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Robin A, Eyraud JL, Catalan C, Aubard Y, Coste Mazeau P. [Impact of a service protocol on the practice of vaginal delivery of breech presentations at term]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:45-52. [PMID: 34530145 DOI: 10.1016/j.gofs.2021.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The delivery of breech presentations remains controversial. Our study analysed the impact of a service protocol on the proportion of planned vaginal delivery and its success. Immediate neonatal morbidity and factors that may influence the success of vaginal delivery were studied. METHODS Retrospective study, between 2009 and 2020 at the CHRU of Limoges, type 3 maternity hospital, on patients with a breech foetus at term. The proportion of planned vaginal delivery and the rate of effective vaginal delivery were compared before/after 2015. Neonatal morbidity was compared for planned vaginal delivery and planned cesarean delivery groups. RESULTS We included 923 patients. The rate of planned vaginal delivery was significantly higher after 2015 from 5.2% to 19% (P<0.001), with a success rate increasing from 60% to 82.1% (P=0.06). The rate of vaginal breech deliveries significantly increased from 3.8% to 17% (P<0.001). We found significantly more newborns with moderate acidosis when a vaginal delivery was attempted (P<0.001). The success of vaginal delivery was correlated to the Magnin index (P=0.044), to gestational age (P=0.037), and to multiparity (OR 3.78 95% CI [1.42-10.03] P=0.006). CONCLUSION Our study demonstrates the benefits of setting up a service protocol for the practice of breech vaginal delivery.
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Affiliation(s)
- A Robin
- Service de gynécologie obstétrique, hôpital Mère-Enfant, CHRU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - J-L Eyraud
- Service de gynécologie obstétrique, hôpital Mère-Enfant, CHRU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - C Catalan
- Service de gynécologie obstétrique, hôpital Mère-Enfant, CHRU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - Y Aubard
- Service de gynécologie obstétrique, hôpital Mère-Enfant, CHRU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France
| | - P Coste Mazeau
- Service de gynécologie obstétrique, hôpital Mère-Enfant, CHRU de Limoges, 8, avenue Dominique-Larrey, 87000 Limoges, France; Inserm U1092, centre de biologie et de recherche en santé, université de Limoges, CHRU de Limoges, 2, rue du Pr Bernard Descottes, 87000 Limoges, France.
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Asymmetric pelvis and term breech presentation: is planned vaginal delivery still a safe option? Arch Gynecol Obstet 2021; 304:919-927. [PMID: 33791843 DOI: 10.1007/s00404-021-06036-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To evaluate the obstetrical prognosis of term breech delivery in case of asymmetric pelvis. METHODS An observational, comparative, retrospective, bi-centric study of 559 patients who had a computer tomography pelvimetry prior to delivery of a term breech presentation was conducted between August 2013 and August 2019. Patients with an attempted vaginal delivery were divided into two groups: a group of asymmetric pelvis (AP) when the difference between the lengths of both oblique diameters was ≥ 1 cm and a group of symmetric pelvis (SP) when the two oblique diameters differed by < 1 cm. The primary outcome was the rate of vaginal delivery. Secondary outcomes were a composite variable of neonatal and maternal morbidity and mortality. RESULTS Of the 370 patients who attempted a vaginal breech delivery, 8% (n = 29) had an AP and 92% (n = 341) had a SP. In the AP group, the vaginal delivery rate was higher (93% versus 78%, p = 0.05). There was no statistically significant difference in neonatal (3% versus 1% in the AP and SP groups, respectively, p = 0.4) and maternal (17% versus 23% in the AP and SP groups, respectively, p = 0.5) morbidity and mortality. CONCLUSION When a pelvimetry is performed before an attempt of vaginal breech delivery, a difference of less than two centimetres between both oblique diameters does not seem to reduce the rate of vaginal birth and is not an indication for an elective caesarean section.
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Azria É. [Breech Presentation: CNGOF Guidelines for Clinical Practice - Case Selection for Trial of Labour]. ACTA ACUST UNITED AC 2019; 48:120-131. [PMID: 31678509 DOI: 10.1016/j.gofs.2019.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The objective of this chapter is to examine on the basis of the knowledge currently available the criteria available before labour for selecting women who would be eligible for trial of vaginal delivery. METHODOLOGY Bibliographical research in French and English using the Medline and Cochrane databases between 1980 and 2019 and the recommendations of international societies. RESULTS It is recommended to offer women who wish to attempt a vaginal delivery at term a pelvimetry to decide with them on their mode of delivery (Grade C). The pelvimetric standards used at the time of the PREMODA study were anteroposterior diameter of inlet≥105mm, a transverse diameter of inlet≥120mm, a transverse interspinous diameter≥100mm. However, since there is no evidence about which pelvic measures to use, nor any evidence to set decision-making thresholds other than those set in published studies, the selected decision-making thresholds can be adjusted according to gestational age at delivery or fetal biometrics (Professional consensus). There is no argument for recommending the practice of pelvimetry in the case of delivery before 37 weeks gestational age (Professional consensus) and in the case of breech presentation discovered at the time of beginning of labour, the absence of pelvimetry alone does not contraindicate the attempt of vaginal delivery (Professional consensus). There is insufficient data to recommend the systematic use of fetal weight estimation and/or biparietal diameter measurement as acceptance criteria for a vaginal delivery attempt. In the event of a known fetal weight estimation before birth greater than 3800g, a cesarean section is to be preferred (Professional consensus). The breech presentation is not in itself a contraindication to an attempt of vaginal delivery for a small fetus for gestational age (Professional consensus). The presentation of the non-frank breech is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus). In the case of premature breech delivery, current data do not allow to recommend one delivery route over another (Professional consensus). It is recommended to check the absence of hyperextension of the fetal head by ultrasound before an attempt of vaginal delivery (Professional consensus) and to prefer a cesarean section if such a position is found (Professional consensus). It is not recommended to propose a caesarean section with the sole reason of nulliparity (Grade C). The history of cesarean section is not in itself a contraindication to an attempt of vaginal delivery in the case of fetal breech presentation (Professional consensus). Premature rupture of the membranes is not in itself a contraindication to an attempt of vaginal delivery (Professional consensus). CONCLUSION A number of the factors analyzed in this chapter are to be incorporated into the decision-making process in order to choose with the woman whose fetus is in breech presentation the delivery route.
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Affiliation(s)
- É Azria
- Maternité Notre-Dame-de-Bon-Secours, groupe hospitalier Paris Saint-Joseph, DHU risques et grossesse, 185, rue Raymond-Losserand, 75674 Paris cedex 14, France; Inserm UMR 1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), centre de recherche épidémiologie et statistique Sorbonne Paris Cité, 75000 Paris, France; Université de Paris, 75000 Paris, France.
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Batrak AS, Khodasevich LS. [Water aerobics as a means for the prenatal correction in the case of breech presentation of the fetus]. VOPROSY KURORTOLOGII, FIZIOTERAPII, I LECHEBNOI FIZICHESKOI KULTURY 2019; 96:30-36. [PMID: 30724879 DOI: 10.17116/kurort20199601130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND The delivery of the fetus in breech presentation remains one of the most serious challenge for obstetricians. In the cases of pregnancy of more than 29 weeks, it is recommended to carry out the activities aimed at translating breech presentation into cephalic presentation by means of the external preventive rotation of the fetus to the head with the use various complexes of gymnastic exercises as well as other methods applied for the correction of the abnormal fetal presentation including water aerobics. AIM The objective of the present study was to evaluate the effectiveness of the method for the prenatal correction of the pathological presentation of the fetus based on the use of the water aerobics procedures. MATERIAL AND METHODS The study included 100 women at the age from 21 to 38 years presenting with the purely gluteal presentation of the fetus in 83 cases, the transverse presentation in 14 cases, the footling presentation in 2 cases, and the slanting presentation in 1 one case. To prepare women for the childbirth at the direction of the attending doctor and under the guidance of an instructor a complex of water aerobics exercises was employed. RESULTS The successful prenatal correction of fetal presentation with the use of water aerobics exercises was achieved in 83 cases. In these women, pregnancy ended in the delivery through the natural birth canal. In 17 cases, antenatal correction proved inefficient which was regarded as the indication for the planned operation of cesarean section. Fetal turnaround occurred after 2-3 sessions of water aerobics in 66.3% of the women, with the gestational age at the time of the version being 32-33 weeks in 81.9% of the cases. CONCLUSIONS Our experience of the work with pregnant women gives evidence of the high effectiveness of corrective water aerobics and allows to recommend the performance of external cephalic version with the use of this physiotherapeutic procedure for the application in the clinical practice.
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Affiliation(s)
- A S Batrak
- Research Centre of Balneotherapy and Rehabilitation - the branch of the North-Caucasian Federal Research and Clinical Centre, Russian Federal Medico-Biological Agency, Sochi, Russia
| | - L S Khodasevich
- Research Centre of Balneotherapy and Rehabilitation - the branch of the North-Caucasian Federal Research and Clinical Centre, Russian Federal Medico-Biological Agency, Sochi, Russia; Sochi State University, Sochi, Russia
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Breton A, Gueudry P, Branger B, Le Baccon FA, Thubert T, Arthuis C, Winer N, Dochez V. [Comparison of obstetric prognosis of attempts of breech delivery: Spontaneous labor versus induced labor]. ACTA ACUST UNITED AC 2018; 46:632-638. [PMID: 30170864 DOI: 10.1016/j.gofs.2018.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Delivery mode in breech presentation (BP) is often controversial. Spontaneous labor, when vaginal birth seems safe, allows to better estimate uterus contractility, fetus' accommodation to maternal pelvis and optimize monitoring with a partograph. Induced labor in BP was usually contra-indicated. Lack of strong scientific evidence on this matter has permitted a progressive and careful evolution in obstetrical management, with the introduction of induced labor in BP. The aim of our study is to compare vaginal birth rates when labor is induced versus when spontaneous in BP. Maternal and fetal morbidity and mortality parameters were also evaluated. METHODS In this retrospective study were included 206 patients carrying fetuses in BP, between June 2012 and June 2017. 182 of them had spontaneous labor and 24 experienced induced labor. Inclusion criteria were singleton pregnancy, BP after 34 weeks of gestation and vaginal delivery authorized by a senior obstetrician. Multiple pregnancy, birth before 34 weeks of gestation, uterine scar, planned caesarian section for BP, intra-uterine fetal death and medical termination of pregnancy were excluded. Induction of labor was performed for medical reason on a favorable cervix. RESULTS There was no significant difference in cesarean section rates between the two "induced" and "spontaneous" labor groups in BP (OR=1.69 [CI95%: 0.71-4.04]). We observed no difference between the two groups in neither perineum trauma nor post-partum hemorrhage. No difference was found between the two groups in rates of Apgar score<7 5minutes after birth, neonatal transfer, fetal trauma and pH at birth. CONCLUSION Despite our small population, it seems acceptable to propose induced labor for medical reason if cervix is favorable in BP if a protocol is available stating acceptability criteria for vaginal birth. It can avoid unnecessary caesarian section and allow better obstetrical outcome. It would be interesting to study fetal and maternal morbidity and mortality criteria in induced labor versus planned cesarean section when patients could be eligible for induced labor in BP.
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Affiliation(s)
- A Breton
- Service de gynécologie-obstétrique, hôpital mère-enfant-maternité, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - P Gueudry
- Service de gynécologie-obstétrique, hôpital mère-enfant-maternité, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - B Branger
- Réseau sécurité naissance des pays de la Loire, 44000 Nantes, France
| | - F-A Le Baccon
- Service de gynécologie-obstétrique, CHU de Rennes, 35033 Rennes, France
| | - T Thubert
- Service de gynécologie-obstétrique, hôpital mère-enfant-maternité, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - C Arthuis
- Service de gynécologie-obstétrique, hôpital mère-enfant-maternité, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - N Winer
- Service de gynécologie-obstétrique, hôpital mère-enfant-maternité, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France
| | - V Dochez
- Service de gynécologie-obstétrique, hôpital mère-enfant-maternité, CHU de Nantes, 38, boulevard Jean-Monnet, 44093 Nantes cedex 1, France.
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Hejl L, Perdriolle-Galet E, Gauchotte E, Callec R, Morel O. [Vaginal delivery in case of breech presentation: Impact of a service's incentive]. ACTA ACUST UNITED AC 2017; 45:596-603. [PMID: 28964728 DOI: 10.1016/j.gofs.2017.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 08/23/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices. METHODS A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared. RESULTS One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes. CONCLUSIONS This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.
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Affiliation(s)
- L Hejl
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France.
| | - E Perdriolle-Galet
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France; Laboratoire IADI, unité Inserm U947, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France
| | - E Gauchotte
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France
| | - R Callec
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France; Laboratoire IADI, unité Inserm U947, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France
| | - O Morel
- Service d'obstétrique et médecine fœtale, maternité du centre hospitalier régional universitaire de Nancy, 10, rue du Dr-Heydenreich, Nancy, France; Laboratoire IADI, unité Inserm U947, université de Lorraine, 54500 Vandoeuvre-lès-Nancy, France; France PremUp Foundation, Paris, France
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Jarniat A, Eluard V, Martz O, Calmelet P, Calmelet A, Dellinger P, Sagot P. Induced labour at term and breech presentation: Experience of a level IIB French maternity. J Gynecol Obstet Hum Reprod 2017; 46:597-600. [DOI: 10.1016/j.jogoh.2017.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 04/09/2017] [Accepted: 04/12/2017] [Indexed: 11/28/2022]
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Lorthe E, Quere M, Sentilhes L, Delorme P, Kayem G. Incidence and risk factors of caesarean section in preterm breech births: A population-based cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 212:37-43. [DOI: 10.1016/j.ejogrb.2017.03.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 03/08/2017] [Indexed: 11/26/2022]
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Walker S, Scamell M, Parker P. Principles of physiological breech birth practice: A Delphi study. Midwifery 2016; 43:1-6. [PMID: 27788418 DOI: 10.1016/j.midw.2016.09.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 08/25/2016] [Accepted: 09/11/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE to establish a multi-professional consensus on shared principles underlying the practice of physiological breech birth. DESIGN three-round Delphi e-survey. SETTING multi-national. PARTICIPANTS a panel of thirteen obstetricians and thirteen midwives, experienced in facilitating physiological breech births in varied settings, and involving varied maternal birthing positions, and two service user representatives. METHODS an initial survey contained open-ended questions. Answers were coded and amalgamated into 60 statements in Round 1 and a further 6 statements in Round 2. Participants considered statements in the following categories: first principles (14), maternal positioning (12), birth environment (18), fetal positions (14), safe progress (8). The panel indicated the extent of their agreement using a 5-point Likert scale. The pre-determined level of consensus was 70% of respondents indicating 4 or 5 on the Likert scale (agreement or strong agreement). FINDINGS the panel indicated consensus on 37 of 66 proposed statements concerning 'Principles of Practice.' Negative data (29/66 statements) are also reported, highlighting areas of divergent opinions. The findings suggest a paradigm shift away from risk management strategies based on prediction and control, and towards facilitation strategies based on relationship and response. Upright positions are a tool and not a rule of physiological breech birth. CONCLUSION the parameters of 'normal for breech' require further exploration to support professionals working within a paradigm of complex normality. The principles articulated in this research can be used to design further research exploring the influence of physiological breech practices on neonatal and maternal outcomes, including women's experiences of maternity care.
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Affiliation(s)
- Shawn Walker
- Centre for Maternal and Child Health Research, City, University of London, Northampton Square, London EC1V 0HB, UK.
| | - Mandie Scamell
- Centre for Maternal and Child Health Research, City, University of London, Northampton Square, London EC1V 0HB, UK.
| | - Pam Parker
- Department for Learning Enhancement and Development, City, University of London, Northampton Square, London EC1V 0HB, UK.
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Bruey N, Reinbold D, Creveuil C, Dreyfus M. Sièges prématurés avant 35 semaines d’aménorrhée : quelle influence de la voie d’accouchement sur l’état néonatal ? ACTA ACUST UNITED AC 2015; 43:699-704. [DOI: 10.1016/j.gyobfe.2015.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Indexed: 11/27/2022]
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Sataf R, Gauchotte E, Muhlstein J, Bernard C, Gauchotte G, Morel O. Enquête sur la pratique de la radiopelvimétrie dans les maternités de l’inter-région Nord-Est. ACTA ACUST UNITED AC 2015; 44:252-7. [DOI: 10.1016/j.jgyn.2014.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 04/15/2014] [Accepted: 04/25/2014] [Indexed: 11/24/2022]
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Ortega Marcilla S, Royo Arilla B, Tejero Cabrejas E, Savirón Cornudella R, Rodriguez Solanilla B, Castán Mateo S, Campillos Maza J. Resultados perinatales en 492 presentaciones podálicas: cesárea vs. parto vaginal. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2014. [DOI: 10.1016/j.gine.2012.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Marzouk P, Arnaud E, Oury JF, Sibony O. Induction du travail et présentation du siège : expérience de la maternité de l’hôpital Robert-Debré, Paris. ACTA ACUST UNITED AC 2011; 40:668-74. [DOI: 10.1016/j.jgyn.2011.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2011] [Revised: 03/18/2011] [Accepted: 03/21/2011] [Indexed: 11/27/2022]
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Evaluation of a decision protocol for type of delivery of infants in breech presentation at term. Eur J Obstet Gynecol Reprod Biol 2011; 158:194-8. [DOI: 10.1016/j.ejogrb.2011.05.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 04/08/2011] [Accepted: 05/05/2011] [Indexed: 11/18/2022]
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Accouchement du siège par voie basse : l’expérience des internes en gynécologie obstétrique français. ACTA ACUST UNITED AC 2010; 39:144-50. [DOI: 10.1016/j.jgyn.2009.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Revised: 10/22/2009] [Accepted: 10/27/2009] [Indexed: 11/19/2022]
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