Vaginal Birth at Term – Part 1. 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. This first part presents recommendations and statements about patient information and counselling, general patient care, monitoring of patients, pain management and quality control measures for vaginal birth.

Methods The German recommendations largely reproduce the recommendations of the National Institute for Health and Care Excellence (NICE) CG 190 guideline “Intrapartum care for healthy women and babies”. Other international guidelines were also consulted in specific cases when compiling this guideline. In addition, a systematic search and analysis of the literature was carried out using PICO questions, if this was considered 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 the 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 1. 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 Mandate holder	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

BEL

breech presentation

BGA

blood gas analysis

CG

clinical guideline

CI

confidence interval

CTG

cardiotocography/cardiotocogram

CRP

C-reactive protein

CSE

combined spinal and 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. (Germany Society for Gynecology and Obstetrics)

DGHWi

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

DRG

diagnosis-related groups

DS

dilation stage

EA

epidural anesthesia

EC

expert consensus

ECG

electrocardiogram

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

Hct

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

PPH

postpartum hemorrhage

PROM

premature/prelabor rupture of the membranes

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 trial

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 indicated due to failure to progress in labor or abnormalities detected during fetal monitoring but this 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 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 or options to avoid an intervention. The information provided in this guideline should serve as an orientation for the actions carried out by all persons involved in the care of parturient women and should also 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 the 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 about 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 indicates, 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  Information and counselling

This chapter provides recommendations on the information and counselling given to healthy women during pregnancy to support them to make their individual decisions. In special situations, the recommendations given in the appropriate guidelines must be considered (e.g., caesarean section, breech presentation [BP], twins, preterm birth, gestational diabetes [GDM] etc.).

3.1	Recommendation
GR A	Women must be informed about the different birth settings they can choose.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies, Recommendation 1.1.2 1 ,  2 ,  3 ,  4 ,  5 ,  6 ,  7 ,  8 ,  9 ,  10 ,  11 ,  12 ,  13 ,  14 ,  15 ,  16 ,  17 ,  18 ,  19 ,  20 ,  21 ,  22 ,  23 ,  24 ,  25 ,  26 ,  27 ,  28 ,  29 ,  30 ,  31 ,  32 ,  33
	Level of consensus: 80%

It was calculated that in 2017, 98.7% of all newborn infants in Germany were born in hospital, and just 1.28% were born in a non-clinical setting 34 ; however, no complete statistics are available. In Austria, 1.3% of all births in the same period took place either at home or in a midwifery-led setting 35 while in Switzerland around 2.6% of all births took place at home or in a midwifery-led setting 36 .

Recommendation 3.1. has adapted recommendation 1.1.2 of the NICE guideline CG190 (for a summary of the underlying studies, see below) and has considered steps 1, 4, 6, 7, 8 and 9 of the International Childbirth Initiative as well as the freedom of choice of every pregnant woman in Germany as formulated and regulated in Sec. 134a of SGB V and Sec. 24f sentence 2 of the SGB V to choose the birth setting. Recommendation 3.1. corresponds to the different birth settings possible (hospital, free-standing midwifery-led unit or home) in Germany, Austria and Switzerland.

3.2	Recommendation
GR A	In principle, women must be informed about the different options for obstetric settings which are available to them, e.g., access to one-to-one care from a midwife, access to medical care, access to different pain-relieving measures and pharmacological painkillers, the option to have a vaginal birth for women who have had a caesarean section, BP or twins, as well as other aspects.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies, Recommendation 1.1.7 1 ,  2 ,  3 ,  4 ,  5 ,  6 ,  7 ,  8 ,  9 ,  10 ,  11 ,  12 ,  13 ,  14 ,  15 ,  16 ,  17 ,  18 ,  19 ,  20 ,  21 ,  22 ,  23 ,  24 ,  25 ,  26 ,  27 ,  28 ,  29 ,  30 ,  31 ,  32
	Level of consensus: 100%

3.3	Recommendation
GR A	When discussing the pregnant womanʼs choice of birth setting with her, all personal opinions and judgements about her choice must be avoided in favor of impartial advice.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies, Recommendation 1.1.9 1 ,  2 ,  3 ,  4 ,  5 ,  6 ,  7 ,  8 ,  9 ,  10 ,  11 ,  12 ,  13 ,  14 ,  15 ,  16 ,  17 ,  18 ,  19 ,  20 ,  21 ,  22 ,  23 ,  24 ,  25 ,  26 ,  27 ,  28 ,  29 ,  30 ,  31 ,  32
	Level of consensus: 100%

3.4	Recommendation
GR A	All health professionals must ensure that women receive individualized and respectful care at all times, that they are treated with respect and esteem, and that they can make their own informed decisions.
LoE 4	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies, Recommendation 1.14 5 ,  17 ,  25 ,  29 ,  37 ,  38 ,  39 ,  40 ,  41 ,  42 ,  43 ,  44 ,  45 ,  46 ,  47 ,  48 ,  49
	Level of consensus: 100%

Recommendation 3.4 is based on NICE recommendation 1.14 and raises the issue of the experiences women have in different hospital and non-hospital birth settings. “Individual care” does not mean that medical and support staff are obliged to comply with every wish expressed by the woman (or the person(s) accompanying her).

3.5	Recommendation
GR A	Pregnant women must be offered evidence-based information and support early on which will allow them to make an informed choice about the birth. The viewpoints and concerns of women must be acknowledged as an integral part of the counselling and decision-making process.
LoE 4	Guideline adaptation: NICE guideline CG132 Caesarean section, Recommendation 1.1.1.1 50 ,  51 ,  52 ,  53 ,  54 ,  55 ,  56 ,  57
	Level of consensus: 93.3%

3.6	Recommendation
GR A	Communications and information must be provided in a form which is comprehensible to persons without any medical knowledge; they must take account of the needs of women from ethnic minorities (differentiated by language, culture and religion) whose native language is not German or who cannot read, and the needs of women with disabilities or learning difficulties.
LoE 4	Guideline adaptation: NICE guideline CG132 Caesarean section, Recommendation 1.1.1.3 50 ,  51 ,  52 ,  53 ,  54 ,  55 ,  56 ,  57
	Level of consensus: 100%

For reasons of consistency, recommendations 3.5 and 3.6 and the following background information were taken from the chapter Information and Advice of the S3-guideline “Caesarean Section”, AWMF registry no. 015 – 084 58 (cf. Recommendations 3.1.1 and 3.1.3 in that guideline), which in turn largely follow the recommendations given in the NICE guideline CG132 Caesarean section 59 .

2  General care

Care during the birth includes all stages of the birth described in Fig. 1 . The data on the duration of the dilation stage is based on the onset of labor, which in this context is associated with the start of regular, painful and progressive contractions.

Fig. 1.

 Overview of definitions of the onset of labor and the different stages of stages of labor. [rerif]

2.1  Informed decision-making and self-determined birth

The need to enable women and their families to have a self-determined birth while also complying with legal requirements means that it is imperative for midwives and doctors to consider the issue of the extent to which the pregnant woman must be included in decision-making 60 ,  61 ,  62 ,  63 ,  64 . In obstetrics, participatory decision-making processes may help to reduce decision-related conflicts and anxieties during pregnancy 62 , can affect the womanʼs satisfaction with the birth process, and may have an impact on safety when choosing the type of birth 65 .

2.2  Continuous care and support

In this guideline, one-to-one care by a midwife is defined as follows 66 ,  67 :

• The provision of obstetric, non-medical supportive care and emotional support and the provision of information and advocacy to the woman during the active dilation and expulsion stages by same midwife while taking existing work-time arrangements into account. Care provided by the same midwife must be as continuous as possible in accordance with the womanʼs needs.

This definition largely corresponds to the definition by Bohren et al. from 2017 68 ,  69 .

4.1	Recommendation
GR B	Once the active dilation stage has begun, parturient women should receive one-to-one care from a midwife throughout the birth.
LoE 2+	69 ,  70 ,  71 ,  72
	Level of consensus: 100%

4.2	Recommendation
EC	During the active expulsion stage, obstetric staff must not leave the woman on her own.
	Expert consensus with consideration of 69
	Level of consensus: 100%

4.3	Recommendation
GR B	During the birth, women should be allowed to be supported by (a) birth companion(s) of their choice.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies, Recommendation 22 73
	Level of consensus: 100%
69

It is assumed that one-to-one care corresponds to the needs of women for continuous care and that one-to-one care will also reduce the potential for error which can arise from suboptimal management of interpersonal communication. The existing evidence should be classified as an initial indication for low-intervention births as a result of one-to-one care 73 .

2.2.1  Availability of gynecologists/obstetricians, pediatricians and anesthetists over a period of 24 hours

It is indisputable that in risky situations women and infants will benefit from the rapid availability of specialists for gynecology and obstetrics, pediatrics or even analgesia. But corresponding studies on this point are lacking, so that even IQWiG evidence report no. 635 on the attendance and availability of specialized obstetric staff 69 does not permit any statements to be made which would correspond to a level of evidence. There can be no doubt that in high-risk cases the presence of medical staff is indispensable. According to the IQWiG evidence report (see guideline report), the evidence indicating that obstetricians, pediatricians and anesthetists must be available around the clock in the context of a vaginal birth at term and for predetermined endpoints is rudimentary, meaning that no recommendations based on external evidence can be made.

2.2.2  Experience and expertise of obstetricians (doctors, medical specialists, residents) and midwives

The evaluation included studies which compared the different levels of experience and expertise of obstetricians (doctors, medical specialists, residents) and midwives in hospitals with one another, based on test and comparator interventions 74 ,  75 ,  75 ,  76 ,  77 ,  78 ,  79 ,  80 ,  81 ,  82 .

Although additional training of teams could be expected to have an impact, the identified evidence is insufficient. Moreover, training programs vary greatly and may be quite complex, which makes it more difficult to provide scientific proof of their efficacy. Because of this, it was not possible to make any recommendations regarding training programs and possible minimum case numbers 76  –  82 .

2.3  Adaptation of the environment

The different intervention rates according to birth setting 3 ,  83 suggest that adapting the environment, specifically the birthing room, could be a possible influencing variable for interventions 84 ,  85 .

Overall, the body of evidence is insufficient to answer the question whether modifying the birthing room in a clinical setting increases the rate of low-intervention births and contributes to positive maternal and fetal/neonatal outcomes. The general rule is that all physiological processes during labor are supported better if the environment imparts a feeling of security and safety 86 ,  87 .

2.4  Eating and drinking during the birth

4.4	Recommendation
GR B	Women may drink during labor. Isotonic drinks should be preferred to water. Women in labor should be informed that drinking isotonic drinks during the birth can prevent acidification of the blood and will not result in increased gastric filling.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 27, Chapter 4.4.4 94 ,  95 ,  96 ,  97 ,  98 ,  99 and NICE guideline CG132 Caesarean section 59 , Recommendation 51, Chapter 6.5 88 ,  94 ,  95 ,  96 ,  100 ,  101 ,  102 ,  103 ,  104 ,  105 ,  106 ,  107 as well as inclusion of more recent literature obtained during the update search and comparison of the newly added literature 108 ,  109
	Level of consensus: 79%
88 ,  89 ,  90 ,  91 ,  92 ,  93

4.5	Recommendation
GR A	Women may eat a light diet during labor. They should not have received opioids and should not develop any risk factors for general anesthesia. Women in labor should be informed that a low-fiber diet, e.g., white bread, crispbread or low-fat cheese, increases gastric filling. It is unclear whether this will create a risk of aspiration (pieces of food entering the lungs) if a general anesthetic becomes necessary during the further course of labor. A light diet consumed during labor has no positive or negative impact on maternal or infant outcomes.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 28, Chapter 4.4.4 94 ,  95 ,  96 ,  97 ,  98 and NICE guideline CG132 Caesarean section 59 Recommendation 50, Chapter 6.5 88 ,  94 ,  95 ,  96 ,  100 ,  101 ,  102 ,  103 ,  104 ,  105 ,  106 ,  107 as well as inclusion of more recent literature obtained during the update search and comparison of the newly added literature 108 ,  109
	Level of consensus: 77%

3  Monitoring

The Board of the OEGGG does not support all of chapter 5 “Monitoring” for Austria. For more information on this, please refer to the relevant statements in the guideline report.

Two aspects are important in this context. Firstly, the dictum “primum nil nocere” (“first do no harm”) applies: interventions must only be carried out in consultation with the woman and only under the condition that the intervention will, in all probability, be more beneficial than harmful. All possible advantages and disadvantages must be communicated appropriately to the patient. The second aspect is adherence to and compliance with all standards to ensure the best possible safety of the patient. This includes regular training of the team and interdisciplinary case discussions, but especially the allocation of sufficient staff to permit one-to-one care.

3.1  Auscultation of fetal heart sounds

The staffing ratio must ensure that best practice recommendations can be implemented. For example, it is known that when fetal health is assessed intrapartum, structured intermittent auscultation offers greater benefits in low-risk births than CTG monitoring.

For this, the following conditions must be met:

• one-to-one care must be provided from the start of the active dilation stage (cervical dilation is approx. 4 – 6 cm or the woman has been admitted to the labor room),

• the obstetric staff are appropriately qualified, and

• fetal heart sounds are continuously documented in detail along with any other relevant obstetric findings.

If these conditions are not met, then CTG monitoring should be carried out.

5.1	Recommendation
GR A	The fetal heart rate must be auscultated when the mother is admitted for the birth and during every further assessment of the condition of mother and baby.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.4.6
	Level of consensus: 100%

5.2	Recommendation
GR A	The fetal heart rate must be auscultated immediately for at least 1 minute and recorded as a single rate.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.4.6
	Level of consensus: 100%

5.3	Recommendation
GR A	The maternal pulse must be palpated when auscultating the fetal heart rate to be able to clearly differentiate between fetal and maternal heart rate.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.4.6
	Level of consensus: 100%

5.4	Recommendation
GR A	Accelerations and decelerations must be recorded if heard.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.4.6
	Level of consensus: 100%

5.5	Recommendation
GR A	Intermittent auscultation of the fetal heart rate must be offered to low-risk pregnant women during the active dilation period.
B	Pinard stethoscope or doppler ultrasound should be used. Intermittent auscultation should be carried out every 15 to 30 minutes.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.2
	Level of consensus: 100%

5.6	Recommendation
GR A	If there is a rising baseline fetal heart rate or a suspicion of decelerations, actions must include more frequent intermittent auscultations, e.g., after 3 consecutive contractions, the overall clinical picture must be considered, e.g., the womanʼs position and hydration, the strength and frequency of contractions, and maternal vital signs. If a rising baseline heart rate or decelerations are confirmed, further actions must include starting continuous CTG monitoring, transfer from a midwife-led birth to obstetrician-led care, summoning help.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.3
	Level of consensus: 100%

Possible birth risks must be excluded if intermittent auscultation is used. There is no evidence showing when and for how long auscultation should be carried out. In the studies which were used as the basis for the recommendation in the NICE guideline CG190, auscultation was carried out as follows:

• during and immediately after a contraction for at least 1 minute 171

• for at least 1 minute after a contraction every 15 minutes during the dilation stage and every 5 minutes during the expulsion stage 172

• during and immediately after at least one contraction for an unspecified period of time 173 .

Relevant intrapartum events must be recorded using a standard system (see recommendation 5.8).

3.2  Cardiotocography (CTG)

5.7	Recommendation
GR A	Precise recording of CTG findings requires the date and time on the CTG unit to be set correctly. In addition, the CTG trace must be labelled and include the data of the pregnant woman (name and date of birth) and the maternal heart rate at the beginning of monitoring.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.56
	Level of consensus: 100%

5.8	Recommendation
GR A	Relevant intrapartum events (e.g., vaginal examinations or fetal blood analysis) must be recorded using a standard system.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.57
	Level of consensus: 100%

There are no generally accepted standards on how events during labor should be recorded. Hospitals should develop a specific system based on their in-house standards. The general principle must be that events are recorded in such a manner that the course of the birth is transparent and open to scrutiny.

3.2.1  Indications for CTG monitoring

5.9	Recommendation
GR B	CTG monitoring should not be initiated when onset of the birth process is suspected if the pregnant woman admitted to the labor room is low-risk.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.1
	Level of consensus: 100%

In contrast to previous recommendations which recommended carrying out an initial CTG monitoring for 30 minutes to exclude any risk to the fetus and confirm contractions, this is no longer recommended in the current NICE guideline CG190 because of a lack of evidence.

5.10	Recommendation
* This does not mean that no monitoring is required. Instead of CTG monitoring, fetal heart sounds must be monitored by auscultation (see section 5.1.). The conditions listed in section 3.1 apply. If they cannot be met (e.g., one-to-one care), then safe monitoring using auscultation is not possible and CTG monitoring is indicated.
GR B	CTG monitoring should be avoided in low-risk pregnant women during the active dilation stage.*
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.1
	Level of consensus: 88%

5.11	Recommendation
GR A	CTG monitoring must be recommended if abnormalities are detected during intermittent auscultation of the fetal heart rate.
0	If the CTG trace shows no abnormalities, the CTG may be removed again after 20 minutes.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.3 and 1.10.8
	Level of consensus: 100%

3.2.2  Indications for continuous CTG monitoring

5.12	Recommendation
GR A	Continuous CTG monitoring of low-risk pregnant women must be carried out if one of the following risk factors occurs/is present during the birth: maternal pulse > 120 bpm, on two occasions 30 minutes apart maternal temperature > 38 °C (single reading) or 37.5 °C on two occasions 1 hour apart suspected chorioamnionitis/sepsis untypical pain (significant) green amniotic fluid fresh vaginal bleeding systolic blood pressure ≥ 160 mmHg or diastolic blood pressure ≥ 110 mmHg (measured between contractions) systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on two separate readings taken 30 minutes apart measured between contractions proteinuria (urine stick test ++) is present and systolic blood pressure is ≥ 140 mmHg (single reading) or diastolic blood pressure is ≥ 90 mmHg measured between contractions protracted birth contractions lasting longer than 60 seconds (constant contractions) or more than 5 contractions within the space of 10 minutes (tachysystole) oxytocin is administered intrapartum
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.4
	Level of consensus: 100%

5.13	Statement
	CTG monitoring is not indicated if the amniotic fluid is pale green if no other risk factors are present.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.5
	Level of consensus: 87%

5.14	Recommendation
GR A	CTG monitoring with telemetry must be offered to all women who require continuous CTG.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.9
	Level of consensus: 100%

As described in 5.1, the use of intermittent auscultation is limited to low-risk pregnancies and low-risk births. The guideline authors agree with the authors of NICE guideline CG190 that, overall, the potential benefits of continuous CTG probably outweigh the risks and limitations and that the use of continuous CTG should be recommended in cases with higher birth risks, as no other effective alternatives exist.

3.2.3  Indications for additional monitoring methods

5.15	Recommendation
GR A	Additional measures such as ultrasound assessment must be carried out if the CTG of the fetal heart rate is not clear.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.4.11
	Level of consensus: 100%

Ultrasound assessment of out-of-hospital births must be initiated as quickly as possible.

3.2.4  General measures during CTG monitoring

5.16	Recommendation
GR A	If CTG monitoring is continuous, maternal and fetal heart rates must be clearly differentiated and recorded at least once every hour.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.11
	Level of consensus: 100%

3.2.5  CTG assessment

5.17	Recommendation
GR A	CTGs must be interpreted and recorded according to standard practice.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.10
	Level of consensus: 100%

5.18	Statement
	Standard interpretation of CTG patterns includes assessment and recording of the baseline fetal heart rate, baseline variability, and the presence or absence of accelerations and decelerations.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.12
	Level of consensus: 100%

5.19	Recommendation
EC	The FIGO classification system ( Table 6 ) must be used to interpret CTG patterns.
	Level of consensus: 100%

Table 6 Categorization of fetal heart rate based on the FIGO classification system

	Normal	Suspicious	Pathological
* Decelerations are repetitive if they occur in > 50% of contractions. It is not clear what a lack of accelerations during the birth means.
Baseline	110 – 160 bpm	Lacking at least one of the normal characteristics but without pathological characteristics.	< 100 bpm
Variability	5 – 25 bpm		Limited or increased variability, sinusoidal pattern
Decelerations	No repetitive* decelerations		Repetitive late or prolonged decelerations for > 30 minutes (or > 20 minutes if variability is reduced), prolonged deceleration > 5 minutes
Interpretation	No hypoxia/acidosis	Low probability of hypoxia/acidosis	High risk of hypoxia/acidosis
Clinical management	No intervention required	Conservative measures: correction of reversible causes, close monitoring, further diagnostics	Conservative and/or invasive measures: immediate correction of reversible causes, further diagnostics or (if this is not possible) rapid delivery of the infant

5.20	Recommendation
GR A	Assessment of fetal heart rate baseline variability must take account of the following: Physiological baseline variability is usually at least 5 bpm. Intermittent periods of reduced baseline variability are normal, particularly during periods of rest/sleep. Mild or brief “pseudo sinusoidal” patterns (baseline variability with amplitudes of 5 – 15 bpm) are not significant.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.17 and 1.10.18
	Level of consensus: 100%

5.21	Recommendation
GR B	Fetal heart rate decelerations must be described and include the following information the depth and duration of individual decelerations, the timing of the deceleration in relation to contractions, whether or not the fetal heart rate returns to baseline again, how long they are present, whether they occur in more than 50% of contractions.
A	Decelerations must be described as “early”, “variable” or “late”.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendations 1.10.19, 10.10.20 and 1.10.21
	Level of consensus: 100%

CTG patterns must be interpreted and recorded according to standard practice. Many published CTG scoring systems have limitations and some have only been evaluated for antenatal settings. The standard international FIGO scoring system ( Table 6 ) must be used to interpret CTG patterns. In contrast to other scoring systems also commonly used in Germany, accelerations are no longer used much (NICE guideline CG190 67 ).

5.22	Recommendation
GR A	The condition of mother and baby (including recording CTG patterns) must be monitored every hour, or more often if there are any concerns.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.10
	Level of consensus: 100%

5.23	Recommendation
GR A	No decisions on care must be made during the birth on the basis of CTGs alone. Any consequences arising from the interpretation of a CTG must take account of different factors. These factors include, inter alia maternal vital signs (blood pressure, heart rate, temperature) maternal (subjective) condition meconium or blood in the amniotic fluid vaginal bleeding any medication taken by the mother frequency of contractions stage of labor and progress of labor parity if necessary, the results of fetal blood analysis or reaction to digital fetal scalp stimulation
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.13
	Level of consensus: 100%

5.24	Statement
	The likelihood of fetal acidemia is low if the baseline fetal heart rate and baseline variability are normal.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.10
	Level of consensus: 93%

CTG patterns may be categorized as normal, suspicious or pathological ( Table 6 ). The general rule is that no decisions must be made during the birth on the basis of the CTG alone. Influencing factors (maternal and/or fetal) must be taken into account during the assessment (NICE guideline CG190 67 ).

When CTG patterns are normal, it can be assumed that there is no risk of hypoxia and/or acidosis and therefore no intervention is required.

If the CTG pattern is suspicious, hypoxia/acidosis are unlikely, and conservative measures (i.e., correction of reversible causes, close monitoring and further diagnostic investigations) are indicated. These can include, for example, providing fluids, checking maternal vital signs and, if necessary, informing another midwife and/or the attending obstetrician (see 3.2.11).

If the CTG pattern is pathological, there is a high risk of hypoxia/acidosis, and conservative and/or invasive measures are indicated. Irreversible causes (e.g., umbilical cord prolapse, placental abruption, uterine rupture) must excluded without delay. Reversible causes must be immediately corrected and/or further diagnostic tests (e.g., fetal blood analysis) must be carried out. If an invasive investigation using fetal blood analysis cannot be carried out, operative expediting of the birth may be necessary.

All measures must take account of the womanʼs preferences.

3.2.6  Recommendations for action for fetal tachycardia

5.25	Recommendation
GR A	If the baseline fetal heart rate is between 161 – 180 bpm and there are no abnormalities on the CTG, then possible underlying causes such as infection must be investigated, and the necessary tests must be carried out maternal temperature and heart rate must be checked; if they are elevated, fluids and antipyretic measures should be offered one or more conservative measures should be carried out.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.16
	Level of consensus: 100%

5.26	Recommendation
GR A	If the baseline fetal heart rate is between 161 – 180 bpm, there are no other CTG abnormalities and maternal temperature and heart rate are normal, CTG monitoring and normal care must be continued as the risk of fetal acidosis is low.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.15
	Level of consensus: 100%

5.27	Recommendation
GR A	If the baseline fetal heart rate is over 180 bpm and the CTG is not pathological, possible underlying causes such as infection must be investigated, and the necessary tests must be carried out maternal temperature and heart rate must be checked; if they are elevated, fluids and antipyretic measures should be offered one or more conservative measures must be carried out fetal blood analysis to measure lactate levels or pH must be offered if the fetal heart rate continues above 180 bpm despite implementing conservative measures.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.15
	Level of consensus: 100%

Fetal heart rate is not a good surrogate marker for hypoxia and acidosis, as they are affected by a number of factors but may not be affected by certain types of hypoxia (NICE guideline CG190 67 ).

Studies found an association between poor neonatal/infant outcomes and a fetal heart rate of > 160 bpm. Even though the level of evidence is quite low, a fetal heart rate of 160 bpm was set as the upper limit (NICE guideline CG190). Based on empirical observations, the authors of the NICE guideline consider a fetal heart rate of > 180 bpm to be associated with a great risk of fetal hypoxia/acidosis, which is why this rate is considered to be another upper limit. This has led to there being two categories of fetal tachycardia: 161 – 180 bpm and > 180 bpm.

Irrespective of the above, studies analyzed for neonatal morbidity and mortality rates found only a limited association between fetal tachycardia and poor neonatal outcome (NICE guideline CG190 67 ).

3.2.7  Recommendations for action for fetal bradycardia

5.28	Recommendation
GR B	A baseline fetal heart rate of 100 – 109 bpm is considered suspicious, but if the baseline variability is normal and there are no variable or late decelerations, this should not lead to a direct intervention.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.15 and 1.10.16
	Level of consensus: 100%

5.29	Recommendation
GR A	If the baseline fetal heart rate is between 100 – 109 bpm or over 160 bpm and the CTG shows additional suspicious characteristics, then measures must be taken to normalize the CTG pattern.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendations 1.4.4, 1.10.15 and 1.10.16 with diverging opinions based on EC
	Level of consensus: 88%

5.30	Recommendation
GR A	A baseline fetal heart rate of between 90 – 99 bpm is considered pathological, but this could be a normal variation if the baseline variability is normal (the fetal heart rate has not been confused with maternal heart rate). An experienced doctor must be called in.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.15 and 1.10.16
	Level of consensus: 100%

5.31	Recommendation
GR A	If there is a prolonged deceleration and a fetal heart rate of less than 100 bpm for at least 3 minutes, conservative measures must be carried out. medical assistance must be summoned without delay. preparations must be made for an urgent birth. the birth must be expedited if the prolonged deceleration continues.
LoE	Guideline modification: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.29 with diverging opinions based on EC
	Level of consensus: 94%

There is some limited evidence that a fetal heart rate of less than 110 bpm is associated with adverse fetal/neonatal outcomes. The data is better for a fetal heart rate of < 100 bpm, although the majority of studies investigated a heart rate of less than 90 bpm. This was the basis for determining these current threshold values (NICE guideline CG190 67 ). Empirically, a fetal heart rate of 90 – 99 bpm with a normal baseline variability and no decelerations may be normal in some pregnancies.

The negative and positive predictive value of fetal bradycardia for a poor neonatal outcome is only moderately useful (moderate/high specificity, low sensitivity) (NICE guideline CG190). Only cases of moderate to severe bradycardia during the birth have been found to be associated to some extent with a poor neonatal outcome.

3.2.8  Recommendations for action for abnormal variability

5.32	Recommendation
GR A	If variability is limited (< 5 bpm) and the baseline fetal heart rate is normal with no variable or late decelerations, then conservative measures must be carried out if this persists over a period of 40 minutes. fetal blood sampling to measure pH or lactate levels must be offered if the condition persists for 90 minutes.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.17 and 1.10.18
	Level of consensus: 94%

5.33	Recommendation
GR A	If variability is limited (< 5 bpm) for 40 minutes and there are one or more suspicious signs such as tachycardia (a baseline heart rate of > 160 bpm) or a baseline heart rate of < 100 bpm or variable or late decelerations are present, then: conservative measures must be carried out and fetal blood analysis to measure pH or lactate must be offered. If the findings continue to give reason for concern, then the birth must be expedited promptly.
LoE	Guideline modification: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendations 1.10.17, 1.10.18 and 1.10.19 with diverging opinions based on EC
	Level of consensus: 100%

3.2.9  Recommendations for action for decelerations 110

5.34	Recommendation
GR A	The following points must be considered when assessing decelerations of the fetal heart: Early decelerations (< 60 bpm; the nadir of the FHR and the peak of the contraction occur at the same time) are rarely associated with fetal hypoxia. Early decelerations without suspicious or pathological CTG patterns must not lead to any further measures being taken.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendations 1.10.19, 1.10.20 and 1.10.24
	Level of consensus: 100%

5.35	Recommendation
GR A	Variable decelerations which occur together with a contraction are very common, may be a normal occurrence in the context of an uncomplicated birth and are usually caused by compression of the umbilical cord. The woman must be encouraged to change her position or mobilize.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.23
	Level of consensus: 92%

5.36	Recommendation
GR A	Conservative measures must be carried out if there are variable decelerations with a normal heart rate and normal baseline variability, and the fetal heart rate drops to ≤ 60 bpm and takes ≥ 60 seconds to recover, and variable decelerations occur for > 90 minutes, and variable decelerations occur in > 50% of contractions.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.32 and 1.10.34
	Level of consensus: 100%

5.37	Recommendation
GR A	Fetal blood analysis to measure pH or lactate must be offered if variable decelerations are still present at 30 minutes after the start of conservative measures. are present in addition to fetal tachycardia (the baseline heart rate is > 160 bpm) and/or variability is limited (< 5 bpm).
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.42
	Level of consensus: 100%

5.38	Recommendation
GR A	If late decelerations are present, then conservative measures must be initiated if the late decelerations are present in > 50% of contractions, fetal blood analysis to measure pH or lactate must be offered and/or the birth must be expedited if the late decelerations persist for > 30 minutes and occur in > 50% of contractions. Measures must be initiated earlier if late decelerations are present together with an abnormal baseline fetal heart rate and/or limited variability.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendations 1.10.21, 1.10.30, 1.10.31, 1.10.40 – 55
	Level of consensus: 100%

5.39	Recommendation
GR A	It is important to take into account that the likelihood of fetal acidosis increases, the longer, later and deeper individual decelerations occur, particularly if they are present together with tachycardia and/or limited and/or increased variability. Measures must already be initiated before 30 minutes if there are concerns about the babyʼs well-being.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.32 and 1.10.34
	Level of consensus: 92%

3.2.10  Recommendations for action for (absent) accelerations

5.40	Recommendation
GR A	When evaluating accelerations of the fetal heart rate, it is important to take account of the fact that the presence of accelerations is generally a sign that the baby is healthy an absence of accelerations coupled with otherwise normal CTG patterns is not an indication of acidosis.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.26
	Level of consensus: 100%

3.2.11  Conservative measures for suspicious/ : pathological CTG patterns

5.41	Recommendation
GR A	If the CTG pattern appears suspicious, then possible causes must be evaluated and one or more of the following measures must be taken: The pregnant woman must be encouraged to mobilize or take a left-lateral position and particularly to avoid a supine position Fluids must be administered Paracetamol must be administered if maternal temperature is elevated The administration of oxytocin must be stopped (the attending physician must decide whether and when oxytocin administration should be resumed) Tocolysis
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.34 and 1.10.35
	Level of consensus: 100%

5.42	Recommendation
GR A	Maternal facial oxygen therapy must not be used for intrauterine reanimation as it could harm the baby. However, oxygen therapy may be used for maternal indications such as hypoxia or for preoxygenation prior to an analgesic intervention.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.36
	Level of consensus: 100%

3.3  Fetal blood analysis (FBA)

5.43	Recommendation
GR A	If stimulation of the fetal scalp results in an increased fetal heart rate, this can be taken as a favorable sign; it must be taken into account in the overall assessment.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.38
	Level of consensus: 92%

5.44	Recommendation
GR A	The reaction/changes in the fetal heart rate following digital fetal scalp stimulation during a vaginal examination must be taken into account when assessing the babyʼs condition if fetal blood analysis was not successful or was contraindicated.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.39
	Level of consensus: 100%

5.45	Recommendation
GR A	If fetal blood analysis is offered, an explanation must be given to the woman why this procedure is indicated, that the fetal blood sample will be used to determine the pH value of the babyʼs blood which will provide information about whether the baby is in trouble, that a vaginal examination with instruments is necessary to obtain the blood sample, that a small sample of blood will be taken from the babyʼs head and is obtained by making a small scratch on the babyʼs scalp. This cut will heal quickly after the birth but there is also a small risk of infection, that analyzing fetal blood may help to avoid additional and more serious interventions, what the consequences of different events (normal, borderline, pathological) can be, that in rare cases it may not be possible to take a fetal blood sample (e.g., if cervical dilation is less than 4 cm). If a fetal blood sample cannot be obtained, delivery by caesarean section or a vaginal-operative birth may be necessary as otherwise it is not possible to determine the babyʼs condition.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.44
	Level of consensus: 94%

5.46	Recommendation
GR A	Fetal blood analysis must not be carried out if there are contraindications (e.g., a risk of maternal-to-fetal transmission of infection or of fetal bleeding disorders).
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.40
	Level of consensus: 93%

5.47	Recommendation
GR B	If fetal blood analysis is indicated and it is not possible to obtain a fetal blood sample but digital fetal scalp stimulation results in an improvement of the fetal heart rate pattern, a decision must be taken, after discussion with the woman, whether to continue labor or to expedite the birth in view of the clinical circumstances.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.54
	Level of consensus: 100%

5.48	Recommendation
GR B	If fetal blood analysis is indicated but it is not possible to obtain a fetal blood sample and the CTG pattern does not improve, the recommendation should be given to the woman that the birth should be expedited.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.55
	Level of consensus: 93%

3.3.1  Assessment of fetal blood samples and recommendations for action

5.49	Recommendation
GR A	Either lactate or pH must be measured for fetal blood analysis.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.47
	Level of consensus: 94%

5.50	Recommendation
GR A	The fetal blood sample must be assessed using the following classification:
	Lactate (mmol/l)	pH	Assessment
	≤ 4.1	≥ 7.25	normal
	4.2 – 4.8	7.21 – 7.24	borderline
	≥ 4.9	≤ 7.20	pathological
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.48
	Level of consensus: 88%

5.51	Recommendation
GR A	Previous pH/lactate values, the rate of progress in labor, and any clinical maternal and fetal findings must be taken into account when evaluating the fetal blood sample.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.49
	Level of consensus: 93%

5.52	Recommendation
GR A	If the fetal blood sample is normal and the CTG continues to be suspicious, another fetal blood analysis should be carried out not more than 1 hour later or even earlier if additional pathologies are present.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.52
	Level of consensus: 88%

5.53	Recommendation
GR A	If the fetal blood sample is classified as borderline and the CTG continues to be suspicious, another fetal blood analysis must be carried out no more than 30 minutes later or even earlier if additional pathologies are present.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 1.10.51
	Level of consensus: 94%

5.54	Recommendation
GR A	The time required to carry out the fetal blood analysis must be taken into account when planning a repeat of fetal blood sampling.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 1
	Level of consensus: 92%

5.55	Recommendation
GR A	If the CTG remains unchanged after fetal blood analysis has been repeated and the results of fetal blood analysis (lactate/pH value) remain unchanged, further fetal blood analyses should be postponed until additional pathological features develop.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 1
	Level of consensus: 88%

3.4  Additional procedures

3.4.1  Computerized assessment of CTGs

5.56	Recommendation
GR B	Computer-based systems should not currently be used to interpret CTGs in routine practice.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 1
	Level of consensus: 100%

3.4.2  ST segment analysis (STAN)

5.57	Recommendation
GR B	A fetal electrocardiogram (ECG) obtained using fetal scalp electrodes or by extraction of the fetal signal from an abdominal ECG should not be currently used in routine practice.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 1
	Level of consensus: 100%

3.4.3  Pulse oximetry

5.58	Recommendation
GR B	Fetal oxygenation should currently not be done intrapartum in routine practice.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 1
	Level of consensus: 100%

3.5  Ultrasound in the labor room

3.5.1  Intrapartum ultrasound to detect SGA

5.59	Recommendation
GR B	Ultrasound examination for the early detection of SGA babies should not be carried out intrapartum.
LoE	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67
	Level of consensus: 100%

In contrast to ultrasound examinations performed during pregnancy which can be useful when planning the mode of birth, the use of ultrasound examinations to evaluate the birthweight and detect SGA is not recommended intrapartum as it does not affect the mode of birth, the Apgar score or the acidosis rate.

3.5.2  Intrapartum ultrasound for the early detection of LGA

5.60	Recommendation
GR B	If there is a suspicion of macrosomia, an ultrasound examination should not be carried out intrapartum to confirm this.
LoE	111
	Level of consensus: 100%

An ultrasound examination carried out intrapartum for a suspicion of fetal macrosomia will not affect the mode of birth, the rate of perineal tears or maternal blood loss. The use and validity of ultrasound to estimate fetal weight and/or identify growth disorders or placental pathologies could not be evaluated as no systematic reviews on this issue were included.

3.5.3  Intrapartum ultrasound: failure to progress in labor, vaginal-operative birth

5.61	Recommendation
GR 0	Transperineal measurement of the angle of progression (AoP) or the head-perineum distance (HPD) and transabdominal assessment of the occiput position may be carried out. AoP and HPD are the most reliable ultrasound parameters for the prediction of a successful vaginal-operative birth. Transabdominal assessment of the occiput position and transperineal determination of the level of the head may be carried out. Rotation of the fetal head, measured using the midline angle, and/or the direction of the head may be determined to predict the probability of success for a vaginal-operative birth.
LoE	112
	Level of consensus: 100%

4  Pain management

Women experience the labor pains very differently. Important variables affecting maternal satisfaction with the experience of childbirth include labor pains, the feeling of being in control, perceived self-efficacy, social support, and the womanʼs own expectations of the birth 113 ,  114 ,  115 ,  116 ,  117 . Effective forms of pain relief do not necessarily result in a higher level of satisfaction with the birth experience 118 ,  119 .

4.1  Approach to pain during birth

4.1.1  Attitudes to pain and pain management during birth

6.1	Recommendation
GR B	Healthcare professionals should think about and be aware of their own attitudes to pain during labor and ensure that their care supports the womanʼs choices.
LoE 1	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 65 120 ,  121 ,  122 ,  123
	Level of consensus: 94.4%

4.1.2  Strategies to cope with pain during labor (relaxation techniques, massage and relaxation bath)

6.2	Recommendation
GR A	If a woman wishes to use breathing and relaxation technique to cope with labor pains, then she must be supported in her decisions.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 66 124
	Level of consensus: 94.4%

6.3	Recommendation
GR A	If a woman requests massage techniques which have been taught to her birth companions, then she must be supported in her decision.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 67 125 ,  126
	Level of consensus: 88.2%

6.4	Recommendation
GR A	The woman must be offered the option to labor in water for pain relief.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 68 127
	Level of consensus: 88.2%

6.5	Recommendation
GR B	If the woman is laboring in water, then her body temperature and the temperature of the water should be monitored every hour to ensure that she feels comfortable and does not overheat. The water temperature should not exceed 37.5 °C.
LoE IV	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 69 127
	Level of consensus: 100%

6.6	Recommendation
GR A	Baths and birthing pools must be kept clean in accordance with the standards agreed upon with the local hygiene department. Birthing pools must additionally be cleaned in accordance with manufacturerʼs guidelines.
LoE IV	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 70 127
	Level of consensus: 93.7%

6.7	Recommendation
GR A	The woman must be supported to play the music of her choice during labor.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 73 124
	Level of consensus: 81.3%

4.2  Non-pharmacological interventions for pain relief and relaxation during labor 124 ,  125 ,  127 ,  128 ,  129 ,  130

In addition to providing support during labor in the form of words of encouragement or helping her to move, women are offered a range of physical and complementary medicine pain therapies. The aim is not to eliminate the pain but to provide pain relief.

6.8	Recommendation
GR 0	No negative effects have been reported for acupuncture, acupressure, hypnosis, aromatherapy or yoga. If a woman wishes to use these methods, she can do so. The person(s) providing these forms of pain relief must be appropriately trained.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 , Recommendation 72 124 ,  131 ,  132 ,  133 ,  134 ,  135 ,  136 ,  137
	Level of consensus: 87.5%

6.9	Recommendation
GR 0	Because of the lack of evidence, it is not possible to make any recommendation regarding the use of homeopathic substances for pain relief during birth.
LoE 2	Literature search 138 ,  139
	Level of consensus: 86.6%

4.2.1  Further research required

The two Cochrane reviews ( 140 on TENS and 141 the use of sterile water injections) focused on different methods for pain relief but defined different endpoints. If the endpoints formulated by Derry and colleagues in 2012 141 with regard to pain relief are followed, then there should be more RCTs on methods of coping with pain which use these endpoints.

To obtain clear evidence for or against homeopathy, RCTs using a limited number of homeopathic substances and with comparable designs and endpoints should be carried out.

It is worth discussing whether the endpoint “pain relief” should be analyzed without the endpoint “satisfaction with the birth experience”.

4.3  Pharmacological measures

The following chapter references chapter 1.9 (“Pain relief in labour: regional analgesia”) of NICE guideline CG190. This chapter of the NICE guideline is mainly geared to the situation in Great Britain and focuses in detail on substances and means of application which, for historical reasons, are important in Great Britain. The transferability of those recommendations to the German healthcare system is limited, because some of the substances are not available (e.g., diamorphine = heroin) or in some places they have been replaced by other substances not explicitly recommended in the NICE guideline CG190 (e.g., meperidine instead of pethidine) or historically do not have the same perceived value in German obstetric practice due to the widespread availability of neuraxial anesthesia (EA, CSE) compared to Great Britain (e.g., nitrous oxide).

4.3.1  Epidural anesthesia

6.10	Statement
	Epidural analgesia is an effective method of pain relief during labor and is more efficacious than intramuscular or intravenous administration of opioids.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 Recommendation 1.9.2
	Level of consensus: 88.9%

6.11	Recommendation
GR B	Women in labor who need or request analgesia should be offered epidural analgesia.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 Recommendation 1.9.3
	Level of consensus: 94.4%

6.12	Recommendation
GR A	An effective neuraxial analgesia procedure does not always require the woman to be immobilized. Women in labor should therefore be encouraged to move and adopt a position which feels comfortable.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 Recommendation 1.9.7
	Level of consensus: 100%

6.13	Recommendation
GR B	The woman should be continuously monitored by CTG until no further changes in the womanʼs hemodynamics are expected (usually for a period at least 30 minutes). Routine CTG monitoring is not absolutely necessary once epidural analgesia has been established.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 Recommendation 1.9.12
	Level of consensus: 94.1%

6.14	Recommendation
GR B	The timing of regional analgesia should be determined by the parturient woman and be administered at any time. Waiting for a defined stage of labor before administering regional analgesia is not recommended as, based on the current state of knowledge, there is no objective advantage or disadvantage in terms of the progression of labor associated with the time when the epidural catheter is placed.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 Recommendation 1.9.2
	Level of consensus: 94.1%

6.15	Recommendation
EC taking account of 142	The womanʼs vital signs should be monitored and recorded from the initiation of neuraxial analgesia until the initial dose becomes fully effective and the womanʼs vital signs have stabilized.
	Level of consensus: 94.1%

4.3.2  Nitrous oxide-oxygen mixtures 143 ,  144 ,  145

6.16	Recommendation
EC	A mixture of nitrous oxide and oxygen (50%/50%) may be used for pain relief during labor as long as technical requirements are complied with.
	Expert consensus
	Level of consensus: 100%
146 ,  147 ,  148 ,  149 ,  150 ,  151 ,  152 ,  153 ,  154 ,  155

4.3.3  Systemic opioids

6.17	Recommendation
EC	Even though neuraxial analgesia is considered the most effective method for obstetric analgesia, it may be contraindicated or impossible to establish in individual cases or the woman may not wish for or want neuraxial analgesia. Effective alternatives to neuraxial analgesia with similar potency should therefore be available for obstetric analgesia.
	Level of consensus: 100%

6.18	Recommendation
GR A	As the overall analgesic effect of long-acting systemic opioids can only be described as unsatisfactory, particularly given the fact that dosages are limited because of the potential to induce respiratory depression in both the mother and the baby, non-neuraxial analgesics must at best be used as a bridging analgesic or if the woman is aware of their limited efficacy.
LoE 1+	Guideline adaptation: NICE guideline CG190 Intrapartum care for healthy women and babies 67 Recommendation 1.8.12
	Level of consensus: 87.5%

6.19	Statement
	The most effective analgesic alternative to neuraxial procedures is remifentanil PCIA. However, it must only be used if defined staffing and technical requirements are met.
LoE 1+	156
	Level of consensus: 100%

5  Quality assurance for vaginal births

5.1  History

Quality assurance in obstetrics is considered the nucleus of quality control in the hospital-based sector in Germany. After the publication of the Munich perinatal study in 1975 157 , the use of perinatal surveys expanded rapidly in the old German federal states and the new federal states after reunification. The founding 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 survey frame for quality assurance in obstetrics, and it 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 for hospital-based statutory quality assurance currently refer to vaginal births 158 .

After some preparations 159 , the Society for Quality in Out-of-Hospital Births (QUAG e. V.) was set up in 1999 to cover the outpatient sector. It records the quality of out-of-hospital births in all of Germany. In the main, the recorded items resemble those used in the clinical perinatal surveys with the addition of the special features of out-of-hospital obstetrics and a consideration of the transition from the outpatient to the inpatient sector. In principle, the outcomes of births delivered in hospitals and births which occurred in out-of-hospital settings could be compared. Since 2015, QUAG e. V. which was specifically referenced in the German law regulating the remuneration paid to midwives (Hebammenhilfevertrag) 160 , has been responsible for the external supervision of quality assurance in out-of-hospital obstetrics. The annual federal evaluations of the data collected for the out-of-hospital sector are freely available on the website of QUAG e. V. ( www.quag.de ).

5.2  Changes in the percentages of modes of birth over time

A cursory inspection of changes in the percentages of hospital births over the past decade shows that the percentage of caesarean sections increased until the year 2011 but has 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 158 ,  161 ,  162 ,  163 .

5.3  Indicator-based quality assurance

5.3.1  Indicator-based quality assurance for the inpatient sector

Quality is typically measured using quality indicators. In statutory quality assurance in Germany, the following indicators are currently used to evaluate vaginal births and as starting points for quality improvement processes 158 :

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

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

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

• the presence of a pediatrician during premature births

• a critical-outcomes quality index for term-born newborns

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

• maternal mortality as part of the perinatal survey.

In addition,

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

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

As part of the implementation of quality indicators relevant for planning purposes 164 , 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.

5.3.2  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 place 160 . Peer reviews and structured dialogs may be initiated to provide support with quality assurance to service providers working in the outpatient sector.

5.4  First attempts to create a form of inter-institutional indicator-based quality assurance

The Scientific Institute of the AOK (WIdO) developed further quality indicators for in-hospital vaginal births based on standard data for in-hospital births 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 following the initial stay in hospital for the birth 165 .

5.5  Quality assurance of structural requirements with a special focus on staffing requirements

The German Quality Assurance Directive for Premature and Term-born Infants (QFR-RL) has developed statutory rules for 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 ensure the quality of structures, processes and outcomes of care for premature and term-born neonates while also taking the accessibility of birth facilities across the country into account 166 ,  167 ,  168 ,  169 ,  170 .

10.1	Recommendation
EC	Irrespective of the annual birth rate, a sufficient number of midwives must be present or on call in every obstetric department to ensure the parturient woman will receive one-to-one care for 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 planning staff allocations.
	Level of consensus: 100%

10.3	Recommendation
EC	Midwives who have fulfilled the necessary 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 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%

6  Appendix

6.1  Statements from the consultation process

6.1.1  Statement of 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 classifications of risk, particularly as the available 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 a complete reporting of all births and their outcomes (including those which may start in an out-of-hospital setting and end in hospital).

6.1.2  Statement of the ÖGGG

Special vote by the OEGGG regarding the preamble to 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 using a catalog of risks, many complications can still not be predicted with sufficient certainty.

A transfer, which is expected to occur for around one third of primipara, 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, placental retention or placental remnants, a high loss of blood peripartum, complex childbirth injuries, and neonatal adaptation disorders.

The issue of the safety of out-of-hospital obstetrics in German-speaking countries should be prospectively investigated in studies involving both midwives and physicians and should include the complete recording of all births as well as the recording of 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.