Abstract
Purpose This is an official S3-guideline of the German Society of Gynaecology and Obstetrics (DGGG), the Austrian Society of Gynaecology and Obstetrics (ÖGGG) and the Swiss Society of Gynaecology and Obstetrics (SGGG). The guideline contains evidence-based information and recommendations on indications, complications, methods and care associated with delivery by caesarean section for all medical specialties involved as well as for pregnant women.
Methods This guideline has adapted information and recommendations issued in the NICE Caesarean Birth guideline. This guideline also considers additional issues prioritised by the Cochrane Institute and the Institute for Research in Operative Medicine (IFOM). The evaluation of evidence was based on the system developed by the Scottish Intercollegiate Guidelines Network (SIGN). A multi-part nominal group process moderated by the AWMF was used to compile this S3-level guideline.
Recommendations Recommendations on consultations, indications and the process of performing a caesarean section as well as the care provided to the mother and neonate were drawn up.
Key words: guideline, caesarean section
I Guideline Information
Guidelines programme of the DGGG, OEGGG and SGGG
For information on the guidelines programme, please refer to the end of the guideline.
Citation format
Caesarean Section. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/084, June 2020). Geburtsh Frauenheilk 2021; 81: 896–921
Guideline documents
The complete German-language long version together with a slideshow version of these guidelines and a list of the conflicts of interest of all of the authors are available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-084.html
Guideline authors
Table 1 Lead author and/or coordinating guideline author.
| Author | AWMF professional society |
|---|---|
| Prof. Dr. Frank Louwen | German Society of Gynaecology and Obstetrics [Deutsche Gesellschaft für
Gynäkologie und Geburtshilfe e. V.] Obstetrics and Prenatal Medicine Working Group [AG für Geburtshilfe und Pränatalmedizin (AGG)] |
Table 2 Contributing guideline authors.
| Author Mandate holder |
DGGG working groups/AWMF/non-AWMF professional society/organisation/association |
|---|---|
| * This person has contributed substantially to the preparation of the guideline. They did not participate in the voting on recommendations and statements. | |
| Prof. Dr. Michael Abou-Dakn Prof. Dr. Frank Louwen |
German Society of Gynaecology and Obstetrics [Deutsche Gesellschaft für
Gynäkologie und Geburtshilfe e. V.] Obstetrics and Prenatal Medicine Working Group [AG für Geburtshilfe und Pränatalmedizin (AGG)] (represented by Prof. Louwen) |
| Prof. Dr. Uwe Wagner | German Professional Association of Gynecologists [Berufsverband der Frauenärzte e. V.] |
| Prof. Dr. Jörg Dötsch | German Society of Pediatrics and Adolescent Medicine [Deutsche Gesellschaft für Kinder- und Jugendmedizin e. V.] |
| Dr. Burkhard Lawrenz* | Professional Association of Pediatricians [Berufsverband der Kinder- und Jugendärzte e. V.] |
| Prof. Dr. David Ehm* Prof. Dr. Daniel Surbek* |
Swiss Society of Gynaecology and Obstetrics [Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe] |
| Prof. Dr. Andreas Essig | German Society of Hygiene and Microbiology [Deutsche Gesellschaft für Hygiene und Mikrobiologie e. V.] |
| Prof. Dr. Monika Greening Prof. Dr. Rainhild Schäfers Elke Mattern, M. Sc. Ina C. Waterstradt, M. Sc.* |
German Society of Midwifery Science [Deutsche Gesellschaft für Hebammenwissenschaft e. V.] |
| Dr. Ralph Kästner Dr. Wolf Lütje |
German Society for Psychosomatic Gynecology and Obstetrics [Deutsche Gesellschaft für Psychosomatische Frauenheilkunde und Geburtshilfe e. V.] |
| Univ.-Prof. Dr. Peter Kranke, MBA Dr. Leila Messroghli* Prof. Dr. Manuel Wenk* |
German Society for Anesthesiology and Intensive Care Medicine [Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V.] |
| Prof. Dr. Sven Kehl | German Society for Perinatal Medicine [Deutsche Gesellschaft für Perinatale Medizin e. V.] |
| Prof. Dr. Rolf Schlößer | Society for Neonatology and Pediatric Intensive Care Medicine [Gesellschaft für Neonatologie und Pädiatrische Intensivmedizin e. V.] |
| Dr. Katharina Lüdemann | Working Group on Womenʼs Health in Medicine, Psychotherapy and Society [Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft e. V.] |
| Prof. Dr. Barbara Maier* | Austrian Society of Gynaecology and Obstetrics [Österreichische Gesellschaft
für Gynäkologie und Geburtshilfe] Austrian Society for Psychosomatics in Gynecology and Obstetrics [Österreichische Gesellschaft für Psychosomatik in der Gynäkologie und Geburtshilfe] |
| Dr. Björn Misselwitz* | Office of Quality Assurance Hesse [Geschäftsstelle Qualitätssicherung Hessen e. V.] |
| PD. Dr. Günther Heller* | Institute for Quality Assurance and Transparency in Healthcare [Institut für Qualitätssicherung und Transparenz im Gesundheitswesen] |
| Andrea Bosch Renate Nielsen |
German Midwifery Society [Deutscher Hebammenverband e. V.] |
| Christiane Rothe* | Working Group on Gynecology, Obstetrics, Urology, Proctology/Physio Germany [Arbeitsgruppe Gynäkologie, Geburtshilfe, Urologie, Proktologie/Physio Deutschland] |
| Prof. Dr. Erika Sirsch* | German Society for Nursing Science [Deutsche Gesellschaft für Pflegewissenschaft e. V.] |
| Barbara Stocker Kalberer* | Swiss Midwives Association [Schweizerischer Hebammenverband] |
| Thea Vogel | Family Health Centre Frankfurt [Familiengesundheitszentrum Frankfurt]
(representing pregnant women) Independent patient counselling |
| Prof. Dr. Constantin von Kaisenberg | German Society of Ultrasound in Medicine [Deutsche Gesellschaft für Ultraschall in der Medizin e. V.] |
| Dr. Monika Nothacker* | Methodological support Association of Scientific Medical Societies in Germany [Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V.] |
| Dr. med. Lukas Jennewein* Roman Allert* Barbara Hülsewiesche* |
Guidelines Office, Universitätsklinikum Frankfurt Goethe-Universität, Geburtshilfe und Pränatalmedizin, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany |
| Leitung Prof. Dr. J. Meerpohl* Claudia Bollig* Dr. Britta Lang* Dr. Ralph Möhler* Edith Motschall* Dr. Christine Schmucker* |
Cochrane Germany [Cochrane Deutschland] |
| Barbara Prediger* Stefanie Bühn* Monika Becker* Dr. Dawid Pieper* |
Institute for Research in Operative Medicine [Institut für Forschung in der Operativen Medizin] |
Abbreviations
- EPDS
Edinburgh Postnatal Depression Scale
- DASS
Depression, Anxiety and Stress Scale
- GW
week of gestation
- HBV
hepatitis B virus
- HCV
hepatitis C virus
- HELLP
syndrome: haemolysis, elevated liver enzymes, low platelet count (thrombocytopenia)
- HPV
human papillomavirus
- HIV
human immunodeficiency virus
- IES
Impact of Event Scale
- IFOM
Institute for Research in Operative Medicine
- IUGR
intrauterine growth restriction
- IV
form of administration: intravenous
- MRI
magnetic resonance imaging
- NICE
The National Institute for Health and Care Excellence
- PPH
postpartum haemorrhage
- PO
form of administration: oral (per os)
II Guideline Application
Purpose and objectives
This guideline aims to summarise the currently available knowledge on caesarean sections, focussing on its definition and classification, the information given to patients, the indications, timing and implementation of the procedure, and the impact of a caesarean birth on subsequent pregnancies and deliveries in order to determine the best approach in each individual case following a joint decision-making process.
Targeted areas of care
Inpatient care
Outpatient care
Target user group/target audience
The guideline additionally aims to provide evidence-based recommendations for action for medical professionals involved in the care of mothers and infants to improve the care given to women and their children during the different stages of pregnancy, birth, puerperium and early parenthood. The most important professional groups are
gynaecologists/obstetricians
paediatricians/neonatologists
anaesthetists
midwives
Adoption and period of validity
The validity of this guideline was confirmed by the executive boards/heads of the participating medical professional societies, working groups, organisations and associations as well as the boards of the DGGG, the SGGG and the OEGGG and the DGGG/OEGGG/SGGG guidelines commission in June 2020 and was thus approved in its entirety. This guideline is valid from 1st June 2020 through to 30th June 2023. Because of the contents of this guideline, this period of validity is only an estimate. If changes are urgently required, the guideline may be updated earlier; if the guideline continues to reflect the current state of knowledge, then its period of validity may be extended.
III Methodology
Basic principles
The method used to prepare this guideline was determined by the class to which this guideline was assigned. The AWMF Guidance Manual (version 1.0) has set out the respective rules and requirements for different classes of guidelines. Guidelines are differentiated into lowest (S1), intermediate (S2), and highest (S3) class. The lowest class is defined as consisting of a set of recommendations for action compiled by a non-representative group of experts. In 2004, the S2 class was divided into two subclasses: a systematic evidence-based subclass (S2e) and a structural consensus-based subclass (S2k). The highest S3 class combines both approaches.
This guideline has been classified as: S3
Large parts of the S3-guideline on caesarean section were developed and adapted from the NICE Caesarean Section guideline.
A systematic search for and evaluation of identified guidelines was done using the German guidelines evaluation tool (DELBI) to select the guideline which would be adapted. Additional issues developed and prioritised by the guideline authors were defined during the first session and revised by Cochrane or the Institute for Research in Operative Medicine (IFOM).
Adaptation process
Information about all of the recommendations/statements adapted from the guideline together with the consensus about the adaptations are available in the minutes of the consensus conferences.
Grading of evidence according to SIGN
To assess the level of evidence (levels 1 – 4) of additionally selected primary studies, this guideline used the classification system of the Scottish Intercollegiate Guidelines Network (SIGN) in its most recent version from 2011 ( Table 3 ).
Table 3 Grading of evidence according to SIGN (November 2011).
| Level | Description |
|---|---|
| Source: http://www.sign.ac.uk/pdf/sign50.pdf
Source (contents, abbreviations, notes): http://www.cebm.net/?o=1025 | |
| 1++ | High-quality meta-analyses, systematic review of RCTs, or RCTs with a very low risk of bias |
| 1+ | Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias |
| 1− | Meta-analyses, systematic reviews, or RCTs with a high risk of bias |
| 2++ | High-quality systematic reviews of case-control or cohort studies, or high-quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal |
| 2+ | Well-conducted case-control studies or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal |
| 2− | Case-control studies or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal |
| 3 | Non-analytical studies, e.g., case reports, case series |
| 4 | Expert opinion |
Grading of recommendations
The grading of evidence in an S3-guideline using a level-of-evidence system allows the strength of the recommendations made in the guideline to be graded. The degree of recommendation is differentiated into three levels and the different strengths of recommendation are indicated by the respective choice of words. This commonly used grading of recommendations is not just used by the AWMF but also by the German Medical Association in its National Guidelines on Care ( Nationale Versorgungsleitlinien , NVL). The wording chosen to indicate the strength of the recommendations should be explained in the background text.
In this context, the terms “grade”, “level” or “strength” indicate the degree of certainty about issuing the recommendation after weighing up the benefits and the harm but are not an indication of whether the recommendation itself is binding. Guidelines are recommendatory in nature, i.e., they are not binding. Individual statements and recommendations are differentiated by symbols and syntax ( Table 4 ):
Table 4 Grading of recommendations (based on Lomotan et al., Qual Saf Health Care 2010).
| Symbols | Description of binding character | Expression |
|---|---|---|
| A | Strong recommendation with highly binding character | must/must not |
| B | Regular recommendation with moderately binding character | should/should not |
| 0 | Open recommendation with limited binding character | may/may not |
The above-listed differentiations of recommendations reflect both the assessment of the evidence and the clinical relevance of the studies on which the evidence is based as well as factors which are not included in the grading of evidence such as the choice of patient cohort, intention-to-treat and outcome analyses, medical actions and ethical behaviour towards the patient, country-specific applicability, etc. In contrast, a strong, moderate or poor strength of evidence may correspondingly result in a strong, simple or open recommendation. A recommendation can only be upgraded or downgraded to a grade A or a grade 0 recommendation if the strength of the evidence is moderate. In exceptional cases, the highest level of evidence is only accorded a limited/open recommendation or vice versa, and this needs to be explained in the background text.
Strong evidence → grade A or grade B recommendation
Moderate evidence → grade A or grade B or grade 0 recommendation
Weak evidence → grade B or grade 0 recommendation
Statements
Expositions or explanations of specific facts, circumstances or problems without any direct recommendations for action included in this guideline are referred to as “statements”. It is not possible to provide any information about the grading of evidence for these statements.
Achieving consensus and level of consensus
At structured NIH-type consensus-based conferences (S2k/S3 level), authorised participants attending the session vote on draft statements and recommendations. The process is as follows. A recommendation is presented, its contents are discussed, proposed changes are put forward, and all proposed changes are voted on. If a consensus (> 75% of votes) is not achieved, there is another round of discussions, followed by a repeat vote. Finally, the extent of consensus is determined based on the number of participants ( Table 5 ).
Table 5 Level of consensus based on extent of agreement
| Symbols | Level of consensus | Extent of agreement in percent |
|---|---|---|
| +++ | Strong consensus | > 95% of participants agree |
| ++ | Consensus | > 75 – 95% of participants agree |
| + | Majority agreement | > 50 – 75% of participants agree |
| – | No consensus | < 51% of participants agree |
Expert consensus
As the term already implies, this refers to consensus decisions taken specifically with regard to recommendations/statements issued without a prior systematic search of the literature (S2k) or where evidence is lacking (S2e/S3). The term “expert consensus” (EC) used here is synonymous with terms used in other guidelines such as “good clinical practice” (GCP) or “clinical consensus point” (CCP). The strength of the recommendation is graded as previously described in the chapter on the grading of recommendations but without the use of symbols; it is only expressed semantically (“must”/“must not” or “should”/“should not” or “may”/“may not”).
IV Guideline
1 Introduction
1.1 Definitions
Elective caesarean section is a caesarean section carried out before the start of the first stage of labour or birth. This means that neither (premature) rupture of membranes nor contractions causing cervical opening have occurred.
Emergency caesarean section is a caesarean section carried out after the birth has started; the patient is either experiencing contractions with cervical opening or has had (premature) rupture of membranes.
1.2 Classification using the Robson Classification system
1.3 Epidemiology
According to the German Federal Statistical Office, the rate of caesarean sections in Germany was 29.1% in 2018 after doubling in the period from 1991 (15.1%) to 2014 (31.8%). A survey carried out in 2013 by the OECD showed differences in the global incidence of caesarean sections using data from 32 selected nations. The overall rate for the 32 studied countries was 27.6%. The rates for Germany, Austrian and Switzerland were relatively close together and in the upper half of listed countries just below the USA (32.5%) but significantly below the rates for Turkey (50.4%), Mexico (45.2%) and Chile (44.7%).
2 Information and counselling
2.1 Communication and information
2.2 Discussion of the benefits and risks of vaginal birth and caesarean birth
2.3 Consultation and discussion about the mode of birth
There are no studies which permit conclusions to be drawn about the best time in a pregnancy to have a discussion about the mode of birth.
The following table lists undesirable events which occur more rarely in women who opt for vaginal delivery compared to women who opt for caesarean birth ( Table 6 ).
Table 6 Adverse events occuring in women opting for an elective caesarean section.
| Outcome | Relative risk |
|---|---|
| Hysterectomy after PPH | 2.31 |
| Hysterectomy | 3.6 – 9.0 |
| Cardiac arrest | 4.91 |
| Intubation | 2.21 |
| Long inpatient stay in hospital | Adjusted difference 1.47 days |
| Severe pain 3 days after delivery | 0.7 VAS points (10-point scale) difference |
| Maternal mortality | OR 2.28 – 4.0; a number of studies were unable to find any significant differences. |
| Deep vein thrombosis | 2.20; one study was unable to find any significant differences. |
| Postpartum infection | 2.85; a number of studies were unable to find any significant differences. |
| Obstetric shock | 0.33 |
| Severe acute maternal morbidity | OR: 3.9; one study was unable to find any significant differences. |
Outcomes with no significant difference: acute renal failure, uterine rupture, intraoperative trauma, pulmonary embolism, injury to the bladder/the ureters, the cervix or vagina or other iatrogenic injuries.
2.4 Psychological counselling postpartum
A systematic review into the question of the benefit of psychological support after a traumatic birth was carried out at the instigation of the guideline authors. Four randomised controlled studies were identified. Two of the four studies found significant positive effects associated with psychological interventions (lower rates of depression after 3 months, measured using the EDPS [EDPS > 12] and the DASS [depression > 13], and less post-traumatic stress measured using the IES).
3 Indications for caesarean section
3.1 Breech presentation and external cephalic version
3.2 Intrauterine growth restriction
3.3 Multiple pregnancy
3.4 Preterm birth
3.5 Placenta praevia
3.6 Cephalo-pelvic disproportion
3.7 Caesarean birth at the request of the pregnant woman
3.8 HIV
3.9 Hepatitis B virus
3.10 Hepatitis C virus
3.11 Genital herpes simplex virus (HSV) infection
3.12 HPV infection
4 Performing caesarean section
4.1 Timing of planned caesarean section
4.2 Urgency of caesarean section
4.3 Preoperative care
4.3.1 Laboratory tests
4.3.2 Availability of units of blood
4.4 Timing of prophylactic antibiotic administration
4.5 Surgery
4.5.1 Abdominal skin incision
4.5.2 Instruments for skin incision
4.5.3 Extension of the uterine incision
4.5.4 Foetal laceration
4.5.5 Use of uterotonics
4.5.6 Method of placental delivery
4.5.7 Exteriorisation of the uterus
4.5.8 Closure of the uterus
4.5.9 Closure of the peritoneum
4.5.10 Closure of subcutaneous tissue
4.5.11 Use of wound drains
4.5.12 Closure of the skin
4.6 Thromboprophylaxis
4.7 Maternal preferences
5 Pregnancy and childbirth after caesarean section
5.1 Uterine rupture after previous caesarean birth
5.2 Disorders of placentation: pregnancy and birth
5.2.1 Disorders of placentation: ultrasound examination and MRI
6 Anaesthesia
6.1 Clotting screen prior to regional anaesthesia for caesarean section
6.2 Eating and drinking, avoiding aspiration, and consequences of aspiration
6.3 Anaesthesia for caesarean section
6.4 Intraoperative and postoperative monitoring of women having caesarean section
6.5 Postoperative pain management
7 Postoperative and postnatal care
7.1 Routine care after caesarean section
7.2 Eating and drinking after caesarean section
7.3 Postoperative care
7.4 Postoperative thromboprophylaxis
7.5 Postoperative care: physiotherapy
7.6 Pelvic floor training
7.7 Postpartum changes to abdominal muscles
7.8 Neonatal monitoring
7.9 Bonding after caesarean section
7.10 Breastfeeding after caesarean section
Because of the length of this guideline, we refer all readers interested in the references to the long version of the guideline.
Footnotes
Conflict of Interest/Interessenkonflikt The conflicts of interest are listed in the guidelineʼs Guideline Report./Interessenkonflikte sind im Dokument „Leitlinienreport“ der Leitlinie aufgeführt.
Evidence-based recommendation 1-1.E1.
Level of recommendation A
Level of evidence 3
Caesarean sections must be classified using the Robson Classification system.
Consensus-based recommendation 2-1.E2.
Expert consensus
Level of consensus ++
Pregnant women must be offered evidence-based information and support early on which will enable them to make an informed decision about childbirth.
Womenʼs viewpoints and concerns must be recognised as an integral element in the counselling and decision-making process.
Consensus-based recommendation 2-2.E3.
Expert consensus
Level of consensus +++
Pregnant women requesting a caesarean birth must be provided during their pregnancy with evidence-based information about delivery by caesarean section. Typically, the information provided must include: the indications for caesarean section and the procedural aspects of the operation along with the associated risks and benefits as well as the implications for future pregnancies after a caesarean section.
Consensus-based recommendation 2-3.E4.
Expert consensus
Level of consensus +++
All communications and all information must be provided in a form that is comprehensible to women with no medical knowledge. It must take account of the needs of women who belong to ethnic minorities (specifically: their language, culture and religion) and women whose native language is not German or who are unable to read, and must take account of the needs of women with disabilities or learning difficulties.
Consensus-based recommendation 2-4.E5.
Expert consensus
Level of consensus +++
The discussion about the mode of birth, the benefits and risk of vaginal birth and caesarean birth, and the implications for future pregnancies and births after a caesarean section should be held in an appropriate setting and at an appropriate time in accordance with the principle of shared decision-making.
Consensus-based recommendation 3-1.E6.
Expert consensus
Level of consensus +++
Cases with breech presentation should be offered a consultation about the birth mode early on in a centre with a lot of experience with both modes of delivery, irrespective of the patientʼs parity or whether she has had a previous caesarean section or not.
Consensus-based recommendation 3-1.E7.
Expert consensus
Level of consensus ++
Women with breech presentation at term must be informed that currently no birth mode is associated with better infant outcomes (caesarean birth vs. vaginal birth). Vaginal delivery of breech presentation is an alternative with low maternal morbidity.
Evidence-based recommendation 3-1.E8.
Level of recommendation A
Level of evidence 1+
Women with an uncomplicated singleton pregnancy in breech presentation must be offered external cephalic version from week 36 + 0 of gestation.
Evidence-based maternal and foetal contraindications must be taken into account.
Evidence-based recommendation 3-1.E9.
Level of recommendation A
Level of evidence 2++
Women with a singleton pregnancy in breech presentation must not be offered a planned vaginal delivery before week 36 + 0 of gestation.
Evidence-based recommendation 3-2.E10.
Level of recommendation A
Level of evidence 1+
Elective caesarean section must not be routinely offered for foetuses with IUGR.
Evidence-based recommendation 3-3.E11.
Level of recommendation B
Level of evidence 2+
Perinatal morbidity and mortality rates for the second twin are higher with vaginal delivery in otherwise uncomplicated twin pregnancies with the first foetus in a vertex position. However, it is unclear whether a planned caesarean birth will improve the outcome of the second twin, and caesarean section should therefore not be routinely offered.
Consensus-based statement 3-3.S1.
Expert consensus
Level of consensus ++
It is not clear whether elective caesarean section will improve neonatal outcomes in twin pregnancies with the first twin in breech presentation. The current data does not permit any recommendations regarding the mode of delivery.
Evidence-based recommendation 3-4.E12.
Level of recommendation B
Level of evidence 1+
Preterm birth is associated with a higher neonatal morbidity and mortality. However, it is unclear whether a planned caesarean birth will improve these outcomes, and caesarean section should therefore not be routinely offered.
Evidence-based recommendation 3-5.E12.
Level of recommendation A
Level of evidence 2+
Women with partial or complete placenta praevia must be primarily delivered by caesarean section.
Evidence-based recommendation 3-6.E13.
Level of recommendation B
Level of evidence 1+
Pelvimetry is not useful for the prognosis of the birth and should therefore not be used for decision-making about the mode of birth.
Consensus-based recommendation 3-7.E14.
Expert consensus
Level of consensus +++
When a woman requests a caesarean birth, the reasons for her request must be identified, discussed and documented.
Consensus-based recommendation 3-7.E15.
Expert consensus
Level of consensus +++
If a woman requests a caesarean birth, the risks and benefits of caesarean section compared to vaginal birth must be discussed with her and the substance of what was discussed must be subsequently recorded.
Consensus-based recommendation 3-7.E16.
Expert consensus
Level of consensus +++
If a woman continues to request a caesarean birth after a detailed discussion and, if necessary, support by a specialist specialising in perinatal psychological health with focus on tokophobia, then her request must be granted.
Consensus-based statement 3-8.S2.
Expert consensus
Level of consensus +++
Vaginal delivery for pregnant women with HIV infection is a recommended option under the following conditions:
The pregnant woman is taking antiretroviral combination therapy.
The viral load at the end of the pregnancy, especially near the due date, is < 50 copies/ml.
The obstetrical risks have been evaluated by an experienced obstetrician.
Any logistical problems (e.g., distance to a suitable maternity hospital) have been clarified.
Evidence-based recommendation 3-8.E17.
Level of recommendation B
Level of evidence 2+
HIV-infected pregnant women who do not meet the above-listed conditions for a vaginal birth should still be offered elective caesarean section by an experienced team from week 37 + 0 of gestation at the earliest.
Evidence-based recommendation 3-9.E18.
Level of recommendation B
Level of evidence 2+
No caesarean section should be offered to women with maternal hepatitis B infection, as there is not enough evidence that this will reduce mother-to-child transmission.
Evidence-based recommendation 3-10.E19.
Level of recommendation A
Level of evidence 2+
No planned caesarean section should be offered to hepatitis C-positive pregnant women as this does not reduce mother-to-child transmission.
Evidence-based recommendation 3-11.E20.
Level of recommendation B
Level of evidence 2+
Women with a primary genital herpes simplex virus (HSV) infection which occurs in the third trimester of pregnancy should be offered planned caesarean section as this reduces the risk of neonatal HSV infection.
Consensus-based recommendation 3-12.E21.
Expert consensus
Level of consensus ++
Pregnant women with condylomas in the birth canal and on the vulva must be recommended treatment from week 34 of gestation.
Consensus-based recommendation 3-12.E22.
Expert consensus
Level of consensus +++
Women with HPV infection must not be offered elective caesarean section.
Evidence-based recommendation 4-1.E23.
Level of recommendation A
Level of evidence 2+
The neonatal risk of respiratory disorder after elective caesarean section is higher but decreases significantly from week 39 of gestation. Elective caesarean section must therefore not be carried out before week 39 + 0 of gestation unless there is a good reason to do so.
Evidence-based recommendation 4-2.E24.
Level of recommendation A
Level of evidence 2++
The urgency to perform a caesarean section must be recorded using the following standardised scheme to ensure clear communications with the other medical professionals involved:
Immediate threat to the mother or foetus
Maternal or foetal compromise which is not immediately life-threatening
No maternal or foetal compromise, but early birth is required
No maternal or foetal compromise
Evidence-based recommendation 4-2.E25.
Level of recommendation A
Level of evidence 2+
Category 1 and 2 caesarean sections must be carried out immediately after the diagnosis has been made, especially caesarean sections classified as category 1.
Evidence-based recommendation 4-2.E26.
Level of recommendation A
Level of evidence 4
The foetal and maternal condition must be taken into account when deciding on an early birth. In certain situations, quick delivery may have negative consequences.
Evidence-based recommendation 4-2.E27.
Level of recommendation A
Level of evidence 2+
The maximum decision-to-birth interval (D-B time) for a category 1 caesarean section (emergency caesarean section) must not exceed 20 minutes.
Evidence-based recommendation 4-3.E28.
Level of recommendation B
Level of evidence 4
Maternal haemoglobin status should be determined before carrying out a caesarean section to identify potential anaemia.
Evidence-based recommendation 4-3.E29.
Level of recommendation B
Level of evidence 4
When a caesarean section is performed because of antepartum haemorrhage, placental separation, uterine rupture, placental abruption, a disorder of placentation or placenta praevia, there is a higher risk of losing more than 1000 ml of blood. The caesarean section should be carried out in a clinic with on-site blood transfusion services.
Evidence-based recommendation 4-3.E30.
Level of recommendation B
Level of evidence 4
The following test should not be routinely carried out in healthy pregnant women with uncomplicated pregnancies as it does not affect morbidity: taking blood samples to provide units of blood.
Evidence-based recommendation 4-4.E31.
Level of recommendation B
Level of evidence 1+
Antibiotic prophylactics should be administered before the first skin incision is carried out as it reduces the risk of maternal infection.
Evidence-based recommendation 4-5.E32.
Level of recommendation A
Level of evidence 1−
Caesarean sections must be performed using a transverse lower abdominal incision as this method is associated with less postoperative pain and a better cosmetic effect compared to a midline incision.
Evidence-based recommendation 4-5.E33.
Level of recommendation B
Level of evidence 1+
A transverse lower abdominal incision should be used and subsequent tissue layers should be opened bluntly as this approach is associated with shorter operating times and reduced postoperative febrile morbidity.
Evidence-based recommendation 4-5.E34.
Level of recommendation A
Level of evidence 1+
Changing scalpels between the skin incision and incising the deeper tissue layers is not recommended when performing caesarean section as it does not decrease wound infection.
Evidence-based recommendation 4-5.E35.
Level of recommendation B
Level of evidence 1+
When there is a well-formed lower uterine segment, blunt extension of the uterine incision should be performed as this reduces blood loss, postpartum haemorrhage, and the need for blood transfusion.
Evidence-based recommendation 4-5.E36.
Level of recommendation A
Level of evidence 3
Women must be informed that the risk of foetal laceration during caesarean section is about 2%.
Evidence-based recommendation 4-5.E37.
Level of recommendation B
Level of evidence 1+
Oxytocin or analogues should be administered during caesarean section by slow intravenous injection or short infusion to increase contractions and reduce blood loss.
Evidence-based recommendation 4-5.E38.
Level of recommendation B
Level of evidence 1+
The placenta should be removed by cord traction and not by manual removal as this reduces the risk of endometritis.
Evidence-based recommendation 4-5.E39.
Level of recommendation B
Level of evidence 1+
Closure of the uterus following uterotomy should be done intraabdominally. Exteriorisation of the uterus is not recommended as this is associated with more postoperative pain and does not improve operative outcomes such as haemorrhage and infection.
Evidence-based recommendation 4-5.E40.
Level of recommendation 0
Level of evidence 1+
It is not clear whether single-layer or double-layer closure is more effective and safer. It is therefore not possible to give a clear recommendation.
Evidence-based recommendation 4-5.E41.
Level of recommendation B
Level of evidence 1+
The visceral and parietal peritoneum should not be sutured during caesarean section as this reduces operating time, reduces the need for postoperative analgesics, and is associated with higher maternal satisfaction.
Evidence-based recommendation 4-5.E42.
Level of recommendation B
Level of evidence 1+
Subcutaneous tissue should not be routinely sutured unless the woman has more than 2 cm subcutaneous fat, as this does not reduce the risk of wound infection.
Evidence-based recommendation 4-5.E43.
Level of recommendation A
Level of evidence 1+
Superficial wound drains must not be routinely used in caesarean birth as they do not decrease the incidence of wound infection or haematoma.
Evidence-based recommendation 4-5.E44.
Level of recommendation C
Level of evidence 1+
The effect of different suturing materials or methods of skin closure in caesarean section is not clear.
Evidence-based recommendation 4-6.E45.
Level of recommendation B
Level of evidence 1+
Thromboprophylaxis should be given after caesarean section as caesarean section is associated with a higher risk of venous thromboembolism. The choice of thromboprophylaxis should take account of the initial risk of thromboembolic disease and follow existing guidelines.
Evidence-based recommendation 4-7.E46.
Level of recommendation B
Level of evidence 4
The womanʼs preferences during caesarean birth should be accommodated whenever possible. The atmosphere should contribute to the birth experience.
Consensus-based recommendation 5.E47.
Expert consensus
Level of consensus ++
When advising about the method of delivery after a previous caesarean section, the following factors must be taken into account: maternal preferences and the risks and benefits of repeat caesarean section compared to those of a vaginal birth.
Consensus-based statement 5.S3.
Expert consensus
Level of consensus ++
The risk of birth complications such as fever, bladder injuries and organ lacerations is not associated with the planned mode of delivery in women who have had up to 4 caesarean sections.
Evidence-based recommendation 5.E48.
Level of recommendation A
Level of evidence 2+
All women who have had a previous caesarean section must be monitored by continuous CTG of the foetus during labour and must be given the recommendation to give birth in a clinic where immediate emergency caesarean section can be carried out at all times.
Evidence-based recommendation 5-1.E49.
Level of recommendation A
Level of evidence 2+
During induction of labour in a woman who has had a previous caesarean section, mother and foetus must be monitored continuously because of the higher risk of uterine rupture, and the clinic must be able to perform an emergency caesarean section.
Evidence-based recommendation 5-1.E50.
Level of recommendation A
Level of evidence 2+
Women who have had a previous caesarean birth and a previous vaginal birth must be informed that the probability of delivering vaginally again is higher than if they had not previously had a vaginal birth.
Consensus-based recommendation 5-2.E51.
Expert consensus
Level of consensus +++
Patients with disorders of placentation must, on principle, present at an early stage to a suitable maternity hospital, where they will be treated by a multidisciplinary team (at the optimum time by the optimum team).
Evidence-based recommendation 5-2.E52.
Level of recommendation B
Level of evidence 2+
If there is a suspicion of placentation disorder, the birth must be planned together with an experienced obstetrician.
An experienced obstetrician, anaesthetist and paediatrician must be present and a haematologist who perform a blood transfusion must be on standby.
Sufficient cross-matched blood and blood products must be readily available.
It may be necessary to call in consultants from other medical specialties. A management protocol for the treatment of disorders of placentation must be available which sets out how local elements of care such as those listed above will be provided.
Consensus-based statement 5-2.S4.
Expert consensus
Level of consensus +++
It appears that ultrasound examination has a high sensitivity, while the overall diagnostic accuracy of MRI tends to be lower. It is not possible to make a conclusive statement about the diagnostic accuracy of a combination of ultrasound examination and MRI.
Consensus-based recommendation 6-1.E53.
Expert consensus
Level of consensus +++
A routine clotting screen prior to regional anaesthesia for caesarean section must not be carried out if the patient has no prior history of clotting disorder and the pregnancy is uncomplicated.
Consensus-based recommendation 6-2.E54.
Expert consensus
Level of consensus +++
Women in labour must be permitted fluid intake in the form of clear beverages (e.g., water, tea or isotonic drinks) during labour.
Consensus-based recommendation 6-2.E55.
Expert consensus
Level of consensus ++
If the likelihood of surgical intervention during the birth is very low, the pregnant woman may have a light meal, depending on her needs.
Consensus-based recommendation 6-2.E56.
Expert consensus
Level of consensus +++
If it becomes clear during labour that the risk of requiring caesarean section is high, the pregnant woman must refrain from having any food; the intake of clear beverages is permitted if absolutely necessary.
If a caesarean section is indicated, there should be no intake of food. The recommended rules on abstaining from eating and drinking prior to surgery apply.
Consensus-based recommendation 6-2.E57.
Expert consensus
Level of consensus +++
As part of the preparations for a planned caesarean section, an H2 blocker (ranitidine) as well as a non-particulate antacid (sodium citrate) should be administered as prophylaxis against aspiration and the consequences of aspiration.
Consensus-based recommendation 6-2.E58.
Expert consensus
Level of consensus +++
The timing of the administration of medications for aspiration prophylaxis and the mode of administration (IV versus PO) should be chosen based on the situational conditions and should take account of the time to onset of action and the duration of action. This means that, in principle, PO administration is possible for planned caesarean sections and generally implies that IV administration of the substances is permissible in cases requiring unplanned caesarean section.
Evidence-based recommendation 6-3.E59.
Level of recommendation A
Level of evidence 1+
When providing information about the types of anaesthesia available, women having caesarean section should be offered a regional anaesthesia (spinal or epidural anaesthesia or modifications of the two) as the first-choice approach.
Evidence-based recommendation 6-3.E60.
Level of recommendation B
Level of evidence 1+
If general anaesthesia is indicated (e.g., regional anaesthesia is contraindicated, maternal preference), the mother should be informed that, based on the current state of knowledge, this decision is not associated with relevant adverse effects in terms of maternal or neonatal outcomes.
Consensus-based recommendation 6-3.E61.
Expert consensus
Level of consensus +++
If a general anaesthesia is administered, rapid sequence induction must be performed in pregnant women from week 20 + 0 of gestation at the latest in the same way as for non-fasted patients.
Consensus-based recommendation 6-4.E62.
Level of recommendation A
Level of consensus +++
The same standards of intraoperative monitoring as are used in all other procedures carried out with neuraxial blockade or under general anaesthesia must be applied when monitoring pregnant women having a planned caesarean section.
Consensus-based recommendation 6-4.E63.
Level of recommendation A
Level of consensus +++
In the postoperative phase of caesarean sections, instrument-based monitoring must be used for postoperative observation which comply with minimum requirements in terms of the available equipment in the room and the documentation of readings.
Consensus-based recommendation 6-5.E64.
Expert consensus
Level of consensus +++
Pregnant women planning a caesarean section must be informed about the options for postoperative pain relief. This will allow a needs-based analgesia concept to be defined and implemented which meets the patientʼs expectations and takes account of procedural, logistical and individual circumstances.
Consensus-based recommendation 6-5.E65.
Expert consensus
Level of consensus +++
The analgesia concept must include suitable systematic measures which reduce the need for pro re nata analgesia postoperatively.
Such measures include, for example, the administration of intrathecal or epidural opioids, loading a previously placed epidural catheter or rapid prescription of non-opioid drugs (e.g., ibuprofen and paracetamol).
Consensus-based recommendation 6-5.E66.
Expert consensus
Level of consensus +++
A systematic postoperative analgesia concept must ensure that patients have access to effective opioids according to their needs, e.g., as part of a patient-controlled process.
Consensus-based recommendation 7-1.E67.
Expert consensus
Level of consensus ++
After a caesarean section, mother and infant must be suitably monitored by trained medical professionals. It is important to bear in mind that intensive care is required more often after caesarean section than after vaginal delivery. The observation rooms must be equipped with the appropriate technical equipment.
Evidence-based recommendation 7-2.E68.
Level of recommendation A
Level of evidence 1+
Women recovering well from caesarean section must be offered food and to drink.
Evidence-based recommendation 7-3.E69.
Level of recommendation B
Level of evidence 1+
The urinary catheter should be removed after caesarean section as soon as the woman is mobile.
Consensus-based recommendation 7-3.E70.
Expert consensus
Level of consensus +++
The patientʼs temperature should be measured daily during the first few postoperative days and the patient should be monitored for signs of wound infection. Women should be informed about wound care following caesarean section.
Evidence-based recommendation 7-4.E71.
Level of recommendation B
Level of evidence 2++
There is a higher risk of thrombotic disease after caesarean section. Women who have had a caesarean section should therefore receive non-pharmacological thromboprophylaxis. After risk stratification, prophylactic postoperative heparin therapy should be initiated.
Evidence-based recommendation 7-5.E72.
Level of recommendation B
Level of evidence 2+
Women at risk of postoperative complications should be offered respiratory therapy after caesarean section.
Consensus-based recommendation 7-6.E73.
Expert consensus
Level of consensus +++
Postpartum therapy for pelvic floor dysfunction must be recommended to women who have had a caesarean section.
Evidence-based recommendation 7-7.E74.
Level of recommendation B
Level of evidence 1+
Women who have had a caesarean section should be offered functional therapy for postpartum and postoperative changes to abdominal muscles.
Evidence-based recommendation 7- 7.E75.
Level of recommendation V
Level of evidence 2 – 3
Women who have had a caesarean section should receive support and advice about pain reduction when changing position, lifting and carrying and performing sports-related activities.
Evidence-based recommendation 7-8.E76.
Level of recommendation A
Level of evidence 2+
A physician skilled in the resuscitation of neonates must be on standby when a caesarean section is carried out.
Consensus-based recommendation 7-8.E77.
Expert consensus
Level of consensus +++
A physician skilled in the resuscitation of neonates (preferably a paediatrician) must be present if a caesarean section is carried out under general anaesthesia or foetal complications are expected.
Consensus-based recommendation 7-8.E78.
Expert consensus
Level of consensus +++
Infants delivered by caesarean section are more likely to have a lower temperature. This risk must be managed appropriately.
Consensus-based recommendation 7-9.E79.
Expert consensus
Level of consensus +++
Early skin-to-skin contact between mother and baby must be supported and facilitated because it improves the infantʼs awareness and reduces the stress of mother and baby. Skin contact facilitates maternal bonding and encourages breastfeeding.
Consensus-based recommendation 7-9.E80.
Expert consensus
Level of consensus +++
Women who had a caesarean section must be helped to start bonding with their baby (skin contact) already in the operating room if their baby is doing well.
Consensus-based recommendation 7-10.E81.
Expert consensus
Level of consensus ++
Women who had a caesarean section must be given additional support to facilitate the start of breastfeeding as they face greater difficulties when they start breastfeeding.
Consensus-based recommendation 7-10.E82.
Expert consensus
Level of consensus ++
The baby must be placed at the breast when the mother is awake and sufficiently focused. Alternatively, colostrum must be harvested. Even after general anaesthesia, the colostrum does not need to be discarded.