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Guideline – Vaginal Birth at Term – General information

In 2020 in Germany a set of guidelines containing recommendations for obstetric staff came into force.

1. General information
2. What does "vaginal birth at term" mean?
3. To whom do the recommendations apply?
4. Who drafted the guidelines?
5. Topics from the guideline

  1. General information
    The inner attitude and approach of the staff is seen as a factor that affects the mother, the child and the father as well as the birth process. The mothers/parents should be involved, informed and have advantages and disadvantages explained so that they can agree or refuse. The LL encourages to respect and implement with appreciation the wishes of the woman giving birth. This also includes, for example, not to make offers of a medical nature to women who are in good health.
    Aims of the guideline:
    a) to be based on published, recognised scientific studies
    b) to include the practical experience of midwives and doctors,
    c) to take into account and implement the wishes and needs of the pregnant woman/parents and their child more than before.
    Places of birth
    Women have the right to choose the place of birth for their child. This recognises that they are responsible for their own health (German Constitution Article 2(2).). The guidelines apply to the five places of birth recognised in Germany, which are :
    1. home birth: birth takes place in one's own home .
    2. birth centre birth: there are about 140 birth centres in Germany which are run by midwives.
    3. out-patient birth: the woman is attended by her midwife, who has a contract with the maternity hospital.
    The midwife accompanies the mother into the clinic and cares for her throughout the birth.
    4. midwife-led delivery room in clinics. Birth attendance exclusively by midwives. The proximity to the doctor-led delivery room should facilitate a possible transfer. One-to-one attendance by a midwife of choice only takes place in exceptional cases.
    5. doctor-guided delivery room. One-to-one support by a midwife is very rare. As a rule, you will encounter an unknown midwife, shift changes and the situation that you have to share a midwife with several women.
    Registration can and should take place in advance from the 30th week of pregnancy.
    It is advisable to find out how the various and different aspects of the pregnancy and actual birth are handled at all five birthplaces and what best corresponds with the mother’s wishes.
    What we expect from the implementation of the guideline
    The S3 guidelines will bring about changes, especially in the doctor-led delivery room. Parental disappointments, complaints about abuses up to and including violence, legal disputes and the attention paid to this in the public media have led to a willingness to change direction. This becomes tangible with the guideline. It points out what is desirable and what is avoidable.
    Underlying scientific principles
    The S3 guideline is largely based on the “National Institute for Health and Care Excellence (NICE) guideline CG 190 Intrapartum care for healthy women and babies[1]” from the United Kingdom. Other studies were also taken into account in the preparation of the guideline. The result is this first high-quality guideline for Germany. S3 designates the highest possible level for guidelines, based on recognised scientifically high-quality methods in scientific studies.

    2 What does "vaginal birth at term" mean?
    Within the period of 5 weeks (= 35 days) a child becomes individually ready for birth. The calculation begins on the first day of the 37th week. It ends on the 6th day of the 41st week. The calculated mean value (ET), which is also entered in the maternity pass and sometimes corrected, serves as a guide for calculating maternity protection, parental allowance and parental leave. Not only employers want to be able to plan. For parents it is advisable to abide by the rule of thumb: mean value (ET) +/- 14 days, in order to calmly wait for the first maturation signal of their baby. The technically calculated ET by means of ultrasound is determined on the basis of the size of the baby. Other calculations are based on centuries old empirical knowledge and experience and the information provided by the woman.
    About 85% of pregnant women have a symptom-free pregnancy. Only 10-15 out of 100 women require medical assistance both during pregnancy and childbirth. The high number of certified risks in the mother's maternity pass is attributed by recognised critics to the fee structure and billing system among other things. This means that if a woman is certified as being at risk (starting with her age), more examinations can be carried out and billed accordingly.

    3 Who do the recommendations apply to?
    The S3 guidelines refers to the 85% of women at low risk (World Health Organisation (WHO). These can expect a "normal" birth (vaginal) at home, in a birth centre or in hospital. Parents should be aware of these important recommendations from the S3 guidelines. If they want to deliver their child in the clinic, they should ask there whether the staff follow the new guideline.
    The guideline contains recommendations for midwives and doctors. They are not prescriptions. It contains information and advice that concerns the mothers, the baby, the father and accompanying persons. The recommendations distinguish between "should" and "ought". There is no "must" because the individual situation requires room for decision.
    In future, the parents' voice will be taken all the more seriously the better they are informed about the new guideline. Midwives will be listened to more in hospitals in the future in order to adapt the conditions more to the needs of the women giving birth. Improved working conditions will in turn lead to greater job satisfaction among doctors as well.

    4 Who drafted the guidelines?
    The recommendations were developed, discussed and agreed upon by 28 representatives of different associations. Midwives, doctors, other specialists and a parent representative were involved. The result of the vote is noted for each recommendation. Often there was 100 % agreement. For some recommendations there are reservations or abstentions. In these cases, the approval rate is lower.
    Participating representatives of the professional associations: 28 persons

    5 Topics from the guideline 
    (listed in alphabetical order in the original German) listening to fetal heart sounds - cord clamping - breech presentation - postpartum bonding - CTG/telemetry (wireless) - episiotomy - one-to-one care - eating and drinking - woman-centred care - opening of the membranes, not routinely - Birth standing, kneeling, squatting.... - Places of birth - Caesarean section (vaginal birth after) – Kristeller manoeuvre- latency phase - medical interventions offered routinely - Pain - Vaginal birth "at term" - premature rupture of membranes - water birth - twins.

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