
gastric volume and acidity for elective caesarean sec-
tion and 98% for emergency caesarean section;
1
99%
use H
2
receptor blockers (ranitidine, cimetidine), 2%
proton pump inhibitors (omeprazole) and 99% non-
particulate antacid (sodium citrate). RCTs have shown
that sodium citrate reduces acidity without affecting
gastric volume,
34
that ranitidine combined with sodium
citrate reduces gastric volume and increases pH,
35
that
omeprazole also reduces the risk of aspiration
36
and that omeprazole results in higher mean pH than
ranitidine, although ranitidine with sodium citrate is
cheaper.
3739
Nausea and vomiting may be provoked by hypoten-
sion during regional anaesthesia for caesarean section.
Treatment of the cause will alleviate the symptom. Var-
ious RCTs and a meta-analysis showed reduced nausea
and vomiting with metoclopramide, propofol, droperidol
and ondansetron in women having caesarean section un-
der spinal anaesthesia.
4045
One RCT found that acu-
pressure and metoclopramide were equally effective in
this context.
46
Ondansetron appears to be more effective
than metoclopramide but the latter is cheaper, while
The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections 151
ondansetron is not advised for use during pregnancy and
breastfeeding.
To reduce the risk of aspiration pneumonitis, women
should be offered drugs to reduce gastric volume and
acidity before caesarean section. [B]
To reduce the incidence of nausea and vomiting, women
having caesarean section should be offered antiemetics
(either pharmacological or acupressure). [A]
General versus regional anaesthesia for caesarean
section
Regional anaesthesia is reportedly used in 77% of
emergency and 91% of elective caesarean sections.
1
In category 1 caesarean sections, general anaesthesia
was used in 41%, regional anaesthesia in 54% and
general anaesthesia following failure of regional
anaesthesia in 3%. A UK survey of anaesthetic tech-
niques for caesarean section reported an overall fail-
ure rate for epidural anaesthesia of 7.1%, for
combined spinal epidural 2% and for single-shot
spinal anaesthetic 1.9%. Failure of regional anaesthe-
sia accounted for 10% of general anaesthetics for cae-
sarean section.
47
The guidelines cite three RCTs comparing the effect
of general versus regional anaesthesia for elective caesar-
ean section on maternal and neonatal morbidity.
4850
At
least three more were published in 2003. The document
asserts that no difference in neonatal outcomes was
detected between general and regional anaesthesia
groups, and overlooks the adverse effect that spinal as
opposed to general or epidural anaesthesia may have
on fetal acid-base balance.
General anaesthesia has commonly been found to re-
sult in increased blood loss.
51
The same applies to cae-
sarean section for placenta praevia.
5254
The authors cite
one RCT comparing general with regional anaesthesia
for severe preeclampsia, which found little difference
in maternal and/or fetal complications.
55
The recommendations state:
Women should be offered regional anaesthesia
because it is safer and results in less maternal and
neonatal morbidity than general anaesthesia. This
includes women who have a diagnosis of placenta
praevia. [A]
This may be misleading in relation to spinal anaesthe-
sia and newborn acid-base balance.
Converting epidural analgesia to anaesthesia for
caesarean section
Conversion of an analgesic epidural to one suitable for
anaesthesia in the shortest time possible is desirable in
category 1 and 2 caesarean sections because this avoids
general anaesthesia. One RCT comparing 0.5% bupiva-
caine alone, 2% lidocaine plus epinephrine and a mix-
ture of the two found no difference between the
groups in time to adequate block.
56
Another found that
the addition of bicarbonate accelerated the onset of 2%
lidocaine plus epinephrine and fentanyl.
57
Place of induction and monitoring during caesarean
section
One non-obstetric RCT comparing induction in the oper-
ating theatre with that in an anaesthetic room showed no
difference in patient anxiety between the two groups.
58
A survey of 115 women having elective caesarean sec-
tion under regional anaesthesia reported that stress was
related to anxiety about pain and the baby rather than
to the environment.
59
The controversy relating to top-
ping up other than in the environs of the operating the-
atre was not addressed. The recommendations state:
For caesarean section under regional block continu-
ous pulse oximetry, non-invasive blood pressure
capable of one-minute cycles and electrocardiogra-
phy are recommended; for general anaesthesia there
should be full monitoring as recommended in the
national guidelines.
60,61
The fetal heart rate should
be recorded during the initiation of regional block
and until the abdominal skin preparation is begun in
emergency caesarean section.
Regional anaesthesia for caesarean section should be
induced in theatre because this does not increase
patient anxiety [B]
They do not mention that the important fact that this
allows continuous monitoring throughout induction and
maintenance of anaesthesia.
Procedures to avoid hypotension
Lateral tilt of the operating table is standard practice
in the UK for the prevention of hypotension caused
by aortocaval compression.
47
A systematic review of
three early studies, and one more recent one found
no differences in Apgar scores or umbilical artery
pH with lateral tilt,
62,63
which is odd because early
studies certainly detected a benefit. Another RCT
comparing lateral with no tilt at emergency caesarean
section found no differences in maternal or neonatal
outcomes.
64
Two RCTs comparing the effect of the
full lateral position (described incorrectly as laternal
tilt) versus 15 wedge found no difference in inci-
dence of hypotension between the methods.
64,65
A sys-
tematic review that included 20 RCTs reported that
the following interventions reduce the incidence of
hypotension under spinal anaesthesia for caesarean
section: pre-load with crystalloid 20 mL/kg versus
control, pre-emptive colloid versus crystalloid, ephe-
152 International Journal of Obstetric Anesthesia
drine versus control and lower limb compression ver-
sus control.
66
No differences in maternal or neonatal
side effects were reported. The use of crystalloid has
been shown by systematic review to be inconsistent
in its ability to prevent maternal hypotension [see
Conclusion].
The guidelines recommend the use of phenyl-
ephrine and ephedrine indiscriminately as being
equally effective as vasopressors, but fail to mention
that mothers given phenylephrine may have fewer
episodes of nausea and vomiting and that their babies
are less likely to be acidotic.
6769
The recommenda-
tions state:
The operating table for caesarean section should have
a lateral tilt of 15 because this reduces maternal
hypotension. [A]
Intravenous ephedrine or phenylephrine should be
used in the management of hypotension during cae-
sarean section. [A]
Failed intubation
The document points out that failed intubation has a re-
ported incidence of 1/249
70
and is still an occasional
cause of maternal death.
27
The place of the laryngeal
mask and the importance of a failed intubation drill
are mentioned.
7176
General anaesthesia for caesarean section should
include preoxygenation, cricoid pressure and rapid
sequence induction to reduce the risk of aspiration
[GPP]
Each maternity unit should have a drill for failed intu-
bation [D]
Surgical techniques for caesarean section of
relevance to the anaesthetist
Use of uterotonics
The authors remind us that the licensed dose of oxytocin
for caesarean section is 5 units by slow intravenous
injection; problems associated with the use of larger bo-
lus doses given rapidly are highlighted.
27,77
One RCT
comparing different oxytocin infusion concentrations
(20 versus 160 units/L) showed no difference in the inci-
dence of hypotension but the lower-concentration group
were more likely to need additional utertonics.
78
Evi-
dence is divided about whether prostaglandins are as
effective as oxytocin.
7983
Oxytocin, however, has a
half-life of only 410 min.
Oxytocin 5 units by slow intravenous injection should
be used at caesarean section to encourage contraction
of the uterus and to decrease blood loss. [C]
Perhaps ill-advisedly, there is no mention of the need
to follow this with an oxytocin infusion.
Uterine exteriorisation
Only a minority of obstetricians in the UK exteriorise
the uterus.
84
One RCT found that uterine exteriorisa-
tion did not increase nausea, vomiting, sensation of
tugging or pain scores,
85
although two women in
the exteriorised group had their epidurals converted
to general anaesthesia because of pain. This has
implications for the anaesthetist as supplementary
analgesia or conversion to general anaesthesia may
be needed and there may be medico-legal implica-
tions. No surgical advantage has been found for the
technique.
85,86
Exteriorisation of the uterus is not recommended
because it is associated with more pain and does
not improve operative outcomes such as haemorrhage
or infection. [A]
Use of antibiotics
Prophylactic antibiotics reduce the incidence of fever,
endometritis, wound, urinary tract and other infection.
87
There is no advantage in using multiple doses compared
with a single dose.
88
Ampicillin and first generation
cephalosporins are equally effective.
Women having caesarean section should be offered
prophylactic antibiotics to reduce the risk of post-
operative infections, which occur in about 8% of
women. [A]
Thromboprophylaxis for caesarean section
The reported incidence of pulmonary thromboembolism
is 6 per 10 000 maternities but varies with maternal age,
obesity and smoking.
89
It is the leading direct cause of
maternal death in the UK.
27
Various interventions have
been explored for its prevention but the trials were too
small to evaluate outcome.
90
Increased risk is associated
with emergency versus elective caesarean section,
maternal age >35 years, weight >80 kg and medical
complications. Recommended thromboprophylaxis in-
cludes hydration, early mobilisation, graduated elastic
compression stockings and low-molecular-weight
heparin.
91,92
Women having caesarean section should be offered
thromboprophylaxis because they are at increased
risk of thromboembolism. The chosen method of pro-
phylaxis... should take into account risk of thrombo-
embolic disease and should follow existing
guidelines. [D]
Care of the baby born by caesarean section
The guidelines state that infants born by caesarean sec-
tion under general anaesthesia are at an increased risk of
The National Institute of Clinical Excellence (NICE) guidelines for caesarean sections 153
1-and 5-min Apgar scores <7 when compared with those
born with regional anaesthesia, but most studies find that
only the one-minute score is affected.
49
An appropriately trained practitioner skilled in
resuscitation of the newborn should be present at
caesarean section performed under general anaes-
thesia or where there is evidence of fetal compro-
mise. [C]
Care of the woman after caesarean section
High dependency and intensive care admission
The incidence of severe morbidity among parturients has
been reported to be 12 per 1000 deliveries.
93
A small
proportion of women (0.10.9%) develop complications
of pregnancy that require admission to intensive care.
94
The NSCSA reported that 10% of women who had cae-
sarean section required admission to a high dependency
unit; 3.5% of these women were transferred to intensive
care.
1
Table 3 shows the proportion of women who re-
quired admission to intensive care following caesarean
section, according to the reason for caesarean section.
The indications for caesarean section that were most
likely to lead to admission to intensive care accounted
for <20% of all caesarean sections. Maternal disease
produced the largest number of women. The recommen-
dation given was:
Health professionals caring for women after caesar-
ean section should be aware that, although it is rare
for women to need intensive care following childbirth
this occurs more frequently after caesarean section
(about 9 per 1000). [B]
Routine monitoring after caesarean section
Poor postoperative care is a recurring factor in maternal
deaths.
27
The national obstetric anaesthetic service
guidelines state that the postoperative care of a caesar-
ean section patient should meet the same standard of
care as that required for any postoperative patient.
60,61,95
After caesarean section, women should be observed
on a one-to-one basis by a properly trained member
of staff until they have regained airway control and
cardiorespiratory stability and are able to communi-
cate. [D]
After recovery from anaesthesia, observations (respi-
ratory rate, heart rate, blood pressure, pain and seda-
tion) should be continued every half hour for two
hours and hourly thereafter provided that the observa-
tions are stable or satisfactory. If these observations
are not stable, more frequent observations and medi-
cal review are recommended. [GPP]
Pain management after caesarean section
Intrathecal and epidural analgesia
Morphine is commonly used in countries other than the
UK,
9698
where diamorphine is available and used with
good effect.
99103
Both are effective but diamorphine
has fewer and less severe side effects.
100
Both morphine
and diamorphine may be given both epidurally and
intrathecally,
103,104
and relative efficacy and side effects
are largely dependent on dosage.
Women should be offered diamorphine (0.30.4 mg
intrathecally) for intra- and postoperative analgesia
because it reduces the need for supplemental analge-
sia after caesarean section. Epidural diamorphine
(2.55.0 mg) is a suitable alternative. [A]
Patient controlled analgesia (PCA) and non-steroidal
anti-inflammatory analgesics
In the absence of intrathecal or epidural opioid analge-
sia, opioid PCA may be used for postoperative analge-
sia. There is little difference among the various
recipes.
105,106
Rectal diclofenac administered immediately after
caesarean section is regularly found to reduce the need
for other types of analgesia.
107,108
Patient controlled analgesia using opioid analgesics
should be offered [GPP]
Providing there is no contraindication, non-steroidal
anti-inflammatory drugs should be offered after cae-
sarean section as an adjunct to other analgesics,
because they reduce the need for opioids. [A]
Other local anaesthetic techniques
As an alternative to systemic analgesia, wound infiltra-
tion and ilioinguinal nerve block have been found
equally effective in relieving pain after caesarean
section.
109,110
Table 3. Admission to intensive therapy unit (ITU) according to
reason for caesarean section
Reason for caesarean section % admitted
to ITU
OR (95% CI)
Uterine rupture 6.4 43.3 (9.9 to 189.5)
Maternal medical disease 2.7 17.8 (6.4 to 49.2)
Placenta praevia,
actively bleeding
2.5 16.6 (5.3 to 52.2)
Pre-eclampsia/
eclampsia/HELLP
1.9 12.4 (4.3 to 35.5)
Placenta praevia,
not actively bleeding
1.1 7.0 (2.2 to 22.1)
Placental abruption 1.1 7.2 (1.7 to 30.4)
Breech 0.2 1.00
Data from The National Sentinel Caesarean Section Audit Report.
1
The odds ratio was calculated in relation to the proportion of women
with breech presentation who were admitted to ITU, but by extrapo-
lation it appears that this proportion was similar to that in the caesarean
section population taken as a whole, which is lucky.
154 International Journal of Obstetric Anesthesia
Post partum care
Early eating and drinking after caesarean section
Asystematic reviewof six RCTs comparing early with de-
layed oral fluids and food after caesarean section found
that early eating and drinking were associated with re-
duced time to return of bowel sounds and reduced hospital
stay.
111
There was no difference between the groups with
respect to nausea and vomiting, abdominal distension,
time to bowel action, paralytic ileus or need for analgesia.
Women who are recovering well and who do not
have complications can eat and drink when they
feel hungry or thirsty. [A]
Urinary catheter removal after caesarean section
The best time to remove a urinary catheter and the value
of routine indwelling catheterisation are currently uncer-
tain.
112,113
No difference has been detected in the inci-
dence of urinary retention after general and epidural
anaesthesia.
114
The urinary catheter should be removed once a
woman is mobile after a regional anaesthetic and
not sooner than 12 h after the last epidural top-up
dose. [D]
Length of hospital stay
Women are usually discharged after caesarean section
on day three,
115
but the ideal time is under review.
116
In general, early discharge promotes maternal satisfac-
tion and has little detrimental effect.
117
Early discharge
has implications for the anaesthetist as some of the late
complications of regional anaesthesia may not be readily
detected in the community.
Length of stay is likely to be longer after a caesarean
section (an average of 34 days) than after vaginal
birth. However, women who are recovering well, are
apyrexial and do not have complications should
be offered early discharge (after 24 h) from hospital
and follow-up at home, because this is not associated
with more infant or maternal readmissions. [A]
CONCLUSION
These guidelines are based on some of the evidence
available at the time of writing, but there are areas
where evidence is conflicting or absent; these are pre-
sented as group practice points which are the subject
of discussion, debate and stimulus for further
research.
The recommendations that we feel are of particular
importance to anaesthetists are the value of evidence-
based information, the adoption of the new category
of urgency of caesarean section by the obstetric team
and the use of regional anaesthesia and analgesia to
improve safety and quality of care. One might quibble
with the view that spinal is safer than general anaes-
thesia for the baby,
118
that ephedrine or phenylephrine
may be offered indiscriminately
67,69
or that crystal-
loid is effective to prevent maternal hypotension
119
and with the omission of any mention of maternal
oxygen during regional anaesthesia or of oxytocin
infusion.
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