Vaginal Birth at Term – Part 2. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020)

Abstract

Purpose This guideline aims to summarize the current state of knowledge about vaginal birth at term. The guideline focuses on definitions of the physiological stages of labor as well as differentiating between various pathological developments and conditions. It also assesses the need for intervention and the options to avoid interventions. The second part of this guideline presents recommendations and statements on care during the dilation and expulsion stages as well as during the placental/postnatal stage.

Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG190 guideline “Intrapartum care for healthy women and babies”. Other international guidelines were also consulted in individual cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions where necessary, and other systematic reviews and individual studies were taken into account. For easier comprehension, the assessment tools of the Scottish Intercollegiate Guidelines Network (SIGN) were used to evaluate the quality of additionally consulted studies. Otherwise, the GRADE system was used for the NICE guideline, and the evidence reports of the IQWiG were used to evaluate the quality of the evidence.

Recommendations Recommendations and statements were formulated based on identified evidence and/or a structured consensus.

I  Guideline Information

Guidelines program of the DGGG, OEGGG and SGGG

For information on the guidelines program, please refer to the end of the guideline.

Citation format

Vaginal Birth at Term – Part 2. Guideline of the DGGG, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/083, December 2020). Geburtsh Frauenheilk 2022; 82: 1143–1193

Guideline documents

The complete long version in German and a slide version of these guidelines as well as a list of the conflicts of interest of all of the authors is available on the homepage of the AWMF: http://www.awmf.org/leitlinien/detail/ll/015-083.html

Guideline authors

See Tables 1 and 2 .

Table 1  Lead author and/or coordinating guideline author.

Author	AWMF professional society
Prof. Dr. Michael Abou-Dakn (from Feb. 2017, coordinator, DGGG)	Klinik für Gynäkologie und Geburtshilfe, St. Joseph Krankenhaus Berlin-Tempelhof, Wüsthoffstraße 15, 12101 Berlin, Germany
Prof. Dr. Rainhild Schäfers (coordinator, DGHWi)	Hochschule für Gesundheit, Department für Angewandte Gesundheitswissenschaften, Gesundheitscampus 6 – 8, 44801 Bochum, Germany

Table 2  Contributing guideline authors.

Author Mandatsträger/in	DGGG working group (AG)/ AWMF/non-AWMF professional society/ organization/association
Prof. Dr. Michael Abou-Dakn	German Society for Gynecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V.]
Kirsten Asmushen, M. Sc.	Society for Quality in Non-clinical Obstetrics [Gesellschaft für Qualität in der außerklinischen Geburtshilfe e. V.]
Dr. Susanne Bässler-Weber	Working Group on Womenʼs Health in Medicine, Psychotherapy and Society [Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft e. V.]
Dr. Ulrike Boes	Working Group on Womenʼs Health in Medicine, Psychotherapy and Society [Arbeitskreis Frauengesundheit in Medizin, Psychotherapie und Gesellschaft e. V.]
Andrea Bosch	German Midwifery Association [Deutscher Hebammenverband e. V.]
Prof. Dr. David Ehm	Swiss Society for Gynecology and Obstetrics [Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe]
Univ. Prof. Dr. Thorsten Fischer	Austrian Society for Gynecology and Obstetrics [Österreichische Gesellschaft für Gynäkologie und Geburtshilfe]
Prof. Dr. Monika Greening	German Society of Midwifery [Deutsche Gesellschaft für Hebammenwissenschaft e. V.]
Dr. Katharina Hartmann	Mother Hood e. V.
PD Dr. Günther Heller	Institute for Quality Assurance and Transparency in Healthcare [Institut für Qualitätssicherung und Transparenz im Gesundheitswesen]
Claudia Kapp	German Society of Midwifery [Deutsche Gesellschaft für Hebammenwissenschaft e. V.]
Prof. Dr. Constantin von Kaisenberg	German Society of Ultrasound in Medicine [Deutsche Gesellschaft für Ultraschall in der Medizin e. V.]
Beate Kayer, Mag. (FH)	Austrian Midwifery Committee [Österreichisches Hebammengremium]
Prof. Dr. Sven Kehl	German Society for Perinatal Medicine [Deutsche Gesellschaft für Perinatale Medizin e. V.]
Univ. Prof. Dr. Peter Kranke, MBA	German Society for Anesthesiology and Intensive Care Medicine [Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V.]
Dr. Burkhard Lawrenz	Professional Association of Pediatricians [Berufsverband der Kinder- und Jugendärzte e. V.]
Dr. Christine Loytved	German Society of Midwifery [Deutsche Gesellschaft für Hebammenwissenschaft e. V.]
Dr. Wolf Lütje	German Society for Psychosomatic Gynecology and Obstetrics [Deutsche Gesellschaft für Psychosomatische Frauenheilkunde e. V.]
Elke Mattern, M. Sc.	German Society of Midwifery [Deutsche Gesellschaft für Hebammenwissenschaft e. V.]
Renate Nielsen	German Midwifery Association [Deutscher Hebammenverband e. V.]
Prof. Dr. Frank Reister	German Society for Gynecology and Obstetrics [Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V.]
Prof. Dr. Rainhild Schäfers	German Society of Midwifery [Deutsche Gesellschaft für Hebammenwissenschaft e. V.]
Prof. Dr. Rolf Schlösser	Society for Neonatology and Pediatric Intensive Care [Gesellschaft für Neonatologie und Pädiatrische Intensivmedizin e. V.]
Prof. Dr. Christiane Schwarz	German Society of Midwifery [Deutsche Gesellschaft für Hebammenwissenschaft e. V.]
Prof. Dr. Volker Stephan	German Society for Pediatrics and Adolescent Medicine [Deutsche Gesellschaft für Kinder- und Jugendmedizin e. V.]
Barbara Stocker Kalberer, midwife, M. Sc.	Swiss Midwifery Association [Schweizerischer Hebammenverband]
Dr. Axel Valet	Professional Association of Gynecologists [Berufsverband der Frauenärzte e. V.]
Prof. Dr. Manuel Wenk	German Society for Anesthesiology and Intensive Care Medicine [Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin e. V.]

The guideline was moderated by Dr. med. Monika Nothacker (AWMF).

Abbreviations

ACOG

American College of Obstetricians and Gynecologists

AoP

angle of progression

AWMF

Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (Association of Scientific Medical Societies in Germany)

BE

base excess

BGA

blood gas analysis

BP

breech presentation

CG

clinical guideline

CI

confidence interval

CTG

cardiotocography/cardiotocogram

CRP

C-reactive protein

CSE

combined spinal-epidural anesthesia

DGAI

Deutsche Gesellschaft für Anästhesiologie & Intensivmedizin (German Society for Anesthesiology and Intensive Care Medicine)

DGGG

Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e. V. (German Society for Gynecology and Obstetrics)

DGHWi

Deutsche Gesellschaft für Hebammenwissenschaft e. V. (German Society of Midwifery)

DRG

diagnosis-related groups

DS

dilation stage

ECG

electrocardiogram

EA

epidural anesthesia

EC

expert consensus

ERC

European Resuscitation Council

ES

expulsion stage

FIGO

Fédération Internationale de Gynécologie et dʼObstétrique (Internationale Federation of Gynecology and Obstetrics)

FBA

fetal blood analysis

GBS

group B Streptococci

GDM

gestational diabetes

GR

Grade of Recommendation

GRADE

Grading of Recommendations, Assessment, Development and Evaluation

GW

week(s) of gestation

h

hours

Hb

hemoglobin

Hk

hematocrit

HebG

Hebammengesetz (German Midwifery Act)

HebStPrV

Studien- und Prüfungsverordnung für Hebammen (Study and Examination Regulations for Midwives)

HIE

hypoxic ischemic encephalopathy

HPD

head-perineum distance

ICM

International Confederation of Midwives

ICI

International Childbirth Initiative

IE/IU

Internationale Einheit/International Unit

IFOM

Institut für Forschung in der Operativen Medizin (Institute for Research in Surgical Medicine)

ILCOR

International Liaison Committee on Resuscitation

IM

intramuscular

IPA

International Pediatric Association

IQWiG

Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (Institute for Quality and Efficiency in Health Care)

ISUOG

International Society of Ultrasound in Obstetrics & Gynecology

IUGR

intrauterine growth restriction

IV

intravenous

LGA

large for gestational age

LoE

Level of evidence

MAS

meconium aspiration syndrome

MD

mean difference

mU

milliunit

NHS

National Health Service

NICE

National Institute for Health Care and Excellence

NNT

number needed to treat

OR

odds ratio

PCIA

patient-controlled intravenous analgesia

PICO

Participants Intervention Comparison Outcomes

PL

perineal laceration

PROM

premature/pre-labor rupture of the membranes

PPH

postpartum hemorrhage

PS

placental stage

QSR

Qualitätssicherung mit Routinedaten (quality assurance with routine data)

QUAG

Gesellschaft für Qualität in der außerklinischen Geburtshilfe e. V. (Society for Quality in Non-clinical Obstetrics)

QFR-RL

Qualitätssicherungs-Richtlinie Früh- und Reifgeborene (Quality Assurance Directive for Premature and Mature Births)

RANZCOG

Royal Australian and New Zealand College of Obstetricians and Gynecologists

RCT

randomized controlled study

RR

risk ratio/relative risk

SGB

Sozialgesetzbuch (German Code of Social Law)

SMFM

Society for Maternal-Fetal Medicine

SGA

small for gestational age

SOGC

Society of Obstetricians and Gynaecologists of Canada (SOGC)

STAN

ST segment analysis

SMFM

Society for Maternal-Fetal Medicine

TENS

transcutaneous electrical nerve stimulation

VAS

visual analog scale

VE

vaginal examination

vs.

versus

WIdO

Wissenschaftliches Institut der AOK (Scientific Institute of the AOK)  

II  Guideline Application

Purpose and objectives

Uterotonic drugs are administered in one quarter of births in Germany and almost one third of infants in Germany are delivered by caesarean section. More than half of all caesarean deliveries were considered necessary because of failure to progress in labor or abnormalities detected during fetal monitoring, but this has had no significant impact on reducing perinatal morbidity or mortality. At the same time, there is a growing body of evidence that both the rate of administered uterotonics and the rate of caesarean deliveries correlate with maternal and neonatal morbidity rates.

This guideline aims to summarize the current state of knowledge on vaginal birth at term. The guideline focuses on defining the physiological stages of labor and differentiating pathological stages as well as assessing the need for intervention and the options to avoid an intervention. The information provided in this guideline should serve as an orientation for action for all persons involved in the care of parturient women and also aims to allow women to have a self-determined birth based on their specific situation.

Targeted areas of care

The focus is principally on the birth process and covers all stages of labor including the placental stage.

Target user groups/target audience

The guideline is especially aimed at midwives, gynecologists/obstetricians, pediatricians and specialists for adolescent medicine/neonatologists and anesthetists.

Adoption and period of validity

The validity of this guideline was confirmed by the executive boards/heads of the participating professional societies/working groups/organizations/associations as well as by the boards of the DGGG, SGGG, OEGGG and the DGGG/OEGGG/SGGG guidelines commission in [12/2020] and was thus approved in its entirety. This guideline is valid from 22 December 2020 through to 21 December 2025. Because of the contents of this guideline, this period of validity is only an estimate. The guideline can be reviewed and updated at an earlier point in time if necessary. If the guideline still reflects the current state of knowledge, its period of validity can 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

Grading of evidence according to SIGN

To evaluate 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 evidence

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 in the National Guidelines on Care ( Nationale Versorgungsleitlinien , NVL) issued by the German Medical Association. The wording chosen to indicate the strength of the recommendations is explained in the background text.

In this context, the terms “grade”, “level” or “strength” indicate the degree of certainty when issuing the recommendation after weighing up the benefits and harms 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-described differentiation of recommendations reflects 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 behavior towards the patient, country-specific applicability, etc. In contrast, strong, moderate or weak 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 strength of consensus

At structured NIH-type consensus-based conferences (S2k/S3 level), authorized 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 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  Care during the dilation stage 1

An algorithm was developed to support the recommendations/statements ( Fig. 1 ).

Fig. 1.

 Algorithm outlining the appropriate approach for the active dilation stage. [rerif]

1.1  Premature rupture of membranes (PROM)

1.1.1  Definition

Premature/pre-labor rupture of membranes [PROM] is defined as a rupture of membranes before the onset of labor (contractions and dilation of the cervix) at term (≥ 37 + 0 GW).

1.1.2  Recommendations for general care

1.1.2.1  Recommendations when the station and position of the presenting part of the fetus are not clear

7.1	Recommendation
GR B	The woman must not be advised to lie down following a premature rupture of membranes.
LoE 2−	2
	Level of consensus: 89%

1.1.2.2  Diagnostic examinations after PROM

7.2	Recommendation
GR A	No vaginal examination (palpation, speculum) must be carried out if it is certain that the membranes have ruptured.
LoE 2++	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 59 4 ,  5 ,  6
	Level of consensus: 100%

7.3	Recommendation
GR B	If it is unclear whether the membranes have ruptured, a speculum examination should be advised.
A	A vaginal examination must not be carried out if there are no contractions.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 60 4 ,  5
	Level of consensus: 100%

7.4	Recommendation
GR A	No vaginal swabs must be taken or no measurements of C-reactive protein in maternal blood must be carried out if induction of labor is started or expectant management (beyond 24 hours) is chosen. The womanʼs temperature must be checked every 4 hours when she is awake to exclude her developing a fever, and the woman must immediately report any change in the color and smell of her vaginal loss.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 62
	Level of consensus: 100%

7.5	Recommendation
GR A	After premature rupture of membranes, fetal movement and fetal heart rate must be assessed at initial contact and then every 24 hours as long as no contractions have started. The pregnant woman must be advised to report any decrease in fetal movements immediately.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 63
	Level of consensus: 100%

1.1.2.3  Place where the pregnant woman is cared for after PROM

7.6	Recommendation
GR A	If no contractions have started within 24 hours after premature rupture of membranes, the pregnant woman must be advised to go to a hospital which can provide neonatal care and to remain in hospital postpartum for at least 12 hours.
LoE 2+, 1−, 2−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 64 4 ,  7 ,  8
	Level of consensus: 100%

1.1.2.4  Risk factors for maternal infection after PROM 3 ,  4 ,  7 ,  8

7.7	Statement
	Bathing and showering are not associated with a higher risk of infection if induction of labor is initiated or the woman has chosen expectant management (beyond 24 hours) after premature rupture of membranes.
LoE 2+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 62 9
	Level of consensus: 100%

1.1.2.5  Risk factors for neonatal infection after PROM 9

7.8	Recommendation
GR A	The woman must be informed that the risk of serious neonatal infection after premature rupture of membranes is around 1%, compared to about 0.5% when the membranes are intact.
LoE 2++	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 61 10
	Level of consensus: 100%

1.1.3  Antibiotic prophylaxis 10

7.9	Recommendation
11 ,  13 ,  14
GR B 0	After premature rupture of membranes, the woman should be informed that after 12 hours, the risk of maternal infection rises, and antibiotic prophylaxis may be initiated.
LoE 1+	11 ,  12 ,  13 ,  14
	Level of consensus: 100%

1.1.4  Indication for induction of labor 13

The Board of the OEGGG does not support Chapter 7, item 7.1.4 Indication for the induction of labor for Austria. See the relevant statements in the guideline report.

7.10	Recommendation
12 ,  15 ,  16
GR B	After premature rupture of membranes, around 60% of woman go into labor within 24 hours. Induction of labor should be offered after 24 hours.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 recommendation 61 12 and comparison and inclusion of further evidence 15
	Level of consensus: 100%

1.2  Latent first stage of labor

1.2.1  Definition

7.11	Statement
	The latent first stage of labor (or early dilation stage) is the period from the start of labor until the cervix is dilated to 4 – 6 cm.
LoE 1+	17
	Level of consensus: 100%

1.2.2  Recommendations for general care 17

7.12	Recommendation
GR A	All nulliparous women must be informed during their pregnancy about what they can expect during the latent stage, the strategies they can use to cope with the pain, how they can contact their obstetric team, and what must be done in an emergency.
LoE 1+, 1−, 2−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 32 18 ,  19 ,  20
	Level of consensus: 100%

7.13	Recommendation
GR A	All nulliparous women must be informed in the run-up to the birth what the signs of onset of labor are, how to differentiate Braxton Hicks contractions from active labor contractions, the frequency and duration of labor contractions, how to recognize a rupture of membranes, and what constitutes normal vaginal loss or discharge during pregnancy and labor.
LoE 1+, 1−, 2−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 33 18 ,  19 ,  20
	Level of consensus: 100%

7.14	Recommendation
GR 0	Assessment of possible onset of labor by telephone may be helpful.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 34 21 ,  22 ,  23
	Level of consensus: 88%

7.15	Recommendation
GR 0	To assess a possible onset of labor, a low-risk nulliparous woman may be examined either at home or at her planned maternity hospital.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 35 22 ,  24
	Level of consensus: 100%

7.16	Recommendation
GR B	At the initial examination/on admission the pregnant woman should be asked about her condition, her wishes, her expectations and her fears. the pregnant woman should be asked about fetal movements and any possible changes. the pregnant woman should be informed about what she can expect in the latent stage. and how she can work with the labor pains she experiences. the pregnant woman should be informed about the support she can expect. a plan of care going forward should be agreed upon with the pregnant woman, including information about who is responsible for her at what times and how they can be contacted. her birth companions should be provided with guidance and support.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 36 25
	Level of consensus: 94%

7.17	Recommendation
GR B	The next steps and the recommendations should be recorded during the initial examination/ on admission.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 37
	Level of consensus: 94%

7.18	Recommendation
GR B	If a pregnant woman presents with painful contractions during the latent stage/early dilation stage it should be remembered that she may be experiencing painful contractions but without cervical changes, which may give her the subjective impression that she is in labor. she should be offered individual support and pain therapy if needed. she should be encouraged to return home if there is no increased risk that she could give birth without anyone in attendance.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 38
	Level of consensus: 94%

1.2.3  Diagnostic measures 18 ,  19 ,  20 ,  21 ,  22 ,  23 ,  24 ,  25

The questions about which points should be included in the initial examination at the onset of labor or if onset of labor is suspected could not be answered based on current studies.

1.2.3.1  Patientʼs history

7.19	Recommendation
GR A	During the initial assessment of a woman in labor she must be asked about her previous medical history and her expectations and wishes.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 41
	Level of consensus: 100%

7.20	Recommendation
GR A	During the initial assessment of a woman in labor, the following information and findings must be reviewed or obtained: previous entries in her maternity record (“Mutterpass”) including all antenatal notes the length, strength and frequency of her contractions the perceived level of pain (the options for pain relief should be discussed) vaginal bleeding, vaginal discharge or loss of amniotic fluid fetal movements in the last 24 hours
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 42
	Level of consensus: 100%

1.2.3.2  Clinical examination

7.21	Recommendation
GR A	During the initial assessment of a woman in labor, the following clinical findings must be obtained and recorded: maternal heart rate, blood pressure, temperature urine analysis (urine test strip) fundal height, fetal lie, presentation, position and engagement, frequency and duration of contractions babyʼs vital signs
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 42
	Level of consensus: 94%

7.22	Recommendation
GR 0	A vaginal examination may be useful if it is not clear whether labor has commenced.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 42
	Level of consensus: 100%

7.23	Recommendation
GR A	When carrying out a vaginal examination, the following points must be considered: The medical person must be certain that this examination is necessary to obtain useful information for the further course of the birth. The reasons for the vaginal examination must be explained to the woman in labor. The vaginal examination may be very unpleasant for the woman in labor, which is why the specifics of the examination must be taken into account. Findings and their assessed importance for the birth process must subsequently be explained to the woman in labor.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 45
	Level of consensus: 100%

1.2.4  Time of admission as an inpatient/transfer to an obstetrician-led delivery room

Most births in Germany take place in a maternity hospital. But even in maternity hospitals, some births, for example in midwife-led delivery rooms, are initially not under obstetric-led care. The conditions for these births and for births which are planned as non-hospital births must be considered. The aim is to recognize any risks to the birth at an early stage to be able to provide appropriate care.

7.24	Recommendation
GR A	The woman must be transferred to obstetric-led care if any of the following are observed during the initial examination of the pregnant woman: a heart rate of more than 120 beats per minute (bpm) on two occasions 30 minutes apart a single reading of either a systolic blood pressure of ≥ 160 mmHg or a diastolic blood pressure of ≥ 110 mmHg either a systolic blood pressure of ≥ 140 mmHg or a diastolic blood pressure of ≥ 90 mmHg on two consecutive readings taken 30 minutes apart proteinuria (++) on urine analysis and a single reading of raised blood pressure (systolic blood pressure of ≥ 140 mmHg and/or diastolic blood pressure of ≥ 90 mmHg) maternal temperature is > 38 °C vaginal bleeding which is not a show premature rupture of membranes occurred more than 24 hours before the onset of labor dark green amniotic fluid pain reported by woman which differs from normal contractions high-risk pregnancy which requires an obstetric-led birth
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 recommendation 43
	Level of consensus: 100%

7.25	Recommendation
GR A	The woman must be transferred to obstetric-led care if any of the following are observed during the initial examination of the fetus : report of decreasing fetal movements in the last 24 hours deceleration of the fetal heart rate fetal heart rate is < 110 bpm or > 160 bpm suspicion of SGA, IUGR or fetal macrosomia BP, transverse or oblique lie umbilical cord presentation high or free-floating head in a nulliparous woman suspicion of anhydramnios, oligohydramnios or polyhydramnios
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 43
	Level of consensus: 100%

The individual points listed under 7.1.25 and 7.1.26 are a partial list of common risk factors and do not claim to be a comprehensive list. The decision to transfer the pregnant woman to a place of obstetric-led care must be made after the clinical findings have been considered and the options have been discussed with the pregnant woman and her birth companion(s). If an obstetric-led birth is advisable but the birth is imminent, an assessment must be made whether it would be better to transfer the woman in labor or to continue with the birth where she is.

7.26	Recommendation
GR A	If a transfer of the pregnant woman is planned, the person attending the labor (the midwife or physician) must organize the ambulance service and contact the hospital admitting her.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 48
	Level of consensus: 88%

1.2.5  Therapeutic measures during the latent stage

7.27	Recommendation
26 ,  27 ,  28 ,  29 ,  30 ,  31
GR B	The woman in labor should be informed that breathing exercises, a bath and a massage may reduce labor pains during the latent stage.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 39 26 ,  27 ,  28 ,  29 ,  30 ,  31
	Level of consensus: 100%

1.3  Active dilation stage

1.3.1  Definition

7.28	Statement
	The active (or late) dilation stage is defined as the period from a cervical dilation of 4 – 6 cm until full cervical dilation.
LoE 1+	17
	Level of consensus: 100%

1.3.2  Recommendations for overall monitoring and recording

7.29	Recommendation
GR B	During the dilation stage, the following must be recorded: maternal wellbeing frequency of contractions, every 30 minutes maternal heart rate, every 60 minutes temperature and blood pressure, every 4 hours frequency of urination results of vaginal examinations which are carried out every 4 hours or at the request of the woman in labor or if progress in labor is doubtful
LoE 2−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 162 32 ,  33
	Level of consensus: 82%

A partogram is a useful means of recording events during the birth and must provide a quick overview of the progress of labor. A partogram is basic documentation of key parameters and events. The general rule is that documentation must ensure that progress of labor and the birth is transparent at all times 32 ,  33 ,  34 ,  35 ,  36 ,  37 .

7.30	Recommendation
GR A	The presence or absence of significantly green amniotic fluid must be recorded. Significant means that the amniotic fluid is dark green or thick and tenacious or contains lumps of meconium.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 164
	Level of consensus: 100%

7.31	Recommendation
GR A	If significantly green amniotic fluid is found, the option to carry out fetal blood analysis must be available. In addition, it is important to ensure that appropriate care is available after delivery, with staff on hand who are trained in neonatal resuscitation.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 165
	Level of consensus: 100%

7.32	Recommendation
GR B	A pain scale should not be routinely used to assess pain.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 169 38 ,  39 ,  40 ,  41 ,  42 ,  43 ,  44 ,  45 ,  46 ,  47 ,  48 ,  49 ,  50
	Level of consensus: 94%

1.3.3  Monitoring 38 ,  39 ,  40 ,  41 ,  42 ,  43 ,  44 ,  45 ,  46 ,  47 ,  48 ,  49 ,  50

Please refer to chapter 5 for recommendations and advice on monitoring/cardiotocography.

1.3.4  Therapeutic measures

1.3.4.1  General measures

7.33	Recommendation
GR A	No interventions must be offered or recommended if labor is progressing normally and mother and child are well.
LoE 2−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 158 51 ,  52 ,  53 ,  54
	Level of consensus: 93%

7.34	Recommendation
GR A	Active management must not be routinely offered.
LoE 2−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 172 51 ,  52 ,  53 ,  54
	Level of consensus: 94%

NICE guideline CG190 states that active management must not be routinely offered. According to NICE guideline CG190, active management includes interventions such as early amniotomy, routine vaginal examinations every 2 hours, or the administration of oxytocin as soon as labor slows.

7.35	Recommendation
51 ,  52 ,  53 ,  54
GR B	The woman in labor should be encouraged to mobilize and adopt the position which feels most comfortable to her.
A	She must be actively supported to adopt her chosen positions.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 19 55 ,  56 ,  57 ,  58 ,  59 ,  60
	Level of consensus: 94%

1.3.4.2  Amniotomy

7.36	Recommendation
61 ,  62
GR A	Amniotomy must not be routinely carried out if labor is progressing normally.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 173 61 ,  62
	Level of consensus: 94%

1.3.4.3  Oxytocin

7.37	Recommendation
GR A	Early amniotomy must not be routinely combined with the use of oxytocin.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 174 63
	Level of consensus: 100%

1.3.4.4  Measures if protracted labor is suspected 3 ,  63

7.38	Recommendation
GR A	If delay is suspected during the active dilation stage, the following must be considered: parity cervical dilation and rate of change contractions station and position of presenting fetal part the emotional state of the woman in labor The woman in labor must be offered support, fluids and effective pain therapy.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 175 17
	Level of consensus: 94%

7.39	Recommendation
GR A	If delay is suspected during the active dilation stage, then all aspects relating to the progress of labor must be assessed; they include: cervical dilation of < 2 cm in 4 hours in a nulliparous woman cervical dilation of < 2 cm in 4 hours or slowing in the progress of labor in a multiparous woman descent and rotation of the babyʼs head changes in the strength, duration and frequency of uterine contractions. A physician must be consulted if delay is diagnosed.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 176 17
	Level of consensus: 100%

7.40	Recommendation
GR B	If delay is suspected during the active dilation stage, an amniotomy should be considered if the membranes are still intact. The woman in labor should be informed how this is carried out and that it may lead to stronger and more painful contractions and that it may shorten her labor.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 177 64
	Level of consensus: 85%

7.41	Recommendation
GR A	If delay during the active dilation stage is suspected, irrespective of whether or not an amniotomy is performed, the woman must be advised to have a vaginal examination 2 hours later; delay is diagnosed if labor has not progressed (< 1 cm) by that time.
LoE 3	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 178 17
	Level of consensus: 100%

7.42	Recommendation
GR A	If delay in the active dilation stage is diagnosed in women with intact amniotic membranes, amniotomy followed by vaginal examination 2 hours later must be recommended.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 179 64
	Level of consensus: 83%

7.43	Recommendation
GR B	If delay during the active dilation stage is confirmed, the woman in labor should be informed that use of oxytocin after rupture of membranes/amniotomy may bring the time of birth forward without affecting the mode of birth.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation180 64
	Level of consensus: 100%

7.44	Recommendation
GR B	All women in labor with delay during the active dilation stage should be offered support and effective pain therapy.
LoE 3	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 182 17
	Level of consensus: 100%

7.45	Recommendation
GR B	The woman in labor should be informed that oxytocin will increase the frequency and strength of contractions and that this makes constant monitoring necessary. The woman should be offered epidural analgesia before oxytocin is administered.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 183 65 ,  66 ,  67
	Level of consensus: 100%

7.46	Recommendation
GR A	If oxytocin is administered, the interval between the administered increments of the dose must not be less than 30 minutes.
B	The oxytocin dose should be increased until there are 4 – 5 contractions in 10 minutes.
LoE 1−	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 184 66 ,  68 ,  69 ,  70 ,  71 ,  72 ,  73 ,  74
	Level of consensus: 94%

7.47	Recommendation
GR B	The woman in labor should be advised to have a vaginal examination 4 hours after starting oxytocin: If the cervix has dilated by less than 2 cm during the previous 4 hours following the start of oxytocin, the situation should be re-evaluated and the need for a caesarean section should be assessed. If the cervix has dilated by ≥ 2 cm, vaginal examinations should be carried out every 4 hours.
LoE 3	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 185 17
	Level of consensus: 100%

The NICE guideline authors have stated that administering the oxytocin dose more often than every 20 minutes may be associated with higher rates of uterine overstimulation and pathological CTG readings 3 ,  17 ,  64 ,  65 ,  66 ,  67 ,  68 ,  69 ,  70 ,  71 ,  72 ,  73 ,  74 ,  75 .

Fig. 1 shows the appropriate approach for the active dilation stage, based on the NICE pathway “Care in established first stage of labour” 76 .

2  Care in the expulsion stage

2.1  Definition of the expulsion stage

The start of the expulsion stage is generally defined as the point when the cervix has completely dilated 17 . The expulsion stage is divided into 2 stages: the latent/passive expulsion stage and the active/late expulsion stage.

8.1	Statement
17
	The passive expulsion stage is characterized by the following: complete cervical dilation (still) no urge to push
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 187, consideration given to IQWiG report no. 517 17 and expert consensus
	Level of consensus: 100%

8.2	Statement
	The active expulsion stage is characterized by the following: the baby is visible, and/or a reflexive urge to push with full dilation of the cervix, or active pushing without a reflexive urge to push
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 187, consideration given to IQWiG report no. 517 17 and expert consensus
	Level of consensus: 100%

2.2  Duration of the expulsion stage 17

8.3	Recommendation
GR B	The situation should be re-assessed if there are no signs of progress at 1 hour after confirmation of complete dilation of the cervix despite strong contractions.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 194
	Level of consensus: 100%

8.4	Statement
	Protracted expulsion is diagnosed if progress, measured by fetal rotation and/or descent of the presenting part, is insufficient in the active stage after more than 2 hours for a nulliparous woman and more than 1 hour for a multiparous woman. Stalled labor in the ES is diagnosed if the active stage of the ES takes longer than 3 hours for a nulliparous woman and more than 2 hours for a multiparous woman.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendations 192/193 and 197/198 and comparison with the “Obstetric Care Consensus” of the ACOG and SMFM 77 /expert consensus
	Level of consensus: 92.3%

8.5	Recommendation
77 ,  78 ,  79
GR B	If the diagnosis of protracted expulsion is confirmed, a vaginal examination should be proposed (unless a vaginal examination was already carried out just a short time previously) and an amniotomy should be offered if the membranes are still intact.
A	An experienced obstetrician must be called in at this point.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendations 197/198/199
	Level of consensus: 80%

Because of the increased maternal risk associated with protracted expulsion (see statement 8.4), the clinical experience of the team responsible for the care of the pregnant woman is very important. Numerous factors must be considered when deciding on the course of action to be taken. They include the following (by no means exhaustive) factors 80 :

• previous obstetric history (e.g., previous spontaneous birth/c-section)

• difficult prior psychosocial history

• obstetrically relevant co-morbidities (e.g., diabetes)

• maternal constitution/pelvic size

• estimated fetal weight (on ultrasound/clinical)

• obstetric findings (fetal station/position/cephalohematoma, etc.)

• fetal wellbeing (CTG)

• effectiveness of pushing/maternal exhaustion

• preferences of the woman

2.3  Care in the expulsion stage

8.6	Recommendation
GR B	The following findings should be recorded in the partogram: frequency of contractions vaginal examination to assess progress which takes account of the womanʼs behavior, the quality of the contractions and the effectiveness of pushing as well as the babyʼs wellbeing while also taking the obstetric findings at the start of the ES (primarily fetal station and rotation in this context) into consideration pulse/blood pressure, temperature frequency of passing urine consideration of the womanʼs emotional and psychological needs
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 188 and consideration of the 2018 ISUOG guideline 81
	Level of consensus: 100%

2.4  Maternal position in the expulsion stage

8.7	Recommendation
GR A	The woman in labor must be discouraged from being supine during the ES. She must be motivated to adopt a position which feels most comfortable for her.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 and consideration of a recent systematic review 82
	Level of consensus: 93.75%

2.5  Analgesia in the expulsion stage

8.8	Recommendation
EC	If analgesia is required in the final stage of the ES, a bilateral transvaginal pudendal block may be offered.
	Level of consensus: 81.2%

2.6  Pushing

8.9	Recommendation
GR B	The woman in labor should be informed that she should let herself be guided by her own urge to push. This includes both the timing as well as the manner and duration of pushing. There is no good-quality evidence showing that “being instructed to push” has a positive effect on the birth outcome.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 190 and consideration of another systematic review 83
	Level of consensus: 100%

8.10	Recommendation
GR B	If pushing is ineffective or if requested by the woman, strategies to assist the birth should be offered such as support, encouragement, change of position and emptying the bladder. In addition, the need for adequate analgesia should be regularly assessed and addressed. This is particularly important during protracted expulsion and/or if the mother is excessively distressed.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 191
	Level of consensus: 100%

2.7  Intrapartum measures to reduce birth trauma

Warm compresses

8.11	Recommendation
GR B	The application of warm compresses to the perineum should be offered.
LoE 1++	Two systematic reviews were considered 84 ,  85
	Level of consensus: 78.6%

“Hands-on” vs. “Hands-off”

8.12	Recommendation
GR 0	Both the “hands-on” (→ “perineal protection”) and the “hands-off” technique (→ no “perineal protection”: the midwifeʼs hands are not touching either the perineum or the fetal head but she is ready to help at any time) may be used during the birth of the baby.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 209, as well as comparison and inclusion of recent literature following an update search 84 ,  86
	Level of consensus: 92.9%

2.8  Episiotomy

8.13	Recommendation
GR A	An episiotomy must not be routinely carried out during a spontaneous vaginal birth.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 211 as well as comparison and inclusion of recent literature 87
	Level of consensus: 100%

8.14	Recommendation
a on mediolateral incisions 88 b on the angle/approach/length 91
GR A	If an episiotomy is carried out, the recommended technique is a mediolateral episiotomy. The angle at the time of the episiotomy (→ when the perineum is stretched) should be 60° to the vertical axis and should not start directly from the median line. The length of the episiotomy must correspond to the scissor arm.
LoE 1a / 2 b	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 212 as well as comparison and inclusion of recent literature 88 ,  89 ,  90 ,  91
	Level of consensus: 87%

Dissenting opinion: Mother Hood and the Working Group on Womenʼs Health in Medicine, Psychotherapy and Society reject recommendation 8.14.

8.15	Recommendation
GR A	An episiotomy must be performed if an episiotomy could expedite the birth of a compromised baby.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 213
	Level of consensus: 80%

8.16	Recommendation
GR A	Effective analgesia must be provided before carrying out an indicated episiotomy except in an emergency due to acute fetal compromise.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 2014
	Level of consensus: 93%

2.9  Measures for protracted expulsion

8.17	Recommendation
GR 0	The use of oxytocin may be considered in addition to other measures (e.g., energy intake, emptying the bladder, mobilization) if the progress of labor begins to slow despite full dilation of the cervix.
B	Oxytocic measures such as energy intake, emptying the bladder, mobilization and the administration of oxytocin should only be used if contractions decrease in frequency even though the cervix is fully dilated.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 196
	Level of consensus: 100%

8.18	Recommendation
GR B	If the diagnosis of protracted ES is confirmed, an obstetric assessment should be carried out every 15 – 30 minutes.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 200
	Level of consensus: 92%

8.19	Recommendation
GR A	If the diagnosis of protracted ES is confirmed, an experienced obstetrician must assess the situation before deciding whether to administer oxytocin.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 199
	Level of consensus: 100%

8.20	Recommendation
GR 0	A high-dose oxytocin regimen appears to result in a higher rate of spontaneous births and a lower rate of caesarean sections. It does not appear to result in poorer neonatal outcomes. This means that if the decision to support labor by administering oxytocin is taken, a high-dose regimen can be justified (e.g., a starting dose of 4 mU/minute which is increased incrementally by 4 mU/minute every 20 minutes). Dosages must be based on their effect. It is important to watch out for hyperstimulation (→ > 4 contractions/10 minutes); early signs of fetal compromise (→ rising baseline, limited variability, increasingly severe variable decelerations with mounting additional criteria).
A	Repeatedly review whether oxytocin support could be stopped.
LoE 3	92 ,  93
	Level of consensus: 75%

8.21	Recommendation
EC	If possible, no fundal pressure must be exerted. Fundal pressure may only be considered in very specific cases. The following conditions must be met: The consent of the woman must be ensured at the very beginning The woman can veto the procedure Continuous communication must be maintained with the woman It should only be done in the late ES Pressure must be administered in synchrony with contractions Fundal pressure must be exerted manually, in a caudal direction Good communication within the obstetric team and with the birth companion(s) is important
	Level of consensus: 100%

2.10  Status post high-grade perineal tear

8.22	Recommendation
GR B	All women who are status post high-grade perineal tear must be offered the chance to discuss the mode of birth. If the woman has no symptoms of anal incontinence, the risk of experiencing symptoms again is low (< 10%, mostly transient flatulence incontinence).
LoE 2	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 215 and inclusion of additional literature 94 ,  95 ,  96
	Level of consensus: 100%

8.23	Recommendation
GR A	Women with persistent symptoms of anal incontinence have a higher risk of experiencing a deterioration of symptoms. Primary caesarean section must be advised after weighing up the overall situation. For women who are status post (transient) symptoms, the risk appears to be less high but it still exists. Objective procedures such as endoanal ultrasonography and measurement of anal closing pressure may be used to make a decision. Additional risk factors for anal incontinence such as fetal macrosomia must also be taken into account.
LoE 2	94 ,  95 ,  96 ,  97
	Level of consensus: 100%

2.11  Water birth

8.24	Recommendation
GR B<	Women should be informed that there is currently insufficient evidence to support or discourage giving birth in water.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 219 and inclusion of recent literature 98
	Level of consensus: 100%

3  Care in the postnatal stage

3.1  Definition

The postnatal stage covers the time from delivery of the baby with clamping of the cord to complete delivery of the afterbirth (placenta and membranes). Uterine contractions ranging from mild to strong occur during this stage. The definitions and evidence were agreed upon in accordance with the IQWiG report no. 517: “Definitions of the stages of labor”, which found information on the placental/postnatal stage in 17 of 50 reviews and 2 of 5 guidelines (including NICE Clinical Guideline 190) 17 .

3.2  Bonding – a sensitive stage

9.1	Recommendation
GR A	The time immediately following the birth is important because it is when the mother (and her birth companion) meet and get to know the baby (bonding). All care, diagnostic measures and medical interventions must be kept to a minimum to prevent the mother and child being separated and to avoid interrupting the time of bonding.
LoE moderate to low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 224/1.14.1
	Level of consensus: 100%

9.2	Recommendation
GR A	Mothers must be encouraged to have skin-to-skin contact with their newborn baby as soon as possible after the delivery of the baby.
LoE moderate to low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 285/1.15.6 99
	Level of consensus: 100%

3.3  Duration of the postnatal stage

9.3	Recommendation
GR A	The diagnosis “prolonged postnatal stage” is made if: the postnatal stage is not completed within 30 minutes of the birth with active management, or it is not completed within 60 minutes of the birth with expectant management.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 226/1.14.3
	Level of consensus: 94%

3.4  Maternal care

3.4.1  Monitoring

9.4	Recommendation
GR A	The following observations must be recorded for the mother during the postnatal stage: her general physical condition, as shown by her color, respiration and own report vaginal blood loss
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 227/1.14.4
	Level of consensus: 88%

3.4.2  Management of the postnatal stage

The Board of the OEGGG does not support chapter 9.4.2 Management of the postnatal stage for Austria. For more information on this, please refer to the relevant passages in the guideline report.

3.4.2.1  Active vs. expectant management

There are a number of options for the management of the postnatal stage. One of the two following strategies are usually used:

1. Active management

Active management of the postnatal stage includes at least one of the following procedures:

• routine use of uterotonic drugs (uterotonics)

• deferred clamping and cutting of the umbilical cord (no earlier than 1 minute, no later than 5 minutes postpartum)

• controlled cord traction after positive signs of separation of the placenta (see below)

2. Expectant/passive management

Expectant/passive management of the postnatal stage includes the following measures:

• no routine use of uterotonics

• no clamping of the umbilical cord until pulsation has stopped

• spontaneous delivery of the placenta and membranes by maternal effort

>Controlled cord traction

After the cord has been clamped, part of active management may, under certain circumstances, consist of cord traction after positive signs of separation of the placenta.

9.5	Recommendation
GR A	Before giving birth, the differences between active and expectant management in the postnatal period must be explained to the woman along with the respective associated benefits and risks.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.6
	Level of consensus: 88%

9.6	Recommendation
GR B	If a woman with low risk of postpartum bleeding chooses expectant management for the postnatal period, then her choice should be respected. The woman should then be supported in her decision.
LoE moderate to very low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.11; 100
	Level of consensus: 89%

9.7	Recommendation
GR A	The woman must be advised to change from expectant to active management if one of the following events occurs: strong vaginal bleeding (PPH) the placenta is not delivered within one hour of giving birth to the baby
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.18
	Level of consensus: 100%

9.8	Recommendation
GR A	The woman must be offered the option of changing from expectant to active management if she wishes to shorten the postnatal stage.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.19
	Level of consensus: 93%

3.4.2.2  Administration of uterotonic drugs

9.9	Recommendation
GR B	As part of active management of the postnatal stage, 3 – 5 IU oxytocin should be administered in the form of a short injection or slowly IV with the birth of the anterior shoulder of the neonate or immediately after the birth but before the umbilical cord is clamped and cut. For women with an increased risk of hemorrhage, active management to deliver the placenta may include the administration of carbetocin.
LoE Moderate	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.13 as well as additional literature 101 ,  102
	Level of consensus: 100%

3.4.2.3  Clamping the cord

9.10	Recommendation
GR A	The umbilical cord must be clamped and cut after the administration of oxytocin. The umbilical cord must not be clamped any earlier than 1 minute after birth of the neonate, unless there is concern about an injury to the umbilical cord or the baby has a heart rate of less than 60 beats/minute and the heart rate does not appear to be increasing.
LoE high to very low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.14
	Level of consensus: 100%

9.11	Recommendation
GR B	The umbilical cord should be clamped and cut before 5 minutes have elapsed after delivery of the baby. If the woman decides that the umbilical cord must only be clamped more than 5 minutes after the birth, then her wish should be respected and the woman should be supported in her decision.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.14
	Level of consensus: 100%

3.4.3  Postpartum complications

9.12	Recommendation
GR A	If postpartum hemorrhage, retained placenta, maternal circulatory failure occurs or there are any other concerns about maternal wellbeing, then the woman must be managed in accordance with the principles of obstetric-led care.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.5
	Level of consensus: 100%

This means that although the medical staff in attendance do not need to be specialists, they must have the competency to act like a medical specialist and they must be able to call in a medical specialist if required.

3.4.3.1  Approach for retained placenta

9.13	Recommendation
GR A	If the placenta is retained, an IV access must be secured and the need for this must be explained to the woman.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.24
	Level of consensus: 93%

9.14	Recommendation
GR A	No medications must be administered via the umbilical cord if the placenta is retained.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 245
	Level of consensus: 100%

9.15	Recommendation
GR A	Oxytocin must be administered intravenously if the placenta is retained and the woman is bleeding excessively.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3
	Level of consensus: 93.3%

9.16	Recommendation
GR A	If the placenta needs to be removed manually and the woman is not already in an obstetric-led unit, urgent transportation to the nearest hospital with an obstetric department must be arranged.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.27
	Level of consensus: 100%

9.17	Recommendation
GR A	The placenta must not be removed without analgesia or anesthesia.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.14.28
	Level of consensus: 100%

Removal of the placenta is usually very painful, irrespective of whether it is carried out manually or surgically. Even though no evidence was found in the literature, such an intervention must not be carried out without analgesia. Because of the risk of maternal aspiration and the risk of hypoventilation, analgosedation must not be administered in the immediate postpartum period.

9.18	Recommendation
GR A	The following maternal parameters and observations must be recorded postpartum: pulse, blood pressure, temperature condition and completeness of the placenta and membranes condition of the cord vessels uterine contraction and lochia emotional and psychological condition ability to void the bladder within 4 hours postpartum Appropriate measures must be initiated if there are any abnormalities.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3
	Level of consensus: 100%

3.4.4  Birth trauma

3.4.4.1  Definition and classification of perineal lacerations

For this guideline, the guideline authors agreed to adopt the classification of perineal lacerations used in the current AWMF guideline 015-079 (Grade 3 and 4 PL after vaginal birth. Management 103 ) for the care of higher-grade perineal lacerations.

3.4.4.2  Inspection of the perineum and for birth trauma

9.19	Recommendation
GR B	Before starting to examine the birth canal and anogenital areas for birth trauma, the planned approach and the reasons for carrying out the examination should be explained to the woman. Appropriate analgesia should be offered in close consultation with the woman. Good lighting must be ensured. The woman should be positioned so that she feels comfortable while ensuring that the genital structures can be seen clearly. The examination for birth trauma must be carried out as gently and carefully as possible.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.16.4
	Level of consensus: 92%

9.20	Recommendation
GR B	If a birth trauma is detected, the woman should be advised to have a further systematic examination including a rectal examination.
LoE low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.16.5
	Level of consensus: 94%

9.21	Recommendation
GR A	It is important to ensure that systematic examination of the birth trauma does not interfere with mother-child bonding. The exception to this is maternal hemorrhage requiring urgent care.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.16.7
	Level of consensus: 93%

9.22	Recommendation
GR B	All relevant professionals involved in obstetric care (midwives and obstetricians) should have attended training in perineal and genital assessment and repair, as well as being trained in the care of surgical wounds. It is important to ensure that these skills are maintained.
LoE low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.16.11
	Level of consensus: 80%

9.23	Recommendation
GR B	If the woman reports inadequate pain relief during repair of birth trauma, this should be addressed immediately in an appropriate fashion.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.16.14
	Level of consensus: 100%

9.24	Recommendation
GR A	Women with a grade 2 perineal tear must be advised that the affected muscle layers should be sutured because this improves healing. If the skin layers are well opposed after suturing the muscles following a grade 2 perineal tear, then the skin will not require suturing.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.16.16 & 1.16.17
	Level of consensus: 100%

3.5  Care of the neonate

3.5.1  Apgar score

9.25	Recommendation
GR A	The Apgar score must be taken at 1, 5 and 10 minutes after the birth and recorded.
LoE Moderate	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.1 and consideration of further evidence
	Level of consensus: 100%

3.5.2  Analysis of blood gases, pH and base excess using cord blood

9.26	Recommendation
GR B	According to NICE, postnatal pH measurement using cord blood is not recommended for healthy neonates based on the existing evidence. Please refer to country-specific guidelines for quality assurance.
LoE low to very low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.4
	Level of consensus: 81%

In Germany, the Childrenʼs Guideline issued by the Federal Joint Committee 104 requires physicians and midwives to determine pH and BE in cord blood when carrying out the U1 examination and to document both parameters in the yellow childʼs medical check-up booklet (Appendix 1 of the Childrenʼs Guideline of the Federal Joint Committee).

3.5.3  Neonatal resuscitation

3.5.3.1  Indications for resuscitation

9.27	Recommendation
GR A	If the neonate is in poor condition (particularly if the values for breathing, pulse or muscle tone are abnormal), the recommendations in the ERC or ILCOR guidelines on resuscitation must be followed. paired cord blood samples (from an umbilical artery and an umbilical vein) must be taken for blood gas analysis and measurement of pH and base excess (BE). the condition of the neonate must be assessed and recorded until it has improved and the baby is stable.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.3
	Level of consensus: 93%

3.5.3.2  Courses on neonatal resuscitation

9.28	Recommendation
GR A	All relevant professionals (midwives, obstetricians, pediatricians, anesthetists) involved in the care of women and children during the birth who are not also regularly involved in the care of critically depressed neonates (neonatologists) must attend a high-quality course in neonatal resuscitation every year.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.14
	Level of consensus: 94%

3.5.3.3  Emergency plans for mother and child

9.29	Recommendation
GR A	In all settings where births occur, it is important to remember that it may be necessary to call for help if the neonate requires resuscitation and to plan for this accordingly. it must be ensured that facilities for the resuscitation and transfer of the neonate to another location are available if needed. All birth settings must have developed an emergency referral pathway for mother and baby. implement this pathway when necessary.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.15
	Level of consensus: 100%

3.5.3.4  Respiratory support with air or 100% oxygen

9.30	Recommendation
GR A	If a neonate requires resuscitation, the basic breathing support must start with air. Depending on how the resuscitation progresses, a rapid increase in the oxygen concentration may be necessary.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.16
	Level of consensus: 100%

3.5.3.5  Separation of mother and child for neonatal resuscitation

9.31	Recommendation
GR A	If a neonate requires resuscitation, separation of mother and baby must be kept to a minimum while taking account of the clinical circumstances.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.17
	Level of consensus: 100%

3.5.3.6  Supporting the family during resuscitation of the neonate

9.32	Recommendation
GR A	Throughout the emergency situation requiring resuscitation of the neonate, a member of the healthcare team must be allocated to talk with the mother and her birth companion(s) and to offer them support.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , Recommendation 1.15.18
	Level of consensus: 100%

3.5.4  Protecting the neonate from cold

9.33	Recommendation
GR A	To keep the neonate warm, the baby must be dried off and covered with a warm dry blanket or similar towel while maintaining skin-to-skin contact with the mother.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.7
	Level of consensus: 93%

3.5.5  First breast feed

9.34	Recommendation
GR A	Mothers must be encouraged to breastfeed their baby as early as possible, preferably within one hour of the birth, to encourage the start of breastfeeding.
LoE low to very low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.9 with additional literature included 105
	Level of consensus: 100%

3.5.6  Parental involvement

9.35	Recommendation
GR A	It is important to ensure that every examination or treatment of the neonate is carried out with the consent of the parents and, where possible, in their presence or, if this is not possible, with their knowledge.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.12
	Level of consensus: 100%

3.5.7  Neonatal care when there is meconium in the amniotic fluid

9.36	Recommendation
GR A	Irrespective of the amount of meconium in the amniotic fluid, the neonateʼs upper airways (nasopharynx and oropharynx) must not be suctioned before the shoulders and trunk have been delivered. the neonateʼs upper airways (nasopharynx and oropharynx) must not be suctioned if breathing, heart rate and muscle tone are normal. the neonate must not be intubated if breathing, heart rate and muscle tone are normal.
LoE high to moderate	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 272/1.15.19
	Level of consensus: 100%

3.5.7.1  Resuscitation when there is significant meconium in the amniotic fluid

9.37	Recommendation
* Meconium in the amniotic fluid is considered significant if the amniotic fluid is dark green or thick and viscous (in German, this is described as “pea-soup-like”) or it contains lumps of meconium.
GR A	If the amniotic fluid contains significant* amounts of meconium and respiration, heart rate or muscle tone of the neonate are not normal, the recommendations of the ERC guideline for the resuscitation of neonates must be followed, including the statements on laryngoscopy and suction under visual control.
LoE high to very low	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.20
	Level of consensus: 100%

3.5.7.2  Care of a healthy neonate with significant meconium in the amniotic fluid

9.38	Recommendation
* Meconium in the amniotic fluid is considered significant if the amniotic fluid is dark green or thick and viscous (in German, this is described as “pea-soup-like”) or it contains lumps of meconium.
GR A	If the amniotic fluid contains significant* amounts of meconium and the neonate appears healthy, the baby must be closely observed together with a neonatologist. The neonate must be carefully observed again at 1 and 2 hours after the birth and then every 2 hours until 12 hours of age.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.21
	Level of consensus: 94%

3.5.7.3  Observation of a healthy neonate with non-significant meconium in the amniotic fluid

9.39	Recommendation
* Meconium in the amniotic fluid is considered significant if the amniotic fluid is dark green or thick and viscous (in German, this is described as “pea-soup-like”) or it contains lumps of meconium.
GR A	If the amniotic fluid contains non-significant* amounts of meconium and the neonate appears healthy, the neonate must be clinically assessed just like all other healthy neonates at one and two hours of age, irrespective of the location of the birth.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.22
	Level of consensus: 94%

3.5.7.4  Advice to parents if the amniotic fluid contains meconium

9.40	Recommendation
GR A	The findings must be explained to the mother and her birth companion(s). The mother must be informed what she needs to look out for and whom to talk to if she has any concerns.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.24
	Level of consensus: 100%

3.5.8  Monitoring of a mature healthy neonate after premature rupture of membranes

9.41	Recommendation
GR A	Every neonate born at term after premature rupture of membranes must be observed closely during the first 12 hours of life. After 1, 2, 6 and 12 hours, the following parameters and symptoms must be assessed and recorded: general condition and feeding skin perfusion temperature (measured by rectal thermometer) heart rate respiratory rate presence of respiratory grunting, subcostal or intercostal retraction, nasal flare, cyanosis and/or hypotonia If any abnormalities are noted, then the baby must be assessed by a pediatrician.
LoE 4	Guideline modification: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.25/deviation based on expert consensus in the German S2k guideline
	Level of consensus: 94%

3.5.8.1  Observation of the neonate at home after premature rupture of membranes

9.42	Recommendation
GR A	After premature rupture of membranes, the mother and her birth companion(s)must be instructed that the mother must inform her midwife and/or her pediatrician immediately if she has any concerns in the first 5 days of life regarding the wellbeing of her baby, particularly in the first 12 hours of life when the risk of infection is highest.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 1.15.28
	Level of consensus: 94%

3.5.9  Approach if neonatal or maternal infection is suspected

9.43	Recommendation
GR A	Neonates with any symptom of possible sepsis and neonates whose mothers show signs of Triple I must be referred immediately to a pediatrician.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 3 , recommendation 283
	Level of consensus: 100%

4  Quality assurance in vaginal births

4.1  History

Quality assurance in obstetrics is considered the nucleus of quality assurance in the inpatient sector in Germany. After the first publication of the Munich Perinatal Study in 1975 106 , perinatal surveys began to be widely used, initially in the old federal states of Germany and then, following reunification, in the new federal states as well. The establishment of the German National Institute for Quality in Healthcare in 2001 together with the introduction of the DRG billing system in hospitals created a national frame of survey for quality assurance in obstetrics which has been centrally maintained and expanded ever since. Quality assurance of vaginal births accounts for a large part of the data, and 5 of 8 quality indicators used for hospital-based statutory quality assurance currently apply to vaginal births 107 .

After certain initial preparations 108 , the Society for Quality in Out-of-Hospital Births (QUAG e. V.) was set up in 1999 to cover the quality assurance in the outpatient sector. It records the quality of non-hospital-based births for all of Germany. The recorded items largely resemble those used in hospital-based perinatal surveys, with the addition of features specific to non-hospital-based obstetric care and an analysis of the transitions between outpatient and inpatient settings. In principle, this would allow the outcomes of births delivered in hospitals and those of births which occur in non-hospital settings to be compared. QUAG e. V., which was specifically referenced in the German law regulating the remuneration paid to midwives (Hebammenhilfevertrag) 109 , has been responsible for the external quality assurance of non-hospital-based obstetrics since 2015. The annual federal evaluations of the data collected for the non-hospital-based sector are available on the website of QUAG e. V. ( www.quag.de ).

4.2  Changes in the distribution of birth modes over time

A cursory review of the change in the numbers of hospital births over the past decade shows that the percentage of caesarean sections increased until the year 2011 but has since slightly decreased again after the introduction of a risk-adjusted indicator for caesarean sections in 2014. At the same time, the percentage of spontaneous deliveries increased very slightly from 2014 onwards (from 60.3% to 61.0%). But during the same period, the percentage of vaginal-operative births rose steadily from 6.0% in 2008 to 6.9% in 2017 107 ,  110 ,  111 ,  112 .

4.3  Indicator-based quality assurance

4.3.1  Indicator-based quality assurance for the inpatient sector

Quality is typically measured using quality indicators. The following indicators are currently used for statutory quality assurance in Germany to evaluate vaginal births and as starting points for quality improvement processes 107 :

• antenatal corticosteroid therapy for premature births with a prepartum in-hospital stay of at least two full days

• the ratio of the observed to expected (O/E) rate of acidosis in mature singletons with determination of umbilical artery pH

• the ratio of the observed to expected (O/E) rate of acidosis in premature singletons with determination of umbilical artery pH

• presence of a pediatrician during premature births

• a critical-outcomes quality index for mature neonates

• the ratio of the observed to expected (O/E) rates of grade 3 or 4 perineal lacerations in spontaneous singleton births

• maternal mortality in the context of the perinatal survey.

In addition,

• the ratio of the observed to expected (O/E) rate of caesarean sections,

i.e., the risk-adjusted caesarean section rate, may also be used as an indicator of whether there are too few vaginal births.

As part of the implementation of the directive on quality indicators which are relevant for planning purposes 113 , the indicators

• antenatal corticosteroid therapy in premature infants with a prepartum in-hospital stay of at least two full days,

• the presence of a pediatrician during premature births, and

• a critical-outcomes quality index for term-born infants,

were selected as quality indicators which are important when planning a vaginal birth and, in accordance with the directive on quality indicators, they were first applied in practice using data from 2017.

4.3.2  Indicator-based quality assurance for the out-of-hospital sector

The current indicator for quality assurance in out-of-hospital obstetrics is the ratio of observed-to-expected rates of transfers during the birth from the planned out-of-hospital birth setting to an obstetric-led care facility 109 . Peer reviews and structured dialogs may be initiated to provide quality assurance support to service providers working in the outpatient sector.

4.4  Initial steps to create inter-institutional indicator-based quality assurance

The Scientific Institute of the AOK (WIdO) has developed additional quality indicators for in-hospital vaginal births based on standard data for in-hospital births collected as part of its quality assurance project “Quality Assurance with Routine Data (QSR)”. These additional indicators also take account of follow-up events which occur after the initial stay in hospital for the birth 114 .

4.5  Quality assurance of structural requirements, with special consideration of staffing requirements

The German Quality Assurance Directive for Premature and Term-born Infants (QFR-RL) has developed statutory rules outlining the minimum standards of care which must be provided to certain pregnant women and to premature and term-born infants in Germany by hospitals registered under Sec. 108 of the SGB V. The aim is to ensure the quality of the structures, processes and outcomes of care for premature and term-born neonates while also taking account of the accessibility of birth facilities across the country 115 ,  116 ,  117 ,  118 ,  119 .

10.1	Recommendation
EC	Irrespective of the annual birth rate, a sufficient number of midwives should be present or on call in every obstetric department to ensure that the parturient woman will receive one-to-one care more than 95% of the time.
	Level of consensus: 100%

10.2	Recommendation
EC	Depending on their previously recorded field of work, senior midwives should be entirely or partially released from carrying out mundane practical tasks in the obstetrics department. The extent of their release must be taken into account when allocating staff.
	Level of consensus: 100%

10.3	Recommendation
EC	Midwives who meet the statutory requirements to work as practical instructors must be partially released from carrying out mundane practical tasks in the obstetrics department in the context of their work as a midwifery instructor. The extent of their release from general duties must be taken into account when allocating staff.
	Level of consensus: 100%

10.4	Recommendation
EC	Student midwives should not be included in the allocation of staff.
	Level of consensus: 100%

5  Appendix

5.1  Statements from the consultation process

5.1.1  Statement by the DGGG, ÖGGG, DEGUM

The professional societies of obstetricians (DGGG, ÖGGG, DEGUM) are of the opinion that the multidisciplinary care of pregnant women provided by midwives, obstetricians, pediatricians and anesthetists in the labor room is superior to the model of midwife-led out-of-hospital obstetric care, irrespective of any risk classifications, particularly as the necessary professional expertise and technical equipment can be provided within a very short space of time. It is not possible to predict all complications which may occur during birth and in the early puerperium with sufficient certainty, nor can their occurrence be prevented by cataloguing the risks. A transfer during the birth may considerably delay prompt intervention in an emergency. Comparable data such as those available in the UK from the Birthplace study are lacking for German-speaking countries. The issue of the safety of out-of-hospital obstetric care in German-speaking countries must therefore first be examined and evaluated in studies which involve both midwives and physicians and which are carried out based on complete reporting of all births and their outcomes (including those which may start in an out-of-hospital setting and end in hospital).

5.1.2  Statement by the ÖGGG

Dissenting preamble of the OEGGG for the AWMF S3 guideline “Vaginal Birth”

The representatives of the Austrian Society for Gynecology and Obstetrics agree with the statement by the German professional societies of obstetricians (DGGG, DEGUM. DGPM) about the information given to pregnant women if it is published in a prominent position in the guideline as a preamble:

Preamble:

The professional societies of obstetricians are of the opinion that the interdisciplinary care of pregnant women provided by midwives, obstetricians, pediatricians and anesthetists in hospital-based labor rooms is superior to the model of midwife-led out-of-hospital obstetric care, as all forms of expertise required to deal safely with any complications of the birth are available within a very short space of time.

Despite cataloging the potential risks, many complications can still not be predicted with sufficient certainty.

A transfer, which is expected to occur with around one third of primiparous women, may delay prompt intervention in emergencies, endangering the pregnant woman and the unborn or newborn child.

Reasons to transfer a woman in labor include, in particular, failure to progress in labor, the need for effective analgesia for unmanageable labor pains, retained placenta or placental remnants, severe loss of blood peripartum, complex childbirth injuries, and neonatal adaptation disorders.

The issue of the safety of non-hospital-based obstetrics in German-speaking countries should be prospectively investigated in studies involving both midwives and physicians and should include the complete records of all births as well as recording perinatal and peripartum outcomes. As long as the results of an extensive examination of out-of-hospital obstetric outcomes are not available, the safety of this approach must remain in doubt.

Comparable data such as those available in the UK from the Birthplace study are lacking for German-speaking countries. Such data need to be recorded and should include births which began in an out-of-hospital setting and were concluded in hospital, irrespective of the out-of-hospital place of birth.