National Institute for Health and Clinical Excellence (NICE)
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Women could avoid having unnecessary caesareans

Women who have previously been advised to have a caesarean section may be able to avoid having unnecessary surgery, following an update to NICE guidelines.

The majority of women who give birth will have a normal vaginal delivery. But for certain groups of women, such as those who are HIV positive and those who have had a previous birth by caesarean section, the current advice has been to opt for a caesarean section instead of a vaginal birth.

NICE's updated guidelines on caesarean section, published recently, now recommend that women in these groups should be offered a vaginal birth.

The recommendations, developed following the emergence of new evidence, say that women who are HIV positive should be told that, in certain circumstances, the risk of transmission of HIV is the same for a caesarean as it is for a vaginal birth. As a consequence, such women should not be offered a caesarean section on the grounds of HIV status to prevent transmission of the disease to their baby.

The updated guideline dispels the myth that “once a caesarean, always a caesarean” as the risk of fever, bladder injuries and surgical injuries in women who have had up to and including four caesarean sections is the same for a vaginal birth as it is for a caesarean section.

Another major change to the existing recommendations is that women should be given prophylactic antibiotics before surgery rather than after it.

Around one in ten women who have a caesarean section suffer infections after surgery, and this new recommendation could help to reduce the rate of infections by as much as a third without having any effect on the baby.

If a woman does decide to request a caesarean section due to anxiety about childbirth, NICE recommends that the woman is referred to a healthcare professional with expertise in providing perinatal mental health support. This is in order to address her anxiety in a supportive manner.

A planned caesarean section should only be offered if, after discussion and offer of support, a vaginal birth is still not an acceptable option.

Dr Gillian Leng, NICE Deputy Chief Executive, stressed that the guideline was not about offering free caesareans for all on the NHS and could actually reduce the rate by highlighting women who do not need to have the surgery.

“For a very small number of women, their anxiety about childbirth will lead them to ask for a caesarean section. The new recommendations in this guideline mean that these fears will be taken seriously and women will be offered mental health support if they need it.

“If the woman's anxiety is not allayed by this support, then she should be offered a planned caesarean section. Offering these women a planned caesarean in these circumstances is a very long way from saying that caesarean section should automatically be offered to every woman.”

Malcolm Griffiths, Consultant Obstetrician and Gynaecologist at Luton and Dunstable Hospital and Chair of the Guideline Development Group, added: “Caesarean section is major surgery which most pregnant women want to avoid if they can. We want women who do not need to have a caesarean section to be able to avoid such surgery.”

A range of new implementation tools is being published alongside the updated guideline to help put the recommendations into practice. This includes a podcast and a costing report that highlights the potential reduction in costs for planned vaginal birth as opposed to caesarean section in women with HIV.

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