List of recommendations on non-clinical interventions to reduce unnecessary caesarean sections
A. INTERVENTIONS TARGETED AT WOMEN
Health education for women is an essential component of antenatal care. The following educational interventions and support programmes are recommended to reduce caesarean births only with targeted monitoring and evaluation.
- Childbirth training workshops (content includes sessions about childbirth fear and pain, pharmacological pain-relief techniques and their effects, non-pharmacological pain-relief methods, advantages and disadvantages of caesarean sections and vaginal delivery, indications and contraindications of caesarean sections, among others).
- Nurse-led applied relaxation training programme (content includes group discussion of anxiety and stress-related issues in pregnancy and purpose of applied relaxation, deep breathing techniques, among other relaxation techniques).
- Psychosocial couple-based prevention programme (content includes emotional self-management, conflict management, problem-solving, communication and mutual support strategies that foster positive joint parenting of an infant).
- Psychoeducation (for women with fear of pain; comprising information about fear and anxiety, fear of childbirth, normalization of individual reactions, stages of labour, hospital routines, birth process, and pain relief [led by a therapist and midwife], among other topics).
B. INTERVENTIONS TARGETED AT HEALTH-CARE PROFESSIONALS
- Implementation of evidence-based clinical practice guidelines combined with structured, mandatory second opinion for caesarean section indication is recommended to reduce caesarean births in settings with adequate resources and senior clinicians able to provide mandatory second opinion for caesarean section indication.
- Implementation of evidence-based clinical practice guidelines, caesarean section audits and timely feedback to health-care professionals are recommended to reduce caesarean births.
C. INTERVENTIONS TARGETED AT HEALTH ORGANIZATIONS, FACILITIES OR SYSTEMS
- For the sole purpose of reducing caesarean section rates, a collaborative midwifery-obstetrician model of care (i.e. a model of staffing based on care provided primarily by midwives, with 24-hour back-up from an obstetrician who provides in-house labour and delivery coverage without other competing clinical duties) is recommended only in the context of rigorous research. This model of care primarily addresses intrapartum caesarean sections.
- For the sole purpose of reducing unnecessary caesarean sections, financial strategies (i.e. insurance reforms equalizing physician fees for vaginal births and caesarean sections) for health-care professionals or health-care organizations are recommended only in the context of rigorous research.
Clinical interventions to reduce Cesarean birth
- Breech presentation – External cephalic version in selected cases. Assisted vaginal delivery of breech in selected cases.
- Dystocia – Partographic monitoring in labour management and active management of labour
- Fetal distress – Confirm fetal acidosis by fetal blood sampling
- VBAC – Vaginal birth after cesarean section in selected cases
- Amnioinfusion – In cases of a variable or early FHR deceleration due to oligohydramnios, meconium stained liquor
- Symphysiotomy – In selected cases of obstructed labour with a Live fetus
- Destructive operations like craniotomy – In selected cases of obstructed labor with a dead or moribund fetus