Malcolm Griffiths

Caesarean section: summary of updated NICE guidance

In England, rates of caesarean section have increased from 9% of births in 1980 to 24.8% in 2010.1 The indications for the procedure vary. Healthcare professionals have to provide evidence based information for women about the risks and benefits of both planned and unplanned caesarean section. To advise women appropriately they also need to be aware of specific indications for caesarean section, effective management to avoid unnecessary caesarean section and reduce morbidity from caesarean section, and birth after a caesarean section. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on caesarean section.2 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italics in square brackets. ### Possible reasons for caesarean section #### Breech presentation (existing recommendations) #### Morbidly adherent placenta Women found antenatally to have morbidly adherent placenta (an abnormal adherence of the placenta to the uterine wall) will be advised to have a caesarean section. #### Diagnosis of morbidly adherent placenta (new recommendation)

Seat belt injury in pregnancy resulting in fetal death. A need for education ? case reports

A 30-year-old married woman in her fifth pregnancy was involved-at 36 weeks gestation-in a road traffic accident as a front seat passenger. She had been wearing a conventional threepoint fixing seat-belt. She was admitted to the accident and emergency department, where she was noted to have marked bruising over the anterior chest wall and abdomen. She had multiple rib fractures. A laceration of her leg required suturing. There was evidence of a cervical whiplash injury. She began to bleed vaginally and was transferred immediately to the nearby maternity hospital. On arrival no fetal heart was heard. Fetal death was confirmed by ultrasound scan. Having excluded any coagulation defect labour was accelerated with intravenous oxytwin. Fetal cells were seen on Kleihauer test. Blood loss was corrected by transfusion. After a short labour she had a spontaneous vertex delivery of a fresh stillborn girl (birthweight 2.668 kg), without apparent abnormalities. The placenta was delivered in two halves, bisected, half spontaneously, half by controlled cord traction. Postmortem examination of the stillbirth revealed evidence of acute asphyxia. There was also bruising over the posterior skull. A large

A simplified method of laparoscopic presacral neurectomy for the treatment of central pelvic pain due to endometriosis

Sir, We were interested to read the recent paper by Nezhat & Nezhat (1992) concerning the use of laparoscopic presacral neurectomy. Undoubtedly these authors havc demonstrated that this procedure can bc performcd safely through the laparoscope. We do not however believe that their paper justifies the addition of this operation to the laparoscopist’s repertoire. Before doing so, the operation needs to be shown not just to be acceptably safe, but to be effective. In their study, only 52 of 85 women were followed up for 12 months or more. Assessment of improvement in pain and dysmenorrhoea were by ‘office visits, telephone interviews and a questionnaire’ only, with no apparent formalised assessment with structured qucstionnaire, visual analogue scoring or other objective means. There were no controls. All subjects had endometriosis, which was treated by laser excision and vaporisationthis alone might have been expected to account for some subjective or objective improvement of symptoms. Vercellini et al. (1991) have recently pointed out that there is no study to demonstrate that presacral neurectomy is effective, either alone or in addition to other forms of treatment in the treatment of pelvic pain due to endometriosis. Until a properly conducted controlled study with appropriate follow up and objective assessment of pain, demonstrates that presacral neurectomy, by whatever route, is an effective form of treatment, we believe there is no justification for its wider use. Malcolm GrBths Dept of Obstetrics & Gynaecology Royal Berkshire Hospital Reading RGl SAN Philip W. Reginald Dept of Obstetrics & Gynaecology Wexham Park Hospital Slough SL2 4HL

Debate over screening for gestational diabetes: Screening should take place only in context of good quality controlled trials

Editor—Jarrett and Soares et al present arguments respectively against and in favour of screening for gestational diabetes.1 Jarrett has been arguing objectively against gestational diabetes as a useful concept for many years.2 In contrast, many obstetricians and diabetologists have aggressively sought and treated this condition despite a lack of real evidence. Rather, they have worked on the assumption that there is a continuum from normal glucose tolerance through gestational diabetes to frank diabetes and that gestational diabetes must be a less severe form of diabetes. Screening for gestational diabetes presents a massive organisational and financial cost as well as a stressful burden to the women concerned. As Walkinshaw has shown, there is no evidence that attempts to control carbohydrate metabolism in women labelled as having gestational diabetes usefully alter perinatal outcome; rather, they lead to unnecessary interference.3 Had either Jarrett or Soares et al referred to Walkinshaw’s systematic review then one of the three arguments of Soares et al for screening could have immediately been dismissed as lacking in supportive evidence. Their other two arguments are no more certain: that the presence of gestational diabetes predicts an increased risk of maturity onset diabetes in later life, and that management of carbohydrate metabolism in the mother may prevent the child from developing long term medical problems as a result of an adverse intrauterine environment. Sufficient evidence probably exists to support the case that a degree of glucose intolerance predicts an increased risk of frank diabetes in later life. What is less clear is whether, as a result of subjects at increased risk being identified, any intervention can alter disease progression. Surely if there were such evidence, confining screening for such glucose intolerance solely to women who happen to be pregnant would be massively unfair—what about men with an increased risk of maturity onset diabetes, and childless women? The hypothesis regarding long term metabolic effects of an adverse (carbohydrate) intrauterine environment requires confirmation by prospective studies. In discussing this hypothesis Soares et al ignore the difference between frank diabetes and gestational diabetes once more. Until the relevance of gestational diabetes is known, screening for it should take place only in the context of good quality controlled trials. In the meantime we should continue to ensure good preconceptional and antenatal control of frank diabetes and aim to detect the few women who have frank diabetes not diagnosed before pregnancy. The benefits of treating such women have been shown by many authors.

Changes in the abortion legislation in Ireland: The Protection of Life During Pregnancy Act 2013

CELIA BURRELL, CONSULTANT OBSTETRICIAN, BHRUT NHS TRUST, UK AND MALCOLM GRIFFITHS, CONSULTANT OBSTETRICIAN & GYNAECOLOGIST ASSOCIATE MEDICAL DIRECTOR LUTON & DUNSTABLE UNIVERSITY HOSPITAL NHS-FT, UK ....................................................................................................................................................................... F over 150 years Ireland has had strict laws on termination of pregnancy (TOP) before viability. When Ireland gained independence from the UK in 1922, the Offences Against the Person Act 1861 remained in force, maintaining all TOPs as illegal and subject to punishment. Section 58 gives the State power to charge any woman who tries to procure a miscarriage or abortion with a criminal offence, carrying the penalty of life imprisonment. Section 59 states that anyone found guilty of helping a pregnant woman to procure a TOP can be sentenced to 3– 5 years imprisonment. The Medical Council of Ireland states that TOP is illegal, except where there is a real and substantial risk to the life of the mother, or threat of suicide.

What is the acceptable decision-to-delivery interval for an emergency caesarean section?

There is continued controversy about how quickly caesarean sections should be performed. In the UK, the urgency classification proposed by Lucas et al. (J R Soc Med 2000;93:346–50) suggested four categories: (i) immediate threat to the life of the woman or the fetus; (ii) maternal or fetal compromise not immediately life-threatening; (iii) needing early delivery but no maternal or fetal compromise; (iv) delivery at a time to suit the patient and maternity team. Jac Richards was delivered by caesarean section at 14:25 h on 15 May 1996, and at the age of 10 years was severely disabled from an acute hypoxic ischaemic insult to the brain, which it was agreed began 15– 20 minutes before birth. Labour had been induced despite a ‘suspicious’ cardiotocography (CTG) trace, and after treatment with Prostin the trace worsened and became ‘pathological’ (increased baseline, decreased variability, repeated decelerations). A decision was made to deliver by caesarean section. Before delivery there was a precipitous fall in fetal heart rate: a terminal bradycardia, which was not resolved until after delivery and neonatal resuscitation. The causation experts agreed that had he been delivered by 13:55 h, i.e. within 10 minutes of the start of the insult, he would have been born intact. Although the obstetric experts for both parties disputed the time at which a decision for caesarean section should have been made and the degree of urgency (category 1 or 2), it was generally agreed that a decisionto-delivery interval (DDI) of 68 minutes was too long. The experts referred to subsequent National Institute of Health and Clinical Excellence guidelines (Caesarean section NCCWH; NICE 2004) and the National Sentinel Caesarean Section Audit Report 2001, and published audits of DDI (Tuffnell et al. BMJ 2001;322:1330–3) to inform their debate on the appropriate limits for DDI for a category–2 caesarean section. The expert for the claimant took the view that the appropriate DDI for both category–1 and -2 caesarean section was up to 30 minutes. The judge pragmatically determined that ‘once the decision had been taken to deliver Jac by emergency caesarean section, the defendant owed a duty of care to Jac to deliver him as quickly as possible with the aim of trying to deliver him within 30 minutes. . .the caesarean section had to be performed as quickly as possible without subjecting Mrs Richards to unnecessary risk. . .If the failure to deliver him within 45 minutes had been shown to be due to the limited resources of the defendant or constraints on those attending Mrs Richards, e.g. the need to deal with other pressing cases, the primary claim would have failed, but no evidence as to how either of these matters affected the speed of Jac’s delivery was placed before the court’. The reference to DDI was clarified in the NICE 2011 guidelines (Caesarean section CG132; NICE 2011), and remains consistent with the judgment in Richards ‘Perform category 1 and 2 caesarean section as quickly as possible after making the decision, particularly for category 10 .