Validity period

The Board of the Dutch Society of Obstetrics and Gynaecology (NVOG) will assess whether these guidelines are still up to date in 2029 at the latest. If necessary, a new working group will be appointed to revise the guideline. The guideline’s validity may lapse earlier if new developments demand revision at an earlier date.

As the holder of this guideline, the NVOG is chiefly responsible for keeping the guideline up to date. Other scientific organizations participating in the guideline or users of the guideline share the responsibility to inform the chiefly responsible party about relevant developments within their fields.

In collaboration with:

• Deutsche Gesellschaft für Gynäkologie und Geburtshilfe
• Vlaamse Vereniging voor Obstetrie en Gynaecologie
• Federação das Sociedades Portuguesas de Obstetricia e Ginecologia
• Svensk Förening För Obstetrik & Gynekologi
• Hellenic Society of Obstetric and Gynecological Emergency
• Schweizerische Gesellschaft für Gynäkologie und Geburtshilfe
• Dansk Selskab for Obstetrik og Gynækologi
• Česká gynekologická a porodnická společnost
• European Midwives Association

Composition guideline development panel

An international panel for the development of the guidelines was formed in 2019. The panel consisted of representatives from all relevant medical disciplines that are involved in medical care for pregnant women.

All panel members have been officially delegated for participation in the guideline development panel by their (scientific) societies. The panel has developed the guidelines in the period from January 2022 until May 2024.

The guideline development panel is responsible for the entire text of this guideline.

All panel members have been officially delegated for participation in the guideline development panel by their scientific societies. The guideline development panel is responsible for the entire text of this guideline.

Members of the EAPM Standing Committee on Guideline Development (SCGD)

• J.J. Duvekot, obstetrician, Consultant Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, the Netherlands (chair)
• D. Ayres de Campos, obstetrician, Consultant Obstetrics and Gynaecology, Faculdade de Medicina, Lisbon, Portugal
• S. Brismar-Wendel, obstetrician, Consultant Obstetrics and Gynaecology, Danderyd Hospital, Stockholm, Sweden
• G. Daskalakis, obstetrician, Consultant Obstetrics and Gynaecology, National & Kapodistrian University, Athens, Creece.
• I. Dehaene, obstetrician, Consultant Obstetrics and Gynaecology, Ghent University Hospital Belgium
• M. Kacerovsky, obstetrician, Consultant Obstetrics and Gynaecology, University Hospital Hradec Kralove, Czech Republic
• S. Kehl, obstetrician, Consultant Obstetrics and Gynaecology, Erlangen University Hospital, Erlangen, Germany
• Julie Glavind, obstetrician, Consultant Obstetrics and Gynaecology, Aarhus University Hospital, Aarhus, Denmark
• A. Hamza, obstetrician, Consultant Obstetrics and Gynaecology, University Medical Center of Saarland, Homburg an der Saar, Germany
• M.A. Ledingham, obstetrician, Consultant Obstetrics and Gynaecology, the Queen Elizabeth Hospital Glasgow, UK
• B. Magowan, obstetrician, Consultant Obstetrics and Gynaecology, and previous Co-Chair UK RCOG Guidelines Committee, NHS Borders, Scotland, UK

Advisor committee (part of the committee since September 2023)

• E. Mestdagh,  Director of Research and Development, AP University of Applied Sciences and Arts Antwerp, Belgium, Scientific advisor and guideline developer, KNOV, The Netherlands
• I. Wilsens, senior program coördinator development & innovation, KNOV, the Netherlands
• I. van Ee, patient representative, Dutch Patient Federation, the Netherlands
• P. Stenbäck, Midwife, MCHS, Program Director - Midwifery education. School of Business and Healthcare, Arcada University of Applied Sciences, Helsinki, Treasurer, board member EMA, European Midwifes Association, Belgium
• C. Matteo, European Midwives Association

Methodological support

• J. Tuijtelaars, advisor, Knowledge Institute of the Dutch Association of Medical Specialists
• J.H. van der Lee, senior advisor, Knowledge Institute of the Dutch Association of Medical Specialists

Representation of the patient perspective

Representatives of the Dutch Patient Federation provided review comments. The comments were discussed and where relevant incorporated by the guideline development panel.

This guideline accounts for everyone who gives birth, even though we speak of women and her/she in the guideline.  

Implementation

Guideline implementation and practical applicability of the recommendations was taken into consideration during various stages of guideline development. Factors that may promote or hinder implementation of the guideline in daily practice were given specific attention.

The guideline is distributed digitally among all relevant professional groups. The guideline can also be downloaded from the Dutch guideline website: www.richtlijnendatabase.nl.

Method

AGREE

This guideline has been developed conforming to the requirements of the report of Guidelines for Medical Specialists 3.0 by the advisory committee of the Quality Counsel. This report is based on the AGREE II instrument (Appraisal of Guidelines for Research & Evaluation II) (www.agreetrust.org)(Brouwers, 2010), a broadly accepted instrument in the international community and on the national quality standards for guidelines: “Guidelines for guidelines” (www.zorginstituutnederland.nl).

Identification of subject matter

Since this was a pilot project, the content of the questions and the support base in clinical practice was considered of less importance than the process of international collaboration and learning from each other.  The panel made an inventory of clinical questions to be addressed based on their expert opinion and their knowledge of existing guidelines. The ‘Danish national clinical guideline concerning primiparous women with dystocia (lack of progress)’ published in 2015 was also used as a source of clinical questions.

Clinical questions and outcomes

The guideline development panel formulated definitive clinical questions and defined relevant outcome measures (both beneficial land harmful effects). The panel rated the outcome measures as critical, important and not important. Furthermore, where applicable, the panel defined relevant clinical differences.

Strategy for search and selection of literature

For the separate clinical questions, specific search terms were formulated and published scientific articles were searched for in (several) electronic databases. Furthermore, studies were scrutinized by cross-referencing for other included studies. The studies with potentially the highest quality of research were searched for first. The panel members selected literature in pairs (independently of each other) based on title and abstract. A second selection was performed based on full text. The databases, search terms and selection criteria are described in the modules containing the clinical questions.

No definitions were available at the time of performing the search. Therefore, definitions as used in the papers were used.

Quality assessment of individual studies

Individual studies were systematically assessed, based on methodological quality criteria that were determined prior to the search, so that risk of bias could be estimated. This is described in the “risk of bias” tables.

Summary of literature

The relevant research findings of all selected articles are shown in evidence tables. The most important findings in the literature are described in literature summaries. In case there were enough similarities between studies, the study data were pooled.

Grading quality of evidence and strength of recommendations

The strength of the conclusions of the scientific publications was determined using the GRADE-method. GRADE stands for Grading Recommendations Assessment, Development and Evaluation (see http://www.gradeworkinggroup.org/).

GRADE defines four gradations for the quality of scientific evidence: high, moderate, low or very low. These gradations provide information about the amount of certainty about the literature conclusions (http://www.guidelinedevelopment.org/handbook/).

The basic principles of the GRADE method are: formulating and prioritising clinical (patient) relevant outcome measures, a systematic review for each outcome measure, and appraisal of the evidence for each outcome measure based on the eight GRADE domains (domains for downgrading: risk of bias, inconsistency, indirectness, imprecision, and publication bias; domains for upgrading: dose-effect association, large effect, and residual plausible confounding).

GRADE distinguishes four levels for the quality of the scientific evidence: high, moderate, low and very low. These levels refer to the amount of certainty about the conclusion based on the literature, in particular the amount of certainty that the conclusion based on the literature adequately supports the recommendation (Schünemann, 2013; Hultcrantz, 2017).

The limits of clinical decision making are very important in grading the evidence in guideline development according to the GRADE methodology (Hultcrantz, 2017). Exceedance of these limits would give rise to adaptation of the recommendation. All relevant outcome measures and considerations need to be taken into account to define the limits of clinical decision making. Therefore, the limits of clinical decision making are not one to one comparable to the minimal clinically relevant difference. In particular for interventions of low costs and without important drawbacks the limit of clinical decision making regarding the effectiveness of the intervention may be lower (i.e. closer to no effect) than the Minimal Clinically Important Difference (MCID) (Hultcrantz, 2017).

Considerations (evidence to decision)

Aspects such as expertise of working group members, patient preferences, costs, availability of facilities, and organisation of healthcare aspects are important to consider when formulating a recommendation. For each clinical question, these aspects are discussed in the paragraph Considerations, using a structured format based on the evidence-to-decision framework of the international GRADE Working Group (Alonso-Coello, 2016a; Alonso-Coello, 2016b). The evidence-to-decision framework is an integral part of the GRADE methodology.

Formulating recommendations

Recommendations provide an answer to the primary question and are based on the best scientific evidence available and the most important considerations. The level of scientific evidence and the importance given to considerations by the working group jointly determine the strength of the recommendation. In accordance with the GRADE method, a low level of evidence for conclusions in the systematic literature review does not rule out a strong recommendation, while a high level of evidence may be accompanied by weak recommendations. The strength of the recommendation is always determined by weighing all relevant arguments.

Knowledge gaps

During the development of this guideline, systematic searches were conducted for research contributing to answering the primary questions. For each primary question, the working group determined whether (additional) scientific research is desirable.

Commentary and authorisation phase

The draft guideline was subjected to commentaries by the scientific societies and patient organisations involved. The draft guideline was also submitted to members of the European Midwives Association (EMA). The comments were collected and discussed with the working group. The feedback was used to improve the guideline; afterwards the working group made the guideline definitive. The final version of the guideline was offered for authorization to the involved scientific societies and patient organisations and was authorized or approved, respectively.

Legal standing of guidelines

Guidelines are not legal prescriptions but contain evidence-based insights and recommendations that care providers should meet in order to provide high quality care. As these recommendations are primarily based on ‘general evidence for optimal care for the average patient’, care providers may deviate from the guideline based on their professional autonomy when they deem it necessary for individual cases. Deviating from the guideline may even be necessary in some situations. If care providers choose to deviate from the guideline, this should be done in consultation with the patient, where relevant. Deviation from the guideline should always be justified and documented.

Literature

Agoritsas T, Merglen A, Heen AF, Kristiansen A, Neumann I, Brito JP, Brignardello-Petersen R, Alexander PE, Rind DM, Vandvik PO, Guyatt GH. UpToDate adherence to GRADE criteria for strong recommendations: an analytical survey. BMJ Open 2017;7:e018593.

Alonso-Coello P, Schünemann HJ, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Rada G, Rosenbaum S, Morelli A, Guyatt GH, Oxman AD; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 1: Introduction. BMJ 2016;353:i2016.

Alonso-Coello P, Oxman AD, Moberg J, Brignardello-Petersen R, Akl EA, Davoli M, Treweek S, Mustafa RA, Vandvik PO, Meerpohl J, Guyatt GH, Schünemann HJ; GRADE Working Group. GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines. BMJ. 2016 Jun 30;353:i2089.

Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna SE, Littlejohns P, Makarski J, Zitzelsberger L; AGREE Next Steps Consortium. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ. 2010 Dec 14;182(18):E839-42.

Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA, Iorio A, Alper BS, Meerpohl JJ, Murad MH, Ansari MT, Katikireddi SV, Östlund P, Tranæus S, Christensen R, Gartlehner G, Brozek J, Izcovich A, Schünemann H, Guyatt G. The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol. 2017 Jul;87:4-13.

Medisch Specialistische Richtlijnen 2.0 (2012). Adviescommissie Richtlijnen van de Raad Kwalitieit. http://richtlijnendatabase.nl/over_deze_site/over_richtlijnontwikkeling.html

Neumann I, Santesso N, Akl EA, Rind DM, Vandvik PO, Alonso-Coello P, Agoritsas T, Mustafa RA, Alexander PE, Schünemann H, Guyatt GH. A guide for health professionals to interpret and use recommendations in guidelines developed with the GRADE approach. J Clin Epidemiol. 2016 Apr;72:45-55. doi: 10.1016/j.jclinepi.2015.11.017. Epub 2016 Jan 6. Review. PubMed PMID: 26772609.

Schünemann H, Brożek J, Guyatt G, et al. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, 2013. Available from http://gdt.guidelinedevelopment.org/central_prod/_design/client/handbook/handbook.html.

Schünemann HJ, Oxman AD, Brozek J, Glasziou P, Jaeschke R, Vist GE, Williams JW Jr, Kunz R, Craig J, Montori VM, Bossuyt P, Guyatt GH; GRADE Working Group. Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 2008 May 17;336(7653):1106-10. 

Schünemann, A Holger J [corrected to Schünemann, Holger J]. PubMed PMID: 18483053; PubMed Central PMCID: PMC2386626.

Wessels M, Hielkema L, van der Weijden T. How to identify existing literature on patients' knowledge, views, and values: the development of a validated search filter. J Med Libr Assoc. 2016 Oct;104(4):320-324.