Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the National Institute for Health and Care Excellence.

Caesarean Birth

National Institute for Health and Care Excellence

Publication Date: Jun 10, 2025

Page Last Updated: May 6, 2026

1.1 Planning mode of birth

Provision of information

1.1.1 - Offer all pregnant women information and support to enable them to make informed decisions about childbirth. Make sure that:
- the information is evidence based
- any information provided is accessible, ideally with a choice of formats to suit different women's needs
- the language used in any information (written or oral) is respectful and suitable for the woman, taking into account any personal, cultural or religious factors that could form part of the woman's choices
- the women's preferences and concerns are central to the decision-making process. [2004, amended 2021]
1.1.2 - Discuss mode of birth with all pregnant women early in their pregnancy. Cover information such as:
- around 25% to 30% of women have a caesarean birth
- factors that mean women may need a caesarean birth (for example, increased maternal age and body mass index [BMI])
- common indications for emergency caesarean birth include slow progression of labour or concern about fetal condition
- planned place of birth may affect the mode of birth (see planning place of birth in the NICE guideline on intrapartum care)
- what the caesarean birth procedure involves
- how a caesarean birth may impact on the postnatal period (for example, need for pain relief)
- implications for future pregnancies and birth after caesarean birth or vaginal birth (for example, after a caesarean birth the chances of caesarean birth in a future pregnancy may be increased). [2011, amended 2021]

Benefits and risks of caesarean and vaginal birth

1.1.3 - Discuss the benefits and risks of both caesarean and vaginal birth with women, taking into account their circumstances, concerns, priorities and plans for future pregnancies. [2021]
1.1.4 - Using the information in appendix A, explain to women that:
- there are benefits and risks associated with both vaginal and caesarean birth, some of which are very small absolute risks and some are greater absolute risks, and they will need to decide which risks are more (or less) acceptable to them
- there are other risks not included in these tables that might be relevant to their individual circumstances (for example, placental adherence problems from multiple caesarean births, fetal lacerations in caesarean birth, term birth injuries with vaginal birth or caesarean birth)
- these tables give summary estimates only and are intended to help discussions, but precise numerical risk estimates cannot be given for individual women. [2021]

1.2 Planned caesarean birth

Breech presentation

1.2.1 - Discuss with women the benefits and risks of planned vaginal birth versus planned caesarean birth for breech presentation, and the option of external cephalic version. [2004, amended 2021]
1.2.2 - Offer women who have an uncomplicated singleton breech pregnancy after 36+0 weeks, external cephalic version, unless:
- the woman is in established labour
- there is fetal compromise
- the woman has ruptured membranes or vaginal bleeding
- the woman has any other medical conditions (for example, severe hypertension) that would make external cephalic version inadvisable. [2004, amended 2021]
1.2.3 - Before carrying out a caesarean birth for an uncomplicated singleton breech pregnancy, carry out an ultrasound scan to check that the baby is in the breech position. Do this as late as possible before the caesarean birth procedure. [2021]

Multiple pregnancy

1.2.4 - For recommendations on mode of birth in multiple pregnancy, see mode of birth in the NICE guideline on twin and triplet pregnancy. [2021]

Preterm birth

1.2.5 - For recommendations on mode of birth in preterm labour and birth, see mode of birth in the NICE guideline on preterm labour and birth. [2021]

Placenta praevia

1.2.6 - Offer caesarean birth to women with a placenta that partly or completely covers the internal cervical os (minor or major placenta praevia). [2004, amended 2011]

Placenta accreta spectrum

1.2.7 - If the routine 20-week ultrasound scan shows placenta praevia or low-lying placenta in a woman or pregnant person with a previous caesarean scar (or a uterine scar from other surgery), refer for a greyscale ultrasound scan with colour doppler to assess for placenta accreta. This scan should be done around 28 weeks, but no later than 29 weeks, by a senior clinician with expertise in the diagnosis of placenta accreta. [2024]
1.2.8 - If placenta accreta is suspected following the greyscale ultrasound scan with colour doppler (see recommendation 1.2.7), refer the woman or pregnant person to a specialist placenta accreta spectrum centre for care and ongoing management. [2024]

Care for women with placenta accreta spectrum in specialist centres

1.2.9 - Consider an MRI scan to complement ultrasound findings when planning ongoing surgical management of placenta accreta spectrum. Discuss the following with the woman or pregnant person:
- what to expect during an MRI procedure
- that MRI can help clarify the degree of invasion, particularly with a posterior placenta
- that current experience suggests that MRI is safe, but that there is a lack of evidence about any long-term risks to the baby. [2024]
1.2.10 - Discuss birth options (for example, timing of birth, operative interventions including possibility of hysterectomy, need for blood transfusion) with a woman or pregnant person suspected to have placenta accreta spectrum. This discussion should be carried out by a senior obstetrician. [2011, amended 2024]
1.2.11 - When planning a caesarean birth for women or pregnant people suspected to have placenta accreta spectrum, the multidisciplinary team should:
- agree which other healthcare professionals need to be consulted or present (for example, specialists in gynaecological surgery, interventional radiology, colorectal surgery, urology or vascular surgery, depending on the nature of the placenta accreta spectrum) and
- the responsibilities of each team member. [2011, amended 2024]
1.2.12 - When performing a planned caesarean birth for a woman or pregnant person suspected to have placenta accreta spectrum, ensure that:
- a consultant obstetrician, a consultant gynaecologist and a consultant anaesthetist are present in the operating theatre
- a paediatric or neonatal registrar or consultant is present to provide immediate care for the baby as soon as it is born
- a haematology registrar or consultant is available to contact for advice
- a critical care bed is available for the woman or pregnant person, and a critical care neonatal cot is available for the baby (although emergency surgery should not be delayed while waiting for a bed)
- sufficient cross-matched blood and blood products are readily available (if blood transfusions are acceptable to the woman or pregnant person). See the NICE guideline on blood transfusion. [2011, amended 2024]
1.2.13 - Specialist placenta accreta spectrum centres and the local maternity units they support should develop protocols covering how placenta accreta spectrum should be diagnosed, assessed and managed across their network. The protocol should include the care and management of placenta accreta spectrum identified late in pregnancy or in labour, including how specialist units can support emergency care in local maternity units. [2024]

Predicting caesarean birth for cephalopelvic disproportion in labour

1.2.14 - Do not use pelvimetry for decision making about mode of birth. [2004, amended 2021]
1.2.15 - Do not use the following for decision making about mode of birth, as they do not accurately predict cephalopelvic disproportion:
- maternal shoe size
- maternal height
- estimations of fetal size (ultrasound or clinical examination). [2004, amended 2021]

Mother-to-child transmission of maternal infections
HIV

1.2.16 - Provide women with HIV information about the benefits and risks for them and their baby of the HIV treatment options and mode of birth as early as possible in their pregnancy, so that they can make an informed decision. Obtain specialist advice about HIV in pregnancy from a sexual health specialist if necessary. [2011, amended 2021]

Hepatitis B virus

1.2.17 - Do not offer pregnant women with hepatitis B a planned caesarean birth for this reason alone, as mother-to-baby transmission of hepatitis B can be reduced if the baby receives immunoglobulin and vaccination. [2004, amended 2021]

Hepatitis C virus

1.2.18 - Do not offer women who are infected with hepatitis C a planned caesarean birth for this reason alone. [2004, amended 2021]
1.2.19 - Offer pregnant women who are co-infected with hepatitis C virus and HIV a planned caesarean birth to reduce mother-to-baby transmission of hepatitis C virus and HIV. [2004, amended 2021]

Herpes simplex virus

1.2.20 - Offer women with primary genital herpes simplex virus (HSV) infection occurring in the third trimester of pregnancy a planned caesarean birth to decrease the risk of neonatal HSV infection. [2004]
1.2.21 - Do not routinely offer pregnant women with recurrent HSV infection a planned caesarean birth outside of the context of research. [2004, amended 2021]

Body mass index

1.2.22 - Do not use a BMI of over 50 kg/m2 alone as an indication for planned caesarean birth. [2011]

Shared decision making

1.2.23 - Ask for consent for caesarean birth only after providing pregnant women with evidence-based information. Ensure the woman's dignity, privacy, views and culture are respected, while taking the woman's clinical situation into account. [2004, amended 2021]
1.2.24 - Advise women that they are entitled to decline the offer of treatment such as caesarean birth, even when it would benefit their or their baby's health. [2004, amended 2021]
1.2.25 - When a woman decides on or declines a caesarean birth, document the factors that that are important to the woman when making her decision. [2004, amended 2021]

Maternal choice for caesarean birth

1.2.26 - When a woman or pregnant person with no medical indication for a caesarean birth requests a caesarean birth:
- offer to discuss and explore the reasons for the request
- ensure they have balanced and accurate information
- offer to discuss alternative birth options (for example, place of birth, continuity of midwifery care where available, pain relief options), which may help address concerns they have about the birth
- offer discussions with a consultant midwife or senior midwife, ideally in a birth options clinic or at a birth options appointment
- offer discussions with a consultant or senior obstetrician and other members of the team (for example, an anaesthetist) if necessary or requested by the woman or pregnant person
- record the discussions and decisions. [2011, amended 2023]
1.2.27 - If a woman or pregnant person requests a caesarean birth, discuss the overall benefits and risks of caesarean birth compared with vaginal birth (see the section on planning mode of birth) and record that this discussion has taken place. [2011]
1.2.28 - If a woman or pregnant person requests a caesarean birth because they have tokophobia or other severe anxiety about childbirth (for example, following abuse or a previous traumatic event), offer referral to a healthcare professional with expertise in providing perinatal mental health support to help with their anxiety. See the NICE guideline on antenatal and postnatal mental health for more detailed advice on providing mental health services during pregnancy. [2011, amended 2021]
1.2.29 - Ensure healthcare professionals providing perinatal mental health support for women or pregnant people with tokophobia or other severe anxiety about childbirth are able to access the planned place of birth with the woman or pregnant person during the antenatal period, as part of the support offered to help them overcome fears and concerns about the labour and birth. [2011, amended 2023]
1.2.30 - If, after an informed discussion about the options for birth (including the offer of perinatal mental health support if appropriate; see recommendation 1.2.27), the woman or pregnant person requests a caesarean birth, support their choice. [2011, amended 2023]
1.2.31 - If a woman or pregnant person requests a caesarean birth this should be offered within their obstetric unit. [2011, amended 2023]

1.3 Factors affecting the likelihood of emergency caesarean birth during intrapartum care

Factors reducing the likelihood of caesarean birth

1.3.1 - Inform women that continuous support during labour from women, with or without prior training, reduces the likelihood of caesarean birth. [2004]
1.3.2 - Use a partogram with a 4‑hour action line to monitor progress of women in spontaneous labour with an uncomplicated singleton pregnancy at term to reduce the likelihood of caesarean birth. [2004]
1.3.3 - Involve a consultant obstetrician in decision-making for caesarean birth. [2004, amended 2021]

No influence on the likelihood of caesarean birth

1.3.4Inform women that the following interventions during intrapartum care have not been shown to influence the likelihood of caesarean birth, although they can affect other outcomes:
- walking in labour
- non-supine position during the second stage of labour
- immersion in water during labour
- epidural analgesia during labour
- the use of raspberry leaves. [2004, amended 2021]
1.3.5Inform women that the effects on the likelihood of caesarean birth of complementary therapies used during labour (such as acupuncture, aromatherapy, hypnosis, herbal products, nutritional supplements, homeopathic medicines, and Chinese medicines) are uncertain. [2004, amended 2021]

Slow progression in labour and caesarean birth

1.3.6Do not offer the following as they do not influence the likelihood of caesarean birth for slow progression in labour, although they can affect other outcomes:
active management of labour (comprising a strict definition of established labour, early routine amniotomy, routine 2‑hourly vaginal examination, oxytocin if labour becomes slow)
early amniotomy. [2004, amended 2021]

Eating during labour

1.3.7Inform women that eating a low-residue diet during labour (toast, crackers, low-fat cheese) results in larger gastric volumes, but the effect on the risk of aspiration if anaesthesia is needed is uncertain. [2004]
1.3.8Inform women that having isotonic drinks during labour prevents ketosis without a concomitant increase in gastric volume. [2004]

1.4 Procedural aspects of caesarean birth

Timing of planned caesarean birth

1.4.1 - Do not routinely carry out planned caesarean birth before 39 weeks, as this can increase the risk of respiratory morbidity in babies. [2004]

Classification of urgency for caesarean birth

1.4.2 - Use the following standardised scheme to document the urgency of caesarean birth and aid clear communication between healthcare professionals:
- Category 1. Immediate threat to the life of the woman or fetus (for example, suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia).
- Category 2. Maternal or fetal compromise which is not immediately life-threatening.
- Category 3. No maternal or fetal compromise but needs early birth.
- Category 4. Birth timed to suit woman or healthcare provider. [2004, amended 2021]

Decision-to-birth interval for unplanned and emergency caesarean birth

1.4.3 - Perform category 1 caesarean birth as soon as possible, and in most situations within 30 minutes of making the decision. [2011, amended 2021]
1.4.4 - Perform category 2 caesarean birth as soon as possible, and in most situations within 75 minutes of making the decision. [2011, amended 2021]
1.4.5 - Take into account the condition of the woman and the unborn baby when making decisions about rapid birth. Be aware that rapid birth can be harmful in certain circumstances. [2011]

Preoperative testing and preparation for caesarean birth

1.4.6 - Before caesarean birth, carry out a full blood count to identify anaemia, antibody screening, and blood grouping with saving of serum. [2004, amended 2021]
1.4.7 - Do not routinely carry out the following tests before caesarean birth:
- cross-matching of blood
- a clotting screen
- preoperative ultrasound for localisation of the placenta. [2004, amended 2021]
1.4.8 - Carry out caesarean birth for pregnant women with antepartum haemorrhage, abruption or placenta praevia at a maternity unit with on-site blood transfusion services, as they are at increased risk of blood loss of more than 1,000 ml. [2004, amended 2021]
1.4.9 - Give women having caesarean birth with regional anaesthesia an indwelling urinary catheter to prevent over-distension of the bladder. [2004, amended 2021]

Anaesthesia for caesarean birth

1.4.10 - Provide pregnant women having a caesarean birth with information on the different types of post‑caesarean birth analgesia, so that they can make an informed choice (see recommendation 1.6.11). [2004]
1.4.11 - Offer women who are having a caesarean birth regional anaesthesia in preference to general anaesthesia, including women who have a diagnosis of placenta praevia. [2004, amended 2021]
1.4.12 - Carry out induction of anaesthesia, including regional anaesthesia, for caesarean birth in theatre. [2004, amended 2021]
1.4.13 - Apply a left lateral tilt of up to 15 degrees or appropriate uterine displacement once the woman is in a supine position on the operating table to reduce maternal hypotension. [2004, amended 2021]
1.4.14 - Offer women who are having a caesarean birth under spinal anaesthesia a prophylactic intravenous infusion of phenylephrine, started immediately after the spinal injection. Adjust the rate of infusion to keep maternal blood pressure at 90% or more of baseline value and avoid decreases to less than 80% of baseline. [2004, amended 2021]
1.4.15 - When using phenylephrine infusion, give intravenous ephedrine boluses to manage hypotension during caesarean birth, for example, if the heart rate is low and blood pressure is less than 90% of baseline. [2004, amended 2021]
1.4.16 - Use intravenous crystalloid co-loading in addition to vasopressors to reduce the risk of hypotension occurring during caesarean birth. [2004, amended 2021]
1.4.17 - Ensure each maternity unit has a set of procedures for failed intubation during obstetric anaesthesia. [2004]
1.4.18 - Offer women antacids and drugs (such as H2‑receptor antagonists or proton pump inhibitors) to reduce gastric volumes and acidity before caesarean birth.
1.4.19 - Offer women having a caesarean birth anti-emetics (either pharmacological or acupressure) to reduce nausea and vomiting during caesarean birth. [2004]
1.4.20 - Include pre-oxygenation, cricoid pressure and rapid sequence induction in general anaesthesia for caesarean birth to reduce the risk of aspiration. [2004, amended 2011]

Prevention and management of hypothermia and shivering

1.4.21 - Warm IV fluids (500 ml or more) and blood products used during caesarean birth to 37 degrees Celsius using a fluid warming device. [2021]
1.4.22 - Warm all irrigation fluids used during caesarean birth to 38 to 40 degrees Celsius in a thermostatically controlled cabinet. [2021]
1.4.23 - Consider forced air warming for women who shiver, feel cold, or have a temperature of less than 36 degrees Celsius during caesarean birth. [2021]

Surgical techniques and medication for caesarean birth
Methods to reduce infectious morbidity

1.4.24 - Use alcohol-based chlorhexidine skin preparation before caesarean birth to reduce the risk of wound infections. See the NICE guideline on surgical site infections. [2021]
1.4.25 - Use aqueous povidone-iodine vaginal preparation before caesarean birth in women with ruptured membranes to reduce the risk of endometritis. If aqueous povidone-iodine vaginal preparation is not available or is contraindicated, aqueous chlorhexidine vaginal preparation can be used. [2021]

Methods to prevent HIV transmission in theatre

1.4.26 - Wear double gloves when performing or assisting a caesarean birth for women who have tested positive for HIV, to reduce the risk of HIV infection of staff. [2004]
1.4.27 - Follow general recommendations for safe surgical practice during caesarean birth to reduce the risk of HIV infection of staff. [2004]

Abdominal wall incision

1.4.28 - Perform caesarean birth using a low, transverse, straight skin incision with subsequent tissue layers opened bluntly and, if necessary, extended using sharp dissection. This may need to be modified with a higher incision for women and pregnant people with class 3 obesity (BMI 40 kg/m2 or more). A vertical midline incision may be required for some clinical indications. [2004, amended 2023]
Instruments for skin incision
1.4.29 - Do not use separate surgical knives to incise the skin and the deeper tissues in caesarean birth, as it does not decrease wound infection. [2004]

Extension of the uterine incision

1.4.30 - When there is a well-formed lower uterine segment, use blunt rather than sharp extension of the uterine incision to reduce blood loss, incidences of postpartum haemorrhage and the need for transfusion during caesarean birth. [2004]

Fetal laceration

1.4.31 - Inform women who are having a caesarean birth that the risk of fetal lacerations is about 2%. [2004]

Use of forceps

1.4.32 - Only use forceps in caesarean birth if there is difficulty delivering the baby's head. The effect on neonatal morbidity of the routine use of forceps at caesarean birth remains uncertain. [2004]

Use of uterotonics

1.4.33 - Follow recommendation 1.10.13 in the section on the third stage of labour in NICE's guideline on intrapartum care. [2004, amended 2025]

Method of placental removal

1.4.34 - Remove the placenta in caesarean birth using controlled cord traction and not manual removal to reduce the risk of endometritis. [2004]

Exteriorisation of the uterus

1.4.35 - Perform intraperitoneal repair of the uterus for caesarean birth. Routine exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection. [2004, amended 2021]

Closure of the uterus

1.4.36 - Use single layer or double layer uterine closure in caesarean birth, depending on the clinical circumstances. Note that single layer closure does not increase the risk of postoperative bleeding or uterine rupture in a subsequent pregnancy. [2021]

Closure of the peritoneum

1.4.37 - Do not suture the visceral or the parietal peritoneum in caesarean birth to reduce operating time and the need for postoperative analgesia, and improve maternal satisfaction. [2004]

Closure of the abdominal wall

1.4.38 - If a midline abdominal incision is used in caesarean birth, use mass closure with slowly absorbable continuous sutures as this results in fewer incisional hernias and less dehiscence than layered closure. [2004]

Closure of subcutaneous tissue

1.4.39 - Do not routinely close the subcutaneous tissue space in caesarean birth unless the woman has more than 2 cm subcutaneous fat, as it does not reduce the incidence of wound infection. [2004]

Use of superficial wound drains

1.4.40 - Do not routinely use superficial wound drains in caesarean birth as they do not decrease the incidence of wound infection or wound haematoma. See recommendation 1.7.2 on the use of negative pressure wound therapy. [2004, amended 2021]

Closure of the skin

1.4.41 - Consider using sutures rather than staples to close the skin after caesarean birth to reduce the risk of superficial wound dehiscence. See closure methods in the NICE guideline on surgical site infections. [2019]

Umbilical artery pH measurement

1.4.42 - Perform paired umbilical artery and vein measurements of cord blood gases after caesarean birth for suspected fetal compromise, to allow for assessment of fetal wellbeing and guide ongoing care of the baby. [2004, amended 2021]

Timing of antibiotic administration

1.4.43 - Offer women prophylactic antibiotics before skin incision for caesarean birth, choosing antibiotics that are effective against endometritis, urinary tract and wound infections. [2011, amended 2021]
1.4.44 - Inform women that:
- endometritis, urinary tract and wound infections occur in about 8% of women who have had a caesarean birth
- using prophylactic antibiotics before skin incision reduces the risk of maternal infection more than prophylactic antibiotics given after skin incision, and that there is no known effect on the baby. [2011, amended 2021]
1.4.45 - Do not use co-amoxiclav when giving prophylactic antibiotics before skin incision for caesarean birth. [2011]

Thromboprophylaxis for caesarean birth

1.4.46 - Offer thromboprophylaxis to women having a caesarean birth. Take into account the risk of thromboembolic disease when choosing the method of prophylaxis (for example, graduated stockings, hydration, early mobilisation, low molecular weight heparin). [2011]

Women's preferences during caesarean birth

1.4.47 - Accommodate a woman's preferences for her caesarean birth whenever possible, such as, music playing in theatre, lowering the screen to see the baby born, or silence so that the mother's voice is the first the baby hears. [2004]

1.6 Care of the woman after caesarean birth

High-dependency unit/intensive therapy unit admission

1.6.1 - Be aware that, although it is rare for women to need intensive care after childbirth, this may occur after caesarean birth. [2004, amended 2021]

Monitoring after caesarean birth
After general anaesthesia

1.6.2 - After caesarean birth under a general anaesthetic, a healthcare professional with airway skills should carry out continuous, one-to-one observation of the woman until she:
- has regained airway control and
- is haemodynamically stable and
- is able to communicate. [2021]
1.6.3 - When a woman has regained airway control, is haemodynamically stable, and is able to communicate after caesarean birth under a general anaesthetic:
- continue observations (oxygen saturations, respiratory rate, heart rate, blood pressure, temperature, pain and sedation) every half hour for 2 hours
- after 2 hours, if these observations are stable, carry out routine observations in accordance with local protocols
- if these observations are not stable, or the woman has other risk factors or complications (for example, severe hypertension, or signs of infection or sepsis), carry out a medical review and increase the duration and frequency of observations.
- Also see recommendation 1.6.6 on use of pulse oximeters for people with dark skin. [2021, amended 2023]

After spinal or epidural anaesthesia

1.6.4 - After caesarean birth under a spinal or epidural anaesthetic, a healthcare professional should carry out continuous one-to-one observation of the woman or person who has given birth until they are haemodynamically stable (for example, when pulse and blood pressure have returned to baseline values). [2021]
1.6.5 - For women or people who have had intrathecal or epidural diamorphine for caesarean birth, and who have known risk factors for respiratory depression:
- carry out hourly monitoring of oxygen saturations, respiratory rate and sedation for at least 12 hours after birth and then
- continue with routine postnatal observations in accordance with local protocols. [2021, amended 2023]
1.6.6 - Take into account that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin so hypoxaemia may not be detected. Close attention to respiratory rate and sedation may therefore be needed to detect respiratory depression.
1.6.7 - For women or people who have had intrathecal or epidural diamorphine for caesarean birth, and do not have any known risk factors for respiratory depression, carry out routine postnatal observations in accordance with local protocols. [2021, amended 2023]
1.6.8 - Take into account that, compared with neuraxial diamorphine, neuraxial morphine may be associated with an increased risk of respiratory depression over a longer period, so additional monitoring may be needed (see recommendations 1.6.9 and 1.6.10). [2023]
1.6.9 - For women or people who have had intrathecal morphine or epidural morphine for caesarean birth, and who have known risk factors for respiratory depression:
- carry out hourly monitoring of oxygen saturations, respiratory rate and sedation for at least 12 hours after birth, and then
- continue with routine postnatal observations in accordance with local protocols, unless clinical assessment suggests concerns, including the potential for prolonged effects of morphine (see recommendation 1.6.8), which mean that ongoing monitoring of respiratory status is needed. [2023]
1.6.10 - For women or people who have had intrathecal morphine or epidural morphine for caesarean birth and who do not have any known risk factors for respiratory depression, carry out routine postnatal observations in accordance with local protocols, unless clinical assessment suggests concerns, including the potential for prolonged effects of morphine (see recommendation 1.6.8), which mean that additional monitoring of respiratory status is needed. [2023]

Pain management after caesarean birth

1.6.11 - Offer intrathecal diamorphine (up to 300 micrograms) to reduce the need for supplemental analgesia after a caesarean birth. Use epidural diamorphine (up to 3 mg) as an alternative if intrathecal diamorphine has not been given.
1.6.12 - If diamorphine is unavailable, offer intrathecal preservative-free morphine (up to 100 micrograms) plus intrathecal fentanyl (up to 15 micrograms). Use epidural preservative-free morphine (up to 3 mg) as an alternative if intrathecal morphine has not been used.
1.6.13 - When using neuraxial morphine in place of diamorphine, ensure that:
- only preservative-free morphine is used
- that preservative-containing and preservative-free morphine are stored separately
- that in settings where both types of morphine injection are kept, preservative-containing morphine is clearly identified as 'not for neuraxial administration'. [2023]
1.6.14 - Discuss options with women for pain relief after caesarean birth and explain that:
- pain after caesarean birth can be controlled using oral or injectable medicines
- their choice of pain relief medicines after caesarean birth will depend on:
- the severity of pain
- whether they had spinal or epidural anaesthesia, or general anaesthesia
- if they wish to breastfeed, they will usually be able to do this and care for their baby while taking pain relief medicines. [2021]
1.6.15 - Offer oral immediate-release morphine sulfate to women who have received spinal or epidural anaesthesia for caesarean birth. If the woman cannot take oral medication (for example, because of nausea or vomiting), offer intravenous, intramuscular or subcutaneous morphine. [2021]
1.6.16 - Consider intravenous patient-controlled analgesia (PCA) using morphine for women and people who have given birth who have had a general anaesthetic for caesarean birth. If intravenous PCA is not acceptable to the woman or person who has given birth, or the pain is less severe, consider oral immediate-release morphine sulfate. [2021]
1.6.17 - Ensure women and people who have had PCA with opioids after caesarean birth have routine hourly monitoring of oxygen saturations, respiratory rate, sedation and pain scores throughout treatment, and for at least 2 hours after discontinuation of treatment. [2004, amended 2023]
1.6.18 - Use paracetamol and, unless contraindicated, a non-steroidal anti-inflammatory drug (for example, ibuprofen) in combination after caesarean birth, to reduce the need for opioids and to allow them to be stepped down and stopped as early as possible. [2004, amended 2021]
1.6.19 - If paracetamol does not provide sufficient pain relief after caesarean birth, or non-steroidal anti‑inflammatory drugs cannot be taken, consider adding immediate-release dihydrocodeine to paracetamol, or changing to co‑dydramol (combination preparation of paracetamol and dihydrocodeine) as an alternative to paracetamol. [2021]
1.6.20 - Do not offer codeine or co‑codamol (combination preparation of paracetamol and codeine) to women who are currently breastfeeding, because this can lead to serious neonatal sedation and respiratory depression. Follow the MHRA safety advice on codeine for analgesia: restricted use in children because of reports of morphine toxicity. [2021]
1.6.21 - When using paracetamol, immediate-release dihydrocodeine, co‑dydramol or a non-steroidal anti-inflammatory drug after caesarean birth, prescribe them to be taken regularly and not just when needed for pain relief. [2021]
1.6.22 - For women with severe pain after caesarean birth, when other pain relief is not sufficient:
- perform a full assessment to exclude other causes for the pain (for example, sepsis, haemorrhage, urinary retention)
- discuss with the woman that stronger pain relief medicines are available
- make sure the woman is aware that, if taken while breastfeeding, these medicines could increase the risk of neonatal sedation and respiratory depression.
- If the woman chooses to take stronger medicines, consider a short course of immediate-release tramadol or immediate-release oxycodone at the lowest effective dose. [2021]
1.6.23 - In breastfeeding women, use immediate-release opioid analgesics (for example, morphine, dihydrocodeine, tramadol or oxycodone) at the lowest effective dose and for the shortest duration, and not for more than 3 days without close supervision. [2021]
1.6.24 - If, after a caesarean birth, a woman is discharged home on opioids, advise the woman to contact their healthcare provider if they are concerned about their baby (for example, drowsiness, breathing difficulties, constipation or difficulty feeding). [2021]
1.6.25 - Consider laxatives for women taking opioids, for the prevention of constipation. [2021]
1.6.26 - Consider anti-emetics for women taking opioids, if needed for nausea and vomiting. [2021]
1.6.27 - Advise women that some over-the-counter medicines contain codeine, and should not be taken while breastfeeding because this can lead to serious neonatal sedation and respiratory depression. [2021]

Early eating and drinking after caesarean birth

1.6.28 - If women are recovering well after caesarean birth and do not have complications, they can eat and drink as normal. [2004]
Urinary catheter removal after caesarean birth
1.6.29 - Offer removal of the urinary bladder catheter once a woman is mobile after a regional anaesthetic for caesarean birth, but no sooner than 12 hours after the last 'top-up' dose. [2004, amended 2021]

Respiratory physiotherapy after caesarean birth

1.6.30 - Do not offer routine respiratory physiotherapy to women after a caesarean birth under general anaesthesia as it does not improve respiratory outcomes (for example, coughing, phlegm, body temperature, chest palpation or auscultatory changes). [2004]

Length of hospital stay and readmission to hospital

1.6.31 - Inform women that length of hospital stay is likely to be longer after caesarean birth than after a vaginal birth. [2004, amended 2021]
1.6.32 - Offer women who are recovering well, are apyrexial and do not have complications after caesarean birth, discharge from hospital after 24 hours and follow up at home, as this is not associated with more readmissions for babies or mothers. [2004, amended 2021]

1.7 Recovery after caesarean birth

1.7.1 - In addition to general postnatal care, provide women who have had a caesarean birth with:
- specific care related to recovery after caesarean birth
- care related to management of other complications during pregnancy or childbirth. [2004]

Wound care

1.7.2 - Consider negative pressure wound therapy after caesarean birth for women with a BMI of 35 kg/m2 or more to reduce the risk of wound infections. [2021]
1.7.3 - When using standard (not negative pressure) wound dressings after caesarean birth take into account that:
- no type of wound dressing has been shown to be better than another at reducing the risk of wound infections
- there is no difference in the risk of wound infection when dressings are removed 6 hours postoperatively, compared with 24 hours postoperatively. [2021]
1.7.4 - Ensure caesarean birth wound care includes:
- removing standard dressings 6 to 24 hours after the caesarean birth
- specific monitoring for fever
- assessing the wound for signs of infection (such as increasing pain, redness or discharge), separation or dehiscence
- encouraging the woman to wear loose, comfortable clothes and cotton underwear
- gently cleaning and drying the wound daily
- if needed, planning the removal of sutures or clips.
- Follow the recommendations in the NICE guideline on surgical site infections. [2004, amended 2021]

Management of symptoms

1.7.5 - When caring for women who have had a caesarean birth who have urinary symptoms, consider possible diagnoses of:
- urinary tract infection
- stress incontinence (occurs in about 4% of women after caesarean birth)
- urinary tract injury (occurs in about 1 per 1,000 caesarean births)
- urinary retention. [2004, amended 2021]
1.7.6 - When caring for women who have had a caesarean birth who have heavy and/or irregular vaginal bleeding, consider whether this is more likely to be because of endometritis than retained products of conception, and manage accordingly. [2004, amended 2021]
1.7.7 - Pay particular attention to women who have respiratory symptoms (such as cough or shortness of breath) or leg symptoms (such as painful swollen calf), as women who have had a caesarean birth may be at increased risk of thromboembolic disease (both deep vein thrombosis and pulmonary embolism). [2004, amended 2021]

Resuming activities and discharge home

1.7.8 - Inform women who have had a caesarean birth that they can resume activities such as driving a vehicle, carrying heavy items, formal exercise and sexual intercourse when they feel they have fully recovered from the caesarean birth (including any physical restrictions or pain). [2004, amended 2021]
1.7.9 - When caring for women who have had a caesarean birth, discuss that after a caesarean birth they are not at increased risk of depression, post-traumatic stress symptoms, pain on sexual intercourse, faecal incontinence or difficulties with breastfeeding. [2004, amended 2021]
1.7.10 - While women are in hospital after having an emergency or unplanned caesarean birth, give them the opportunity to discuss with healthcare professionals the reasons for the caesarean birth, and provide both verbal and printed information about birth options for any future pregnancies. If the woman prefers, provide this at a later date. [2011, amended 2021]
1.7.11 - Inform the woman's GP if follow-up investigations are needed after discharge from hospital (for example, a repeat full blood count if there has been a large amount of blood loss), and include details of the plan or course of action if the results are abnormal. [2021]

Document Overview

Document Title: Caesarean Birth

Authoring Society: National Institute for Health and Care Excellence

Document Publication Date: Jun 10, 2025

Page Last Reviewed/Updated: May 6, 2026

Document Type: Guideline

Country of Publication: United Kingdom

Full Text Freely Available: Yes

Full Text Guideline: www.nice.org.uk/guidance/ng192

Source Citation: Caesarean birth. London: National Institute for Health and Care Excellence (NICE); 2024 Jan 30. PMID: 33877751.

Document Scope, Criteria, and Use Cases

Document Objectives: This guideline covers when to offer and discuss caesarean birth, procedural aspects of the operation, and care after caesarean birth. It aims to improve the consistency and quality of care for women and pregnant people who are thinking about having a caesarean birth or have had a caesarean birth in the past and are now pregnant again.

Scope: Assessment and Screening, Management

Keywords: Caesarean

Target Patient Population: Women and pregnant people who are thinking about having a caesarean birth or have had a caesarean birth in the past and are now pregnant again

Target Provider Population: Obstetrician-gynecologist, anesthesiologist, primary care physician, surgical nurse

Inclusion Criteria: Female, Adult, Childbearing

Health Care Settings: Ambulatory, Hospital, Operating and Recovery Room

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Caesarean Birth

Summary of Recommendations

1.1 Planning mode of birth

1.2 Planned caesarean birth

1.3 Factors affecting the likelihood of emergency caesarean birth during intrapartum care

1.4 Procedural aspects of caesarean birth

1.5 Care of the baby born by caesarean birth

1.6 Care of the woman after caesarean birth

1.7 Recovery after caesarean birth

1.8 Pregnancy and childbirth after caesarean birth

Document Overview

Document Scope, Criteria, and Use Cases