[Couder's maneuver. Knowledge and practices in a French university maternity hospital]

BACKGROUND

During childbirth, the performance of a systematic Couder's maneuver could be linked to a reduction in the risk of perineal tear.

OBJECTIVE

To know the practices and knowledge of childbirth professionals regarding the Couder's maneuver. To measure the effect of a training program for juniors.

MATERIALS AND METHODS

Single-center questionnaire survey of senior and junior obstetricians and midwives. Before-and-after study in juniors to evaluate maneuver training.

RESULTS

One hundred and twenty-five caregivers responded to the questionnaire: (19 physicians and 46 senior midwives; 21 residents and 39 midwifery students). Only one third of the respondents said they practiced the Couder's maneuver "always or almost always" (41/125, 32.8%) and less than one third felt "very comfortable" with the maneuver (34/125, 27.2%), with large differences according to profession and senior vs junior status. Being a doctor (vs midwife) was significantly related to systematic or frequent practice of the maneuver (70.0 vs 15.3%, ORMH=42.7 [9.4; 192.3]) as was being a senior (vs junior) (46.2 vs 18.3%, ORMH=15.9 [3.5; 72.9]). Less than half of the seniors surveyed had received education in maneuvering. Of those who did not practice the maneuver, the majority did not consider its systematic practice to be useful (19/26, 73.1%), and one third considered it potentially harmful (8/26, 30.8%). Theoretical and practical training of the juniors significantly improved their knowledge.

CONCLUSION

There are great differences in the practice of the Couder's maneuver. It deserves to be better known, practiced and evaluated.

[Use of the SBAR tool: Assessment of the value of a short training course on the quality of communication between caregivers in the short and long term]

OBJECTIVES

Communication breakdown is one of the main causes of adverse events in clinical routine. The main objective of this study was to assess whether a short training course on medical communication based on the situation-background-assessment-recommendation (SBAR) tool improved the quality of communication in clinical practice.

METHODS

Interventional study, conducted at the Jeanne de Flandre maternity unit (Lille University Hospital, France) between January 2017 and December 2019. The training sessions lasted 1 hour and consisted of a theoretical part, based on the SBAR tool, and of a practical part (video-stimulated recall and role-play case scenarios). The main outcome measure was the evaluation of the quality of the telephone calls made by a caregiver to the on-call doctor, using a questionnaire completed before (Q1) and remotely from training (Q2).

RESULTS

One hundred and twenty health professionals were trained (n=120). Following the trainings, there was an improvement in communication in the short term, whether in terms of relevance (64.9 vs. 52.6, P<0.001) or conciseness of the message (36.9 vs. 32.2, P<0.001), but also in terms of long-term in a real clinical situation (Q2: 3.9 vs. Q1: 3.0, P<0.001). Finally, 81% of participants were satisfied with the training.

CONCLUSIONS

Short training sessions on communication based on the SBAR tool appeared to improve participants' knowledge and skills in the short-term, but also in the longer term in a real clinical situation.

[Impact of a protocol based on the new national recommendations on the use of oxytocin and its maternal-fetal consequences: A single-center before/after study]

OBJECTIVE

Evaluate oxytocin use and impact on maternal and fetal morbidity before and after implementation of a protocol based on national recommendations.

MATERIALS AND METHODS

A single-center retrospective before-and-after study (Lille, France). A service protocol to harmonize the use of oxytocin was implemented in May 2017 following national recommendations. Data were collected from January to March 2016 for period 1, and from January to March 2019 for period 2. Nulliparous patients in spontaneous labor=37SA delivering a live newborn in cephalic presentation were included. The primary outcome was the use of oxytocin.

RESULTS

Five hundred eighty-seven patients were included, 302 for period 1 and 285 for period 2. The rate of oxytocin use was 48% (n=144) in 2016 versus 28% (n=79) in 2019 (P<0.001). Total labor time was significantly longer after protocol implementation (425.7min vs. 510.4min ; P<0.001). The cesarean section rate was identical between the 2 periods (7.0% vs. 6.0%; P=0.62). The rate of postpartum hemorrhage greater than 500mL was higher in period 1 (17.7% vs. 10.9%; P=0.019), as was the occurrence of a pH<7.05 (5.4% vs. 1.1%; P=0.004).

CONCLUSION

The implementation of a protocol contributed to a decrease in the use of oxytocin and thus would allow a decrease in the rate of postpartum hemorrhage and neonatal acidosis, but with an increase in the duration of labor.

Cesarean section complications according to degree of emergency during labour

OBJECTIVE

Evaluate the complications rate of cesarean section delivery based on degree of labour emergency.

STUDY DESIGN

Monocentric (Lille, France), retrospective study of all term, singleton, and cesarean deliveries during labour. Three groups were categorized based on the degree of emergency according to a color code: green (no time limit between surgical decision and birth), orange (birth within 30 min), and red (birth within 20 min). Scheduled cesareans were excluded. Complications were defined as minor/major and intra-/post-operative.

RESULTS

A total of 881 patients were included. Among these, 303 (34.5 %) were in the green group, 353 (40.1 %) in the orange group, and 225 (25.4 %) in the red group. Major intra-operative complications, mainly postpartum hemorrhage, were more frequent in the red group compared with the green group (16.9 % vs. 9.9 %, p = 0.05; OR 1.9; 95 % CI [1.1-3.1]). Among the minor complications, there was no difference on moderate postpartum hemorrhage and four times uterine artery wounds in the red group (1.7 % vs. 7.1 %, respectively; p = 0.007; OR 4.6; 95 % CI [1.6-12.6]). The overall major post-operative complication rate, mainly infectious morbidity, was 6.1 % and this was more frequent in the red group compared with the green group (12.4 % vs. 1.7 %, respectively; p < 0.0001; OR 8.5; 95 % CI [3.2-22.3]).

CONCLUSION

Pre- and post-operative complications of cesarean section delivery during labour (i.e., emergency cesarean) increase with the degree of labour emergency. It would be ideal to identify women in labour who are at increased risk of emergency cesarean earlier, so that the situation does not escalate to a red code cesarean.

Pregnancy after chemoradiotherapy in childhood: Complications and recommendations - about one case

The question of pregnancy prognosis after radio chemotherapy is unaddressed. We report here the case of three successive spontaneous pregnancies 17 years after the management of a thigh rhabdomyosarcoma treated by radiochemotherapy. In 2018 the patient aged 22 presented with a spontaneous miscarriage. In 2019, she obtained a new spontaneous pregnancy. At 21 W G, she presented with threatened late miscarriage and gave birth to a live girl who would die. Three months after delivery, she had spontaneous pregnancy. At 18 W G, emergency cervical cerclage was performed. At 35 W G the ultrasound found severe intrauterine growth retardation. Cesarean section was performed allowing the birth of a girl in good health status. Childbirth was complicated by 1L8 postpartum hemorrhage secondary to uterine atony, controlled after surgical revision. To conclude, pregnancy in a patient with a history of pelvic irradiation in childhood must be considered high-risk pregnancy and its management must be multidisciplinary.

Influence of averaged fetal heart rate in heart rate variability analysis

In high-income countries, fetal hypoxia affects 3 to 8 newborns per 1000 live births with subsequent moderate or severe Hypoxic-Ischemic Encephalopathy (HIE) in 0.5 to 1 per 1000 live births. Visual interpretation of FHR signal issued from a Doppler ultrasound cardiotocography is the gold standard to monitor fetal condition. Unfortunately, its analysis presents a high rate of inter-observer variability and a low specificity to predict poor neonatal outcomes. Under hypoxia, the fetus develops several adaptive mechanisms regulated by the autonomic nervous system inducing changes in the fetal heart rate variability. Though fetal heart rate variability methods demonstrated abilities to predict perinatal asphyxia, most of the Doppler ultrasound technologies used in clinical practice do not provide sufficiently accurate fetal heart rate signals for heart rate variability analysis. Indeed, Doppler ultrasound cardiotocography usually provides fetal heart rate values averaged over 2 or 3 beats which can constitute a limitation for spectral analysis. We developed a fetal heart rate variability analysis method: the Fetal Stress Index (FSI). The objective of this study was to investigate the influence of averaged fetal heart rate on this new index in order to check the feasibility of computing the FSI from the signal issued from Doppler ultrasound cardiotocography.

Influence of Wilson Ce nter Terminal on fetal electrocardiography acquisition

The acquisition of a standard 10-leads electrocardiography (ECG) is performed using the Wilson Center Terminal (WCT) reference with a normalized electrode positioning. However, in the case of non-invasive fetal ECG (fECG) acquisition, there is no standardization on the positioning of the electrodes on the abdomen and many authors suggest an acquisition with or without a WCT. The use of the WCT for the acquisition of the fetal heart rate (FHR) is not justified. The objective of this paper is to quantify the influence of this reference compared to a direct measurement. For this purpose, we developed a device allowing the acquisition of the fECG and compared the two configurations on 6 volunteer pregnants. The noise levels and the fetal QRS morphology were compared, showing no superiority of the WCT acquisition compared to a direct differential measurement.

AcCorps: A low-cost 3D printed stethoscope for fetal phonocardiography

The analysis of fetal heart rate provides valuable information regarding the fetus wellbeing. Fetal phonocardiography is a low-cost and passive method allowing the acquisition of fetal heart rate by recording acoustic vibrations on the mother's abdomen. However, most of available stethoscopes are not optimized for a robust acquisition of fetal heart sound. In this publication, we investigated a new design of low-cost and 3D printed stethoscope. This device was optimized to provide an acoustic amplification especially in the low-frequency band which corresponds to the fetal heart sounds. This device was tested i) in silico, ii) on a test bench and iii) on 5 pregnant volunteers.

Management of red blood cell alloimmunization in pregnancy

The main cause of fetal anemia is maternal red blood cell alloimmunization (AI). The search of maternal antibodies by indirect antiglobulin test allows screening for AI during pregnancy. In case of AI, fetal genotyping (for Rh-D, Rh-c, Rh-E and Kell), quantification (for anti-rhesus antibodies) and antibody titration, as well as ultrasound monitoring, are performed. This surveillance aims at screening for severe anemia before hydrops fetalis occurs. Management of severe anemia is based on intrauterine transfusion (IUT) or labor induction depending on gestational age. After intrauterine transfusion, follow-up will focus on detecting recurrence of anemia and detecting fetal brain injury. With IUT, survival of fetuses with alloimmunization is greater than 90% but 4.8% of children with at least one IUT have neurodevelopmental impairment.

Influence of ECG sampling rate in fetal heart rate variability analysis

Fetal hypoxia results in a fetal blood acidosis (pH<;7.10). In such a situation, the fetus develops several adaptation mechanisms regulated by the autonomic nervous system. Many studies demonstrated significant changes in heart rate variability in hypoxic fetuses. So, fetal heart rate variability analysis could be of precious help for fetal hypoxia prediction. Commonly used fetal heart rate variability analysis methods have been shown to be sensitive to the ECG signal sampling rate. Indeed, a low sampling rate could induce variability in the heart beat detection which will alter the heart rate variability estimation. In this paper, we introduce an original fetal heart rate variability analysis method. We hypothesize that this method will be less sensitive to ECG sampling frequency changes than common heart rate variability analysis methods. We then compared the results of this new heart rate variability analysis method with two different sampling frequencies (250-1000 Hz).

Simulation training to teach postpartum hemorrhage surgery to residents

OBJECTIVE

Description of the aims, the framework and the results of a postpartum hemorrhage surgery workshop for residents.

STUDY DESIGN

This article is the first publication to describe a simulation workshop for the surgical management of maternal hemorrhage. Training was divided into both theoretical and practical workshops. Four obstetrician-gynecologists supervised residents who performed all the surgical procedures on a cadaver. This training course included the oldest residents at the Faculty of Medicine of Lille and was evaluated by participants using pre-test and post-test questionnaires. Medical knowledge was also evaluated.

RESULTS

The pre-test questionnaire showed that medical knowledge for the treatment of postpartum hemorrhage was acceptable but that real practice was lacking. Eighty-six percent of the residents responded that they were not able deal with the situation correctly and most considered it stressful. The post-test questionnaire showed that training greatly improved the participants' theoretical knowledge and technical skills as well as significantly improving self-confidence.

CONCLUSIONS

Based on these positive results this workshop will be included in the resident training program and also be extended to professionals as a part of the continuing medical education program.

[Aortic dissection in pregnancy]

During pregnancy, the occurrence of aortic dissection is a rare event immediately threatening fetal and maternal prognosis. Its occurrence is more common in cases of connective tissue disease. But the absence risk factor shall not exclude or delay diagnosis. We must learn to think about it, because the prognosis is highly dependent on time management. The clinical presentation of this medical and surgical emergency varies, and pregnancy adds its own symptoms. We have to ask without hesitation that echocardiography or chest CT be performed since these diagnostic methods are both reliable and available.

[Birth of a child with Down syndrome: parental choice or failure of screening policy?]

OBJECTIVES

Birth of a child with Down syndrome (DS) can follow parental choice or failure of screening. The objective of this work is to describe the circumstances of births of children with DS in a French perinatal health network.

METHODS

Retrospective multicentric study, with prospective trial registration of all children born alive with DS, between 2010 and 2013.

RESULTS

Sixty-three children were born with DS. Complete screening was performed by 61 % of patients, incomplete screening by 29 % of patients and no screening test by 10 %. Among these births, 50 % occurred following parental choice, 40 % following failure of screening and for 10 %, parental choice concerning screening was unknown. False negative had often calculating risk close to 1/1000.

CONCLUSION

In this study, the birth of a child with DS occurred following parental choice in half of cases. It's necessary, to optimize the follow-up, to document in medical records the medical information and parental choice concerning DS screening and data of screening when this was done.

[Heart, arteries and women, a care pathway for women at high cardiovascular risk]

Cardiovascular (CV) diseases are the primary cause of death of women. Since they kill 10 times more than breast cancer, preventive measures should be implemented. According to U.S. recommendations, a woman is either at "CV risk" or at "optimal health status" if she has no risk factors and a perfectly healthy lifestyle. Some risk factors are more deleterious to women (smoking, diabetes, stress, depression, atrial fibrillation); or specific to women (preeclampsia, gestational diabetes, contraception, menopause, headaches). The lifestyle plays a key role for them. The blood pressure measurement is the most frequent opportunity to detect women at risk. CV tests should be performed to all symptomatic women and for those over the age of 45 who want to start practicing sport. The cardiologist can play a key role to improve women's CV health by integrating their hormonal risks. Women themselves can also make a powerful contribution to prevention by adopting a healthy lifestyle. From those recommendations concerning women's CV health, there is a great opportunity to initiate a health path for women at high cardiovascular risk. The objectives of the specific path "heart, arteries and women" of University hospital of Lille will be to improve professional practice, awareness of women, educate public authorities and within a few years reduce the epidemic of CVD of French women.

[Links between preeclampsia and intrauterine growth restriction]

OBJECTIVES

Preeclampsia is one of the most frequent and most serious complications of pregnancy. Its occurrence is around 5% of the pregnancies. Its pathophysiology is complex and includes several hypotheses. Preeclampsia is inconsistently associated with intrauterine growth retardation (IUGR). The determinants that explain the variability of this association are unknown. The objective of our study was to identify in a population of French patients who had preeclampsia and/or HELLP syndrome, incidence and risk factors of IUGR to isolate specific characteristics of these women.

PATIENTS AND METHODS

We studied 578 pregnant women treated for preeclampsia or HELLP syndrome according to the presence or absence of IUGR (database compiled since 1996). Comparisons between the groups were done with Wilcoxon test (quantitative data) or Fisher's exact test (qualitative data).

RESULTS

We found that pre-eclampsia appeared earlier and was more severe in the group with IUGR. In addition foetal issues were more defavorable when IUGR was associated with preeclampsia.

CONCLUSION

Combination of IUGR and pre-eclampsia or HELLP syndrome is a criterion of severity for both the mother and the fetus. Our data do not allow distinguishing physiopathological mechanism to explain these differences.