Surveillance du travail dans les situations à risque

[Mode of delivery in spontaneous preterm birth]

OBJECTIVE

To evaluate the benefit/risk balance of way of birth according to fetal presentation, to assess monitoring during preterm labor, to discuss method of delivery and practice of delayed cord clamping in case of spontaneous preterm birth.

METHODS

Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade.

RESULTS

In case of vertex presentation, no studies suggest that cesarean section improve neonatal outcome during spontaneous preterm birth (LE4). Nevertheless, cesarean is associated with higher maternal morbidity than vaginal delivery. Thus, routine cesarean is not recommended simply because of a spontaneous preterm labor (professional consensus). The available data do not allow specific recommendations about the choice of mode of delivery for preterm breech presentation in view of the low levels of proof (Professional consensus). Fetal rate monitoring is necessary during preterm labor (Professional consensus). Current data about second lines method for fetal surveillance (fetal scalp blood for pH or lactates) are insufficient to recommend their use before 34 WG (Professional consensus). Systematic assisted vaginal delivery is not recommended during preterm birth (Professional consensus). Use of vacuum is possible after 34 WG when cranial vertex ossification is considered satisfactory (Professional consensus). Systematic use of episiotomy in case of preterm birth is not recommended (Professional consensus). A delayed cord clamping is possible if the neonatal or maternal state so permits (Professional consensus). The available data are insufficient to recommend a systematic use of this procedure (LE3).

CONCLUSION

In case of preterm delivery, the available data do not allow specific recommendations about the choice of mode of delivery regardless of fetal presentation.

[Delivery of premature infants]

Prematurity is a frequent event and clearly raises an issue concerning how these fetuses with multiple weaknesses should be delivered. Although, a systematic abdominal approach has no scientific basis, there are cases where the caesarean is chosen because of other factors associated to prematurity such as any maternal or fetal indication to terminate the pregnancy while labour induction remains impossible. However, in case of breech presentation, which is often delivered by caesarean, the literature does recommend neither the vaginal nor the abdominal approach. Caesarean in case of prematurity is more difficult because of the absence of any inferior segment and implies making a large incision so as to easily extract these weak fetuses. Increased maternal morbidity related to preterm caesarean sections has been reported through out literature. The viability gestational age limit represents a confounding factor in most studies since caesarean is rarely chosen for these fetuses because of a very low expected survival rate, while it is probably in this situation that the abdominal approach could provide a real benefit. Larger studies are required to show potential advantages. Systematic use of episiotomies or instrumental deliveries in case of vaginal births is not recommended in case of prematurity. Protecting the fetal head with spatulas still requires further evaluations.