Folic acid supplementation use during the peri-conceptional period among professionals of a hospital in France

Folic acid insufficiency is an important risk factor for congenital neural tube defects. Despite recommendations and national campaigns, the proportion of women taking folic acid in the peri-conceptional period remains insufficient worldwide. We describe in this study the proportion of peri-conceptional folic acid supplementation use and its determinants among a population of hospital workers during the course of a prevention campaign. We performed a single-center cross sectional study in a university hospital in France. Data were collected during 2 months in 2019 by an online questionnaire sent to all professionals. We collected information about folic acid supplementation use, its modalities (form, period, frequency and dosage) and reason for initiating or not supplementation. Response rate was 11.4 % (n = 1,075/9,447). Among the 748 women who reported at least one pregnancy, 72.7 % (95 % CI: 69.4-76.0 %) reported taking folic acid during their last pregnancy. Main reason for initiating supplementation was information given by a health professional (87.8 %), especially by gynaecologists-obstetricians. Principal factors associated with folic acid supplementation use were age between 25 and 35 years, high level of education and recent pregnancy. Folic acid supplementation use is still not systematic before and during pregnancy, even among health professionals. There is a case for mandatory folic acid fortification for the French general population.

Women satisfaction on choosing the cervical ripening method: Oral misoprostol versus balloon catheter

Objective

Induction of labor concerns about 29 % of women in Unites States and 33 % in Europe. Among the various methods for cervical ripening, the efficacy and safety profiles of oral misoprostol and balloon catheter are comparable, but data in the literature on maternal satisfaction during induction of labor are few. The objective of this study was to assess the satisfaction of women who chose the method of cervical ripening, i.e. either balloon catheter or oral misoprostol, for induction of labor.

Study design

This retrospective study asked women who had undergone induction of labor between February 1, 2020 and February 28, 2021. After receiving verbal and written information, the choice of method between oral misoprostol and balloon catheter was left to the patient's free appreciation. Satisfaction was assessed by means of a questionnaire distributed to all women during their stay in the maternity unit. The principal assessment criterion was based on women' inclination to choose the same cervical ripening method if induction of labor were to prove necessary in a future pregnancy, and their willingness to recommend this method to a friend. Univariate analyses were conducted using Student's t-test, Chi-2 test or Fisher's exact test.

Results

On 575 women eligible for analysis, 365 (63.5 %) of these women replied to the satisfaction questionnaire. Of this number, 236 (64.7 %) chose cervical ripening by balloon catheter, and 129 (35.3 %) by oral misoprostol. No significant difference was found between the two groups: 68.2 % of women in the balloon catheter group would opt for the same method of cervical ripening if it proved necessary in a future pregnancy and 64.7% would recommend it to a pregnant friend, versus 65.9 % and 63.6 % in the oral misoprostol group, respectively. Women were overall pleased to be able to choose their method of cervical ripening: 90.5 % of patients in the balloon catheter group and 95.3 % in the oral misoprostol group.

Conclusions

When women choose the method of cervical ripening, satisfaction is overall good, irrespective of the method, whether by balloon catheter or misoprostol.

Maternal occupational exposure to organic solvents and intrauterine growth in the ELFE cohort

BACKGROUND

In developed countries, about 15% of women are occupationally exposed to solvents. Associations between this maternal occupational exposure and intrauterine fetal growth are inconsistent, but almost no existing study has investigated this relation by solvent family (oxygenated, petroleum, and chlorinated), although they may affect fetal growth differently.

OBJECTIVES

To investigate the relations between maternal occupational solvent exposure, by solvent family, and the risk of neonates born small for gestational age (SGA), or with low birthweight, or with small head circumference (HC).

METHODS

Among the 18,040 women enrolled in the Elfe rather than included in the Elfe birth cohort, we included 13,026 women who worked during pregnancy (72% of the cohort). Information about maternal occupations and industrial activities during pregnancy was collected by questionnaire at the maternity ward, and completed at 2-month when necessary. Using Matgéné job-exposure matrices, we assessed maternal occupational exposure to solvents. Logistic and multiple linear regressions were used to assess the association between maternal occupational solvent exposure and SGA status, birth weight, and HC. Analyses were conducted for exposure during pregnancy and also stratified by the trimester that pregnancy leave began.

RESULTS

We observed a higher risk of SGA newborns among mothers occupationally exposed during pregnancy to petroleum solvents (OR_adjusted = 1.26; 95%CI: 1.01 to 1.57). Among women working until the third trimester of pregnancy, we observed a higher risk of SGA newborns to those occupationally exposed to oxygenated solvents (OR_adjusted = 1.75; 95%CI: 1.11 to 2.75), a significantly lower birthweight for infants of mothers exposed to petroleum solvents (β_adjusted = -47.37 g; -89.33 to -5.42), and a lower HC among newborns of those occupationally exposed to oxygenated solvents (β_adjusted = -0.28; -0.49 to -0.07) and to chlorinated solvents (β_adjusted = -0.29; -0.53 to -0.05).

DISCUSSION

Our results suggest that maternal occupational solvent exposure may influence fetal growth, especially exposure into the third trimester of pregnancy.

Predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery: A prospective cohort study

OBJECTIVE

The objective was to assess the predictive value of head-perineum distance measured at the initiation of the active second stage of labor on the mode of delivery.

MATERIAL AND METHODS

It was a prospective cohort study in an academic Hospital of Rennes, France, from July 1, 2020 to April 4, 2021 including 286 full-term parturients who gave birth to a newborn in cephalic presentation. A double-blind ultrasound measurement of the head-perineum distance was performed during the second phase of labor within five minutes after the onset of pushing efforts. The primary outcome was the mode of delivery (spontaneous vaginal delivery versus instrumental vaginal delivery or cesarean section). We performed a multivariate analysis to determine the predictive value of the head-perineum distance by adjusting on potential confounders.

RESULTS

Overall, 199 patients delivered by spontaneous vaginal delivery, 80 by instrumental vaginal delivery, and seven by cesarean section. The head-perineum distance measured at the beginning of pushing efforts was predictive of the mode of delivery with a threshold at 44 mm (crude: sensitivity = 56.8 % and specificity = 79.3 %; adjusted: sensitivity = 79.4 % and specificity = 87.4 %). The risk of medical intervention was higher when the head-perineum distance is>44 mm with an adjusted OR of 2.78 [1.38; 5.76].

CONCLUSION

The head-perineum distance measured at the initiation of the active second stage of labor is predictive of the mode of delivery. Head-perineum distance below 44 mm predicts a vaginal delivery with the best diagnostic performance, and optimizes the time to start pushing efforts.

Prediction of successful labor induction with very unfavorable cervix: A comparison of six scores

OBJECTIVE

To compare the ability of six scoring systems to predict successful labor induction with cervical ripening among women with a Bishop score <3.

METHODS

Secondary analysis of data from a prospective, multicenter observational Methods of Induction of Labor and Perinatal Outcomes (MEDIP) cohort study in 94 obstetrical French units. We included women with a Bishop score <3 before cervical ripening. We compared six scores: Bishop, simplified Bishop, modified Bishop, simplified Bishop including parity, Hughey, and Levine scores. Vaginal delivery defined successful labor induction. The ability of each score to predict successful labor induction was evaluated by comparing their area under the curve (AUC).

RESULTS

Among the 600 eligible women in this study, 408 (68%) delivered vaginally. Body mass index (calculated as weight in kilograms divided by the square of height in meters; mean ± standard deviation [SD]: 24.7 ± 5.5 vs 26.0 ± 5.7; P = 0.01) and nulliparity (48.8% vs 85.4%; P < 0.001) were lower in the successful induction group, whereas height was higher (mean ± SD: 165.3 ± 6.0 cm vs 163.7 ± 6.0 cm; P = 0.002). The simplified Bishop including parity, Hughey, and Levine scores had the highest AUC (0.70, 95% confidence interval [CI] 0.65-0.73; 0.68, 95% CI 0.64-0.74; and 0.69, 95% CI 0.65-0.74, respectively).

CONCLUSION

In women with a very unfavorable cervix, scores that include parity predict successful labor induction more accurately, such as simplified Bishop including parity, Hughey, or Levine scores.

A Multicenter, Investigator-Blinded, Randomized Controlled Trial to Assess the Efficacy of Calf Neuromuscular Electrical Stimulation Program on Walking Performance in Peripheral Artery Disease: The ELECTRO-PAD Study Protocol

This paper describes a currently on-going multicenter, randomized controlled trial designed to assess the efficacy of calf neuromuscular electrical stimulation (NMES) on changes in maximal walking distance in people with lower extremity peripheral artery disease (PAD), compared with a non-intervention control-group. This study (NCT03795103) encompasses five participating centers in France. PAD participants with a predominant claudication at the calf level and a maximal treadmill walking distance ≤300 m are randomized into one of the two groups: NMES group or Control group. The NMES program consists of a 12-week program of electrical stimulations at the calf-muscle level. The primary outcome of the study is the change in maximal treadmill walking distance at 12 weeks. Main secondary outcomes include changes in the pain-free treadmill walking distance; 6 min total walking distance; global positioning system (GPS)-measured outdoor walking capacity; daily physical activity level by accelerometry; self-reported walking impairment; self-reported quality of life; ankle-brachial index; and skin microvascular function, both at the forearm and calf levels. Recruitment started in September 2019 and data collection is expected to end in November 2022.

Methods of induction of labor and women's experience: a population-based cohort study with mediation analyses

BACKGROUND

Negative childbirth experience may affect mother wellbeing and health. However, it is rarely evaluated in studies comparing methods of induction of labor (IoL).

AIM

To compare women's experience of IoL according to the method, considering the mediating role of interventions and complications of delivery.

METHODS

We used data from the MEDIP prospective population-based cohort, including all women with IoL during one month in seven French perinatal networks. The experience of IoL, assessed at 2 months postpartum, was first compared between cervical ripening and oxytocin, and secondarily between different cervical ripening methods. Mediation analyses were used to measure the direct and indirect effects of cervical ripening on maternal experience, through delivery with interventions or complications.

FINDINGS

The response rate was 47.8% (n = 1453/3042). Compared with oxytocin (n = 541), cervical ripening (n = 910) was associated less often with feelings that labor went 'as expected' (adjusted risk ratio for the direct effect 0.78, 95%CI [0.70-0.88]), length of labor was 'acceptable' (0.76[0.71-0.82]), 'vaginal discomfort' was absent (0.77[0.69-0.85]) and with lower global satisfaction (0.90[0.84-0.96]). Interventions and complications mediated between 6 and 35% of the total effect of cervical ripening on maternal experience. Compared to the dinoprostone insert, maternal experience was not significantly different with the other prostaglandins. The balloon catheter was associated with less pain.

DISCUSSION

Cervical ripening was associated with a less positive experience of childbirth, whatever the method, only partly explained by interventions and complications of delivery.

CONCLUSION

Counselling and support of women requiring cervical ripening might be enhanced to improve the experience of IoL.

Prolongation of active second stage of labor: Associated factors and perinatal outcomes

BACKGROUND

Current data does not allow to define a reasonable threshold of duration of active second stage (ASS) of labor beyond which a medical intervention should be considered. Primary objective was to analyse perinatal outcomes associated with prolonged ASS beyond 45 min. Secondarily, we analysed associated maternal, gestational, labor and delivery characteristics associated with prolonged ASS.

METHODS

We performed a monocentric retrospective study among women with vaginal delivery, a term singleton cephalic fetus, without history of cesarean section. We compared women with active second stage of labor longer than 45 min (ASS ≥45 min, group A) and women with instrumental vaginal delivery (IVD) only for failure to progress (FtP) before 45 min of pushing (group B). Primary outcome was postpartum hemorrhage (PPH). Maternal and neonatal outcomes associated with ASS ≥ 45 min were assessed with multivariable logistic regression models.

RESULTS

Prolonged ASS ≥45 min (group A, N=177) was associated with lower rate of persistent occiput posterior position (1.7 vs 9.5%, p<0.01) and of non-engaged presentation when expulsive efforts started (10.7 vs 27.4%, p<0.01), compared to IVD for FtP <45 min (group B, N=84). In group A, 52% of women had instrumental delivery. Prolonged active second stage was independently associated with lower odds of episiotomy (38.4 vs 61.9%, AOR(95%CI)=0.43[0.24-0.78]) and was not associated with PPH (5.1 vs 5.9%, AOR=1.01[0.28-3.68]), pH<7.20, 5-min Apgar score < 7 (20.2 vs 15.9%, AOR=2.00[0.89-4.48]), lactates > 6 (23.0 vs 24.3, AOR=1.45[0.68-3.07]) or transfer to neonatal intensive care unit (6.2 vs 2.4%, AOR=4.71[0.76-29.08].

DISCUSSION

Extending the duration of active second stage of labor beyond 45 min seems reasonable under rigorous surveillance of maternal and fetal wellbeing.

Evaluation of a policy of restrictive episiotomy on the incidence of perineal tears among women with spontaneous vaginal delivery: A ten-year retrospective study

INTRODUCTION

Routine episiotomy is no longer recommended to limit obstetrical anal sphincter injuries (OASIs). We aimed to evaluate the effect of a restrictive policy of episiotomy on the risk of OASIs during spontaneous vaginal deliveries.

MATERIAL AND METHODS

We performed a retrospective single-center observational study among women with a term singleton cephalic fetus, with spontaneous vaginal delivery. The occurrence of episiotomy, intact perineum, first, second, third or fourth-degree (OASIs) perineal tears were compared before (period A, from 01/01/2006 to 12/31/2008) and after (period B, from 01/01/2012 to 12/31/2016) implementation of the restrictive policy. Odds of perineal tear were estimated using multivariable logistic regression models, stratified by parity.

RESULTS

From 2006-2016, the rate of episiotomy decreased, from 14.9 % (n/N=200/1141) to 4.7 % (94/1912). In period B (N=8984) vs A (N=8984), the rates of episiotomy were, 12.9 vs 26.6 % for nulliparas (p<0.01) and 2.3 vs 6.8 % for multiparas (p<0.01). Odds of OASIs were not different in period B vs A, both for nulliparas (0.9 vs 0.8 %, AOR=0.88(0.38-2.05)) and multiparas (0.4 vs 0.2 %, AOR=2.28(0.63-8.29). Odds of second-degree tear were higher in period B vs A, both for nulliparas (39.8 vs 17.4 %, AOR=2.55(2.11-3.08) and multiparas (26.2 vs 12.8 %, AOR=2.26(1.95-2.66)); and odds of intact perineum were lower (for nulliparas, 15.8 vs 24.9 %, AOR=0.61(0.42-0.90) and for multiparas, 47.1 vs 56.0 %, AOR=0.61(0.49-0.76)). No difference was observed for first-degree tears.

CONCLUSION

The progressive implementation of a restrictive policy of episiotomy during spontaneous vaginal delivery was not associated with an increased risk of OASIs over a ten-year period.

Evaluation of the implementation of a protocol for the restrictive use of oxytocin during spontaneous labor

INTRODUCTION

Use of oxytocin is associated with uterine hyperstimulation and postpartum hemorrhage with a dose-dependent effect. We aimed to evaluate the effect of the implementation of a protocol for the restrictive use of oxytocin during spontaneous labor on obstetric and neonatal outcomes.

MATERIAL AND METHODS

We performed an observational before-and-after study among 2174 women in spontaneous labor with a term singleton cephalic fetus. Obstetric and neonatal outcomes were compared according to the period, before (period A) and after (period B) the implementation of a protocol for the restrictive use of oxytocin.

RESULTS

1235 women were included in period A and 939 in period B. Compared to period A, the use of oxytocin during period B was significantly lower (45.5 vs. 35.1%, p<0.001) in both nulliparous (61.2 vs 54.6%, p=0.04) and multiparous women (34.0 vs. 21.1%, p<0.001). Labor was significantly longer in period B, both in nulliparous (6.7 vs. 7.9 h, p<0.01) and multiparous women (4.1 vs. 4.5 h, p<0.01). A lower frequency of uterine hyperstimulation (6.6 vs. 2.7%, p=0.01) was observed in period B. The odds of instrumental and cesarean delivery were not different between the periods (respectively adjusted odds ratio (AOR), 95% confidence interval (CI), 1.1(0.8-1.4); 1.2(0.8-1.8)) including for nulliparous women (respectively, 1.3(0.9-1.7); 1.3(0.8-1.9)).

DISCUSSION

Reducing the use of oxytocin during spontaneous labor through the implementation of a protocol may reduce the iatrogenic effects without increasing the risk of caesarean section but this implies longer duration of labor.

Target populations to reduce cesarean rates after induced labor: A national population-based cohort study

INTRODUCTION

Great variations in cesarean rates after induction of labor exist and reasons for these disparities remain unclear. They may be explained by individual characteristics or obstetric practices. Ten-group classification systems have proved their utility to monitor cesarean rates in general population. We aimed to identify groups of women that account for most cesareans after induction of labor using the Nippita reproducible 10-group classification, specifically designed for induced population.

MATERIAL AND METHODS

A prospective population-based cohort study was performed in 94 French maternity units, including 3042 women undergoing induction of labor. Women were sorted according to 10 mutually exclusive groups based on parity, weeks of gestation, number of fetuses, fetal presentation and previous cesarean delivery. Relative size, cesarean delivery rate and contribution to the overall cesarean rate were described for each group. Cesarean rates were compared according to the Bishop score at the onset of labor induction. Indications for cesarean delivery were also described in the groups that contributed most to the overall cesarean rate. The MEDIP protocol was registered in ClinicalTrial (NCT02477085).

RESULTS

The overall cesarean rate was 21.0% among this population of induced women. Nulliparous women with a term singleton cephalic fetus (groups 1, 2 and 3; at 37-38, 39-40 and ≥41 weeks of gestation, respectively) accounted for two-thirds of the overall cesarean rate because they were the largest group (relative size of 10.6, 16.6 and 18.1%, respectively) and had higher cesarean rates (27.2, 30.9 and 33.0%, respectively). When the Bishop score was <6 (n = 2270/3042), cesarean delivery rates were higher (24.1 vs 10.7% if Bishop score ≥6, P < 0.01), in particular for group 1 (29.1 vs 12.5%, P = 0.02), and group 2 (33.3 vs 19.3%, P = 0.01). In groups 1, 2 and 3, which contributed most to the overall cesarean rate, a significant part of the cesareans were performed before 6 cm of cervical dilation for dystocia only (40.0, 16.7 and 17.6%, respectively).

CONCLUSIONS

Nulliparous women with a term singleton cephalic fetus and an unfavorable cervix represent the population to target for auditing induction practices. Specific actions could be implemented among this population to weigh the benefits and risks of induction and improve the management of labor induction.

Comparison of effectiveness and safety of cervical ripening methods for induction of labour: A population-based study using coarsened exact matching

BACKGROUND

There is no consensus about the ideal cervical ripening method to use for induction of labour.

OBJECTIVE

To compare in current practice the effectiveness and safety of four cervical ripening methods.

METHODS

We performed a matched comparative study using data from the MEDIP prospective population-based cohort conducted during one month in 2015 in all maternity units of seven French perinatal networks (3042 consecutive women with a live fetus and induction of labour). We analysed 1671 women with singleton cephalic fetus, unscarred uterus, and bishop score <7. Dinoprostone vaginal pessary (reference) was compared to dinoprostone vaginal gel, misoprostol vaginal tablet, and balloon catheter. Effectiveness outcomes were the need for more than one induction agent, oxytocin use, failure to achieve vaginal delivery within 24 hours (VD < 24 hours), and caesarean delivery. Safety outcomes were meconium-stained amniotic fluid, uterine hyperstimulation, NICU admission, and post-partum haemorrhage. Coarsened exact matching was used to balance confounders among the groups. Outcomes were compared using multivariable logistic regression models.

RESULTS

Compared to the dinoprostone pessary (N = 1142, 68.3%), dinoprostone gel (N = 335, 20.1%) was associated with less failure to achieve VD < 24 hours (adjusted OR 0.66, 95% CI 0.47, 0.91). Misoprostol (N = 103, 6.2%) was associated with less need of more than one induction agent (aOR 0.56, 95% CI 0.34, 0.92) and less oxytocin use (aOR 0.60, 95% CI 0.37, 0.99). The balloon catheter (N = 91, 5.4%) was associated with more failure to achieve VD < 24 hours (aOR 2.62, 95% CI 1.37, 5.01), more caesarean delivery (aOR 1.84, 95% CI 1.09, 3.08), and less meconium-stained amniotic fluid (aOR 0.12, 95% CI 0.02, 0.70). Uterine hyperstimulation rates seemed lower with the balloon catheter (1.2% vs 4.2% for the pessary).

CONCLUSIONS

In current practice, no cervical ripening method appears clearly superior to the others considering all effectiveness and safety outcomes.