[The cesarean procedure: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]

OBJECTIVE

To identify procedures to reduce maternal morbidity during cesarean.

MATERIAL AND METHODS

The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane and EMBASE databases. The quality of the evidence was assessed (high, moderate, low, very low) and a (i) strong or (ii) weak recommendations or (iii) no recommendation were formulated. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations.

RESULTS

Of the 27 questions, there was agreement between the working group and the external reviewers on 26. The level of evidence of the literature was insufficient to provide a recommendation on 15 questions. Preventing hypothermia is recommended to increase maternal satisfaction and comfort (weak recommendation) and to reduce neonatal hypothermia (strong recommendation). The quality of the evidence of the literature did not allow to recommend the skin disinfectant to be used nor the relevance of a preoperative vaginal disinfection nor the choice between the use or nonuse of an indwelling bladder catheterization (if micturition takes place 1 hour before the cesarean section). The Misgav-Ladach technique or its analogues should be considered rather than the Pfannenstiel technique to reduce maternal morbidity (weak recommendation) bladder flap before uterine incision should not be performed routinely (weak recommendation), but a blunt (weak recommendation) and cephalad-caudad extension of uterine incision (weak recommendation) should be considered to reduce maternal morbidity. Antibiotic prophylaxis is recommended to reduce maternal infectious morbidity (strong recommendation) without recommendation on its type or the timing of administration (before incision or after cord clamping). The administration of carbetocin after cord clamping does not significantly decrease the incidence of blood loss>1000 ml, anemia, or blood transfusion compared with the administration of oxytocin. Thus, it is not recommended to use carbetocin rather than oxytocin in cesarean. It is recommended that systematic manual removal of the placenta not to be performed (weak recommendation). An antiemetic should be administered after cord clamping in women having a planned cesarean under locoregional anaesthesia to reduce intraoperative and postoperative nausea and vomiting (strong recommendation) with no recommendation regarding choice of use one or two antiemetics. The level of evidence of the literature was insufficient to provide any recommendation concerning single or double-layer closure of the uterine incision, or the uterine exteriorization. Closing the peritoneum (visceral or parietal) should not be considered (weak recommendation). The quality of the evidence of the literature was not sufficient to provide recommendation on systematic subcutaneous closure, including in obese or overweight patients, or the use of subcuticular suture in obese or overweight patients. The use of subcuticular suture in comparison with skin closure by staples was not considered as a recommendation due to the absence of a consensus in the external review rounds.

CONCLUSION

In case of cesarean, preventing hypothermia, administering antiemetic and antibiotic prophylaxis after cord clamping are the only strong recommendations. The Misgav-Ladach technique, the way of performing uterine incision (no systematic bladder flap, blunt cephalad-caudad extension), not performing routine manual removal of the placenta nor closure of the peritoneum are weak recommendations and may reduce maternal morbidity.

Defining Developmental-Behavioral Pediatrics

There is an insufficient number of specialty developmental-behavioral pediatrics (DBP) physicians, despite nearly 25% of children and adolescents having a developmental, learning, behavioral, or emotional problem. In the nearly 20 years since becoming a board-certified subspecialty, the definition of DBP clinical practice remains somewhat unclear. This lack of clarity likely contributes to recruitment challenges and workforce issues, and limited visibility of DBP among parents, other professionals, payors, and administrators. Defining DBP is therefore an important step in the survival and growth of the field. In this paper, we describe the methodology used to develop this definition along with the origins of DBP, the persistent challenges to defining its scope, what training in DBP involves, and what distinguishes DBP from other overlapping fields of medicine. We propose the following definition of DBP: developmental-behavioral pediatrics (DBP) is a board-certified, medical subspecialty that cares for children with complex and severe DBP problems by recognizing the multifaceted influences on the development and behavior of children and addressing them through systems-based practice and a neurodevelopmental, strength-based approach that optimizes functioning. Developmental behavioral pediatricians care for children from birth through young adulthood along a continuum including those suspected of, at risk for, or known to have developmental and behavioral disorders.

Perinatal outcome after planned vaginal delivery in monochorionic compared with dichorionic twin pregnancy

OBJECTIVE

To assess, according to chorionicity, the perinatal outcome of twin pregnancy in which vaginal delivery is planned.

METHODS

JUMODA (JUmeaux MODe d'Accouchement) was a national prospective population-based cohort study of twin pregnancies, delivered in 176 maternity units in France, from February 2014 to March 2015. In this planned secondary analysis, we assessed, according to chorionicity, the perinatal outcome of twin pregnancies, in which vaginal delivery was planned, that delivered at or after 32 weeks of gestation with the first twin in cephalic presentation. In order to select a population with well-recognized indications for planned vaginal delivery, we applied the same exclusion criteria as those in the Twin Birth Study, an international randomized trial. Monochorionic twin pregnancies with twin-to-twin transfusion syndrome or twin anemia-polycythemia sequence were defined as complicated and were excluded. The primary outcome was a composite of intrapartum mortality and neonatal morbidity and mortality. Multivariable logistic regression models were used to control for potential confounders. Subgroup analyses were conducted according to birth order (first or second twin) and gestational age at delivery (< 37 or ≥ 37 weeks of gestation).

RESULTS

Among 3873 twin pregnancies, in which vaginal delivery was planned, that delivered at ≥ 32 weeks' gestation with the first twin in cephalic presentation, meeting the inclusion criteria of the Twin Birth Study, 729 (18.8%) were uncomplicated monochorionic twin pregnancies and 3144 (81.2%) were dichorionic twin pregnancies. The rate of composite intrapartum mortality and neonatal morbidity and mortality did not differ between uncomplicated monochorionic (27/1458 (1.9%)) and dichorionic (107/6288 (1.7%)) twin pregnancies when adjusting for conception by assisted reproductive technologies (adjusted relative risk, 1.07 (95% CI, 0.66-1.75)). No significant difference in the primary outcome was found between the groups on subgroup analyses according to birth order and gestational age at delivery.

CONCLUSION

When vaginal delivery is planned, and delivery occurs at ≥ 32 weeks of gestation with the first twin in cephalic presentation, uncomplicated monochorionic twin pregnancy is not associated with a higher rate of composite intrapartum mortality and neonatal morbidity and mortality compared with dichorionic twin pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Variations in the use of caesarean section: a Comparison between France and Australia

Background

There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison.

Methods

We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care.

Outcomes

Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.

[Breech Presentation: CNGOF Guidelines for Clinical Practice - Short Text]

OBJECTIVES

To determine the optimal management of singleton breech presentation.

MATERIALS AND METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

In France, 5% of women have breech deliveries (Level of Evidence [LE3]). One third of them have a planned vaginal delivery (LE3) of whom 70% deliver vaginally (LE3). External cephalic version (ECV) is associated with a reduced rate of breech presentation at birth (LE2), and with a lower rate of cesarean section (LE3) without increases in severe maternal (LE3) and perinatal morbidity (LE3). It is therefore recommended to inform women with a breech presentation at term that ECV could be attempted from 36 weeks of gestation (Professional consensus). In case of breech presentation, planned vaginal compared with planned cesarean delivery might be associated with an increased risk of composite perinatal mortality or serious neonatal morbidity (LE2). No difference has been found between planned vaginal and planned cesarean delivery for neurodevelopmental outcomes at two years (LE2), cognitive and psychomotor outcomes between 5 and 8 years (LE3), and adult intellectual performances (LE4). Short and long term maternal complications appear similar in case of planned vaginal compared with planned cesarean delivery in the absence of subsequent pregnancies. A previous cesarean delivery results for subsequent pregnancies in higher risks of uterine rupture, placenta accreta spectrum and hysterectomy (LE2). It is recommended to offer women who wish a planned vaginal delivery a pelvimetry at term (Grade C) and to check the absence of hyperextension of the fetal head by ultrasonography (Professional consensus) to plan their mode of delivery. Complete breech presentation, previous cesarean, nulliparity, term prelabor rupture of membranes do not contraindicate planned vaginal delivery (Professionnal consensus). Term breech presentation is not a contraindication to labor induction when the criteria for acceptance of vaginal delivery are met (Grade C).

CONCLUSION

In case of breech presentation at term, the risks of severe morbidity for the child and the mother are low after both planned vaginal and planned cesarean delivery. For the French College of Obstetricians and Gynecologists (CNGOF), planned vaginal delivery is a reasonable option in most cases (Professional consensus). The choice of the planned route of delivery should be shared by the woman and her caregiver, respecting the right to woman's autonomy.

[Effectiveness of preventive cervical cerclage to prevent preterm birth in women with twin gestation with obstetrical history of late pregnancy loss or preterm birth]

OBJECTIVES

Evaluate the effectiveness of preventive cervical cerclage for twin pregnancy with obstetrical history.

METHODS

Through this retrospective cohort study, subjects exposed between 2002 and 2017 were compared with unexposed ones. All patients who had twin pregnancy with at least one previous late pregnancy loss or prematurity before 34SA were included. Two groups were compared: "preventive cerclage" versus "no preventive cerclage". The outcome was the prematurity before 34 gestation weeks (GW) rate.

RESULTS

Among 1972 twin pregnancies registered between 2002 and 2017, 69 (3.5%) patients with at least one previous late pregnancy loss or prematurity before 34 GW, were part of the study. There were 20 (29.0%) women in the group "preventive cerclage" and 49 (71.0%) women in the group "no preventive cerclage". Women in the "preventive cerclage" group had poorer obstetrical history. The rate of prematurity before 34GW was not significantly different between these both groups (45.0% versus 44.9%; P=0.99, crude OR: 1.00 (0.35-2.83), adjusted OR: 1.06 (0.33-3.44)).

CONCLUSIONS

The prematurity rate before 34GW, in twin pregnancies with a previous late pregnancy loss or preterm birth, is not different with or without preventive cervical cerclage.

Effectiveness of elective cervical cerclage according to obstetric history

OBJECTIVE

To assess the effectiveness of elective history-indicated cervical cerclage according to obstetrical history.

STUDY DESIGN

We analyzed pregnancy outcome of a retrospective cohort of women who have had history-indicated McDonald's cerclage. Principal outcome was gestational age (GA) at delivery.

RESULT

Between January 2003 and December 2013, 205 women were included. We analyzed population in two risk groups: 1- Low-risk (≤2 prior preterm birth (PTB)/second trimester loss (STL), or prior success of cerclage), 2- High risk (≥3 prior PTB/STL, or prior failure of cerclage). In the high-risk group, there was a higher frequency of deliveries before 37 weeks (47.5% vs. 24.5%, P=0.001, OR=2.79, 95% CI [1.49-5.23]). Fifty percent of women (n=6/12) delivered before 37 weeks in case of three or more prior PTB/STL, and 51% (n=24/47) in case of prior failure of cervical cerclage.

CONCLUSION

Elective cervical cerclage may be indicated for women with≤2 prior PTB/STL, or prior successful cerclage. For women with≥3 prior PTB/STL, trachelorraphy or cervico-isthmic cerclage could be possible alternatives to cervical cerclage.

Trachelorraphy in cases of recurrent second trimester loss and prior failed vaginal cerclage

OBJECTIVE

To evaluate the obstetric results of trachelorraphy in the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage.

STUDY DESIGN

Data were collected retrospectively and prospectively from medical records. The analysis examined data for 18 women who underwent trachelorraphy between 2004 and 2013 at a tertiary referral unit in France. All patients in this high-risk population had a history of two or more second trimester losses, or one second trimester loss and one preterm labour, and at least one prior failed transvaginal cerclage. The main outcome measures were: livebirth rate; rate of second trimester loss; and surgical complications.

RESULTS

Twenty pregnancies were conceived in 16 patients following trachelorraphy. Three patients experienced two pregnancies. Among the 20 pregnancies, there was one case of fetal loss in the first trimester; this pregnancy was excluded from the analysis. Of the remaining 19 pregnancies, there were nine (47%) term deliveries (after 37 weeks of gestation), seven (32%) preterm deliveries and three (16%) second trimester losses. The overall fetal survival rate was 84%. Surgical outcomes were excellent, with no complications.

CONCLUSION

Trachelorraphy is a safe, reproducible, easy-to-learn procedure for the prevention of recurrent second trimester loss in cases of prior failed vaginal cerclage. The procedure has encouraging and favourable perinatal outcomes in patients with a poor obstetric history.