A. Chantry

Lateral asymmetric decubitus position for the rotation of occipito-posterior positions: multicenter randomized controlled trial EVADELA.

BACKGROUND Fetal occiput posterior positions are associated with poorer maternal outcomes than occiput anterior positions. Although methods that include instrumental and manual rotation can be used at the end of labor to promote the rotation of the fetal head, various maternal postures may also be performed from the beginning of labor in occiput posterior position. Such postures might facilitate flexion of the fetal head and favor its rotation into an occiput anterior position. OBJECTIVE The purpose of this study was to determine whether a lateral asymmetric decubitus posture facilitates the rotation of fetal occiput posterior into occiput anterior positions. STUDY DESIGN Evaluation of Decubitus Lateral Asymmetric posture was a multicenter randomized controlled trial that included 322 women from May 2013 through December 2014. Study participants were women who labored with ruptured membranes and a term fetus that was confirmed by ultrasound imaging to be in cephalic posterior position. Women who were assigned to the intervention group were asked to lie in a lateral asymmetric decubitus posture on the side opposite that of the fetal spine during the first hour and encouraged to maintain this position for as long as possible during the first stage of labor. In the control group, women adopted a dorsal recumbent posture during the first hour after random assignment. The primary outcome was occiput anterior position at 1 hour after random assignment. Secondary outcomes were occiput anterior position at complete dilation, mode of delivery, speed of dilation during the active first stage, maternal pain, and womens satisfaction. RESULTS One hundred sixty women were assigned to the intervention group, and 162 women were assigned to the control group. One hour after random assignment, the rates of occiput anterior position did not differ between the intervention and control groups (21.9% vs 21.6%, respectively; P=.887). Occiput anterior rates did not differ between groups at complete dilation (43.7% vs 43.2%, respectively; P=.565) or at birth (83.1% vs 86.4%, respectively; P=.436). Finally, the groups did not differ significantly for cesarean delivery rates (18.1% among women in lateral asymmetric decubitus and 14.2% among control subjects (P=0.608) or for speed of cervical dilation during the active first stage of labor (P=.684), pain assessment (P=.705), or womens satisfaction (P=.326). No maternal or neonatal adverse effect that was associated with either posture was observed. CONCLUSION Lateral asymmetric decubitus position on the side opposite that of the fetal spine did not facilitate rotation of fetal head. Nevertheless, other maternal positions may be effective in promoting fetal head rotation. Further research is needed; posturing during labor, nonetheless, should remain a womans active choice.

Oxytocin administration during spontaneous labor: Guidelines for clinical practice. Chapter 1: Definition and characteristics of normal and abnormal labor

Since the mid-1950s, the definitions of normal labor set forth by E. Friedman have guided obstetric practices in maternity units across the globe. But recent work is challenging these definitions, now considered too restrictive and thought to induce excessive interventionism by medical professionals. The objective of this chapter of these Clinical Practice Guidelines is to redefine the structure and duration of normal labor, as well as the criteria defining abnormal labor. Based on a systematic review of the literature, we make various recommendations. In the first place, the diagnosis of labor dystocia is inappropriate during the latent phase. The active phase of the first stage of labor begins at a cervical dilation between 5 and 6 cm. On the other hand, a speed of dilation < 1 cm/4 h at the beginning of the active phase of the first stage is considered abnormal, as is a speed < 1 cm/2 h above 7 cm dilation. The maximum duration of the descent phase of the second stage of labor cannot be determined from the literature, but the risk-benefit balance becomes less favorable after 3 hours. Finally, the literature does not justify any recommendation about the maximum duration of the expulsion phase. These new guidelines should make it possible to reduce the rates of oxytocin use and of cesareans for labor dystocia.

Postpartum practice: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE To make evidence-based recommendations for the postpartum management of women and their newborns, regardless of the mode of delivery. MATERIAL AND METHODS Systematic review of articles from the PubMed database and the Cochrane Library and of recommendations from the French and foreign societies or colleges of obstetricians. RESULTS Because breast-feeding is associated with reductions in neonatal, infantile, and childhood morbidity (lower frequency of cardiovascular, infectious, and atopic diseases and infantile obesity) (LE2) and improved cognitive development in children (LE2), exclusive and extended breastfeeding is recommended (grade B) for at least 4-6 months (professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (professional consensus). Because of potentially serious adverse effects, bromocriptine is contraindicated in inhibiting lactation (professional consensus). For women aware of the risks of pharmacological treatments to inhibit lactation but choose to take them, lisuride and cabergoline are the preferred drugs (professional consensus). Regardless of the mode of delivery, only women with bleeding or symptoms of anemia should be tested for it (professional consensus). Immediate postoperative monitoring after cesarean delivery should be performed in the postanesthesia care unit (PACU). An analgesic multimodal protocol for analgesia, preferring oral administration, should be developed by the medical team and be available for all staff (professional consensus) (grade B). Thromboprophylaxis with compression stockings should begin the morning of all cesarean deliveries and maintained for at least 7 postoperative days (professional consensus) with or without the addition of LMWH, depending on the presence and severity (major or minor) of additional risk factors. It is recommended that women be informed of the dangers of closely spaced pregnancies (LE3), that effective contraception begin no later than 21 days post partum for women who do not want such a pregnancy (grade B), and that it be prescribed at the maternity ward (professional consensus). In view of the postpartum risk of venous thromboembolism, use of combination hormonal contraception is not recommended before six weeks post partum (grade B). Pelvic floor rehabilitation in asymptomatic women to prevent urinary or anal incontinence in the medium or long term is not recommended (professional consensus). Rehabilitation using pelvic floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months post partum (grade A), regardless of the type of incontinence. Postpartum pelvic floor rehabilitation is recommended to treat anal incontinence (grade C), but not to treat or prevent prolapse (grade C) or dyspareunia (grade C). The months following the birth are a period of transition and of psychological changes for all parents (LE2) and are still more difficult for those with psychosocial risk factors (LE2). Situations of evident psychological difficulties can have a significant effect on the childs psychological and emotional development (LE3). Among these difficulties, postpartum depression is most common, but the risk of all mental disorders is generally higher in the perinatal period (LE3). CONCLUSION The postpartum period presents clinicians with a unique and privileged opportunity to address the physical, psychological, social, and somatic health of women and babies.

[Post-partum: Guidelines for clinical practice--Short text].

OBJECTIVE To determine the post-partum management of women and their newborn whatever the mode of delivery. MATERIAL AND METHODS The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. RESULTS Because breastfeeding is associated with a decrease in neonatal morbidity (lower frequency of cardiovascular diseases, infectious, atopic or infantile obesity) (EL2) and an improvement in the cognitive development of children (EL2), exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (Professional consensus). In order to increase the rate of breastfeeding initiation and its duration, it is recommended that health professionals work closely with mothers in their project (grade A) and to promote breastfeeding on demand (grade B). There is no scientific evidence to recommend non-pharmacological measures of inhibition of lactation (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breastfeed (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). For women aware of the risks of pharmacological treatment of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Whatever the mode of delivery, numeration blood count is not systematically recommended in a general population (Professional consensus). Anemia must be sought only in women with bleeding or symptoms of anemia (Professional consensus). The only treatment of post-dural puncture headache is the blood patch (EL2), it must not be carried out before 48 h (Professional consensus). Women vaccination status and their family is to be assessed in the early post-partum (Professional consensus). Immediate postoperative monitoring after caesarean delivery should be performed in the recovery room, but in exceptional circumstances, it may be performed in the delivery unit provided safety rules are maintained and regulatory authorities are informed (Professional consensus). An analgesic multimodal protocol developed by the medical team should be available and oral way should be favored (Professional consensus) (grade B). For every cesarean delivery, thromboprophylaxis with elastic stockings applied on the morning of the surgery and kept for at least 7 postoperative days is recommended (Professional consensus) with or without the addition of LMWH according to the presence or not of additional risk factors, and depending on the risk factor (major, minor). Early postoperative rehabilitation is encouraged (Professional consensus). Postpartum visit should be planned 6 to 8 weeks after delivery and can be performed by an obstetrician, a gynecologist, a general practitioner or a midwife, after normal pregnancy and delivery (Professional consensus). Starting effective contraception later 21 days after delivery in women who do not want closely spaced pregnancy is recommended (grade B), and to prescribe it at the maternity (Professional consensus). According to the postpartum risk of venous thromboembolism, the combined hormonal contraceptive use before six postpartum weeks is not recommended (grade B). Rehabilitation in asymptomatic women in order to prevent urinary or anal incontinence in medium or long-term is not recommended (Expert consensus). Pelvic-floor rehabilitation using pelvic-floor muscle contraction exercises is recommended to treat persistent urinary incontinence at 3 months postpartum (grade A), regardless of the type of incontinence. Postpartum pelvic-floor rehabilitation is recommended to treat anal incontinence (grade C). Postpartum pelvic-floor rehabilitation is not recommended to treat or prevent prolapse (grade C) or dyspareunia (grade C). The optimal time for maternity discharge for low risk newborn depends more on the organisation of the post-discharge follow up (Professional consensus). The months following the birth are a transitional period, and psychological alterations concern all parents (EL2). It is more difficult in case of psychosocial risk factors (EL2). In situations of proven psychological difficulties, the impact on the psycho-emotional development of children can be important (EL3). Among these difficulties, postpartum depression is the most common situation. However, the risk is generally higher in the perinatal period for all mental disorders (EL3). CONCLUSION Postpartum is, for clinicians, a unique and privileged opportunity to address the physical, psychological, social and somatic health of their patients.

Pitfalls of national routine death statistics for maternal mortality study.

BACKGROUND The lessons learned from the study of maternal deaths depend on the accuracy of data. Our objective was to assess time trends in the underestimation of maternal mortality (MM) in the national routine death statistics in France and to evaluate their current accuracy for the selection and causes of maternal deaths. METHODS National data obtained by enhanced methods in 1989, 1999, and 2007-09 were used as the gold standard to assess time trends in the underestimation of MM ratios (MMRs) in death statistics. Enhanced data and death statistics for 2007-09 were further compared by characterising false negatives (FNs) and false positives (FPs). The distribution of cause-specific MMRs, as assessed by each system, was described. RESULTS Underestimation of MM in death statistics decreased from 55.6% in 1989 to 11.4% in 2007-09 (P < 0.001). In 2007-09, of 787 pregnancy-associated deaths, 254 were classified as maternal by the enhanced system and 211 by the death statistics; 34% of maternal deaths in the enhanced system were FNs in the death statistics, and 20% of maternal deaths in the death statistics were FPs. The hierarchy of causes of MM differed between the two systems. The discordances were mainly explained by the lack of precision in the drafting of death certificates by clinicians. CONCLUSION Although the underestimation of MM in routine death statistics has decreased substantially over time, one third of maternal deaths remain unidentified, and the main causes of death are incorrectly identified in these data. Defining relevant priorities in maternal health requires the use of enhanced methods for MM study.

Recommandations pour l’administration d’oxytocine au cours du travail spontané. Texte court des recommandations

OBJECTIVES To define the different stages of spontaneous labour. To determine the indications, modalities of use and the effects of administering synthetic oxytocin. And to describe undesirable maternal and perinatal outcomes associated with the use of synthetic oxytocin. METHOD A systematic review was carried out by searching Medline database and websites of obstetrics learned societies until March 2016. RESULTS The 1st stage of labor is divided in a latence phase and an active phase, which switch at 5cm of cervical dilatation. Rate of cervical dilatation is considered as abnormal below 1cm per 4hour during the first part of the active phase, and below 1cm per 2hours above 7cm of dilatation. During the latent phase of the first stage of labor, i.e. before 5cm of cervical dilatation, it is recommended that an amniotomy not be performed routinely and not to use oxytocin systematically. It is not recommended to expect the active phase of labor to start the epidural analgesia if patient requires it. If early epidural analgesia was performed, the administration of oxytocin must not be systematic. If dystocia during the active phase, an amniotomy is recommended in first-line treatment. In the absence of an improvement within an hour, oxytocin should be administrated. However, in the case of an extension of the second stage beyond 2hours, it is recommended to administer oxytocin to correct a lack of progress of the presentation. If dynamic dystocia, it is recommended to start initial doses of oxytocin at 2mUI/min, to respect at least 30min intervals between increases in oxytocin doses delivered, and to increase oxytocin doses by 2mUI/min intervals without surpassing a maximum IV flow rate of 20mUI/min. The reported maternal adverse effects concern uterine hyperstimulation, uterine rupture and post-partum haemorrhage, and those of neonatal adverse effects concern foetal heart rate anomalies associated with uterine hyperstimulation, neonatal morbidity and mortality, neonatal jaundice, weak suck/poor breastfeeding latch and autism. CONCLUSION The widespread use of oxytocin during spontaneous labour must not be considered as simply another inoffensive prescription without any possible deleterious consequences for mother or foetus. Conditions for administering the oxytocin must therefore respect medical protocols. Indications and patient consent have to be report in the medical file.

Factors affecting rotation of occiput posterior position during the first stage of labor

INTRODUCTION Fetal occiput posterior (OP) positions account for 15 to 20% of cephalic presentations and are associated with poorer maternal and neonatal outcomes than occiput anterior (OA) positions. The aim of this study was to identify maternal, neonatal and obstetric factors associated with rotation from OP to OA position during the first stage of labor. MATERIAL AND METHODS This secondary analysis of a multicenter randomized controlled trial (EVADELA) included 285 laboring women with ruptured membranes and a term fetus in OP position. After excluding women with cesarean deliveries before full dilatation, we compared two groups according to fetal head position at the end of the first stage of labor: those with and without rotation from OP to OA position. Factors associated with rotation were assessed with univariate and multivariate analyses using multilevel logistic regression models. RESULTS The rate of anterior rotation during the first stage was 49.1%. Rotation of the fetal head was negatively associated with excessive gestational weight gain (adjusted odds ratio [aOR]: 0.37, 95% confidence interval [CI]: 0.17-0.80), macrosomia (aOR: 0.35, 95% CI: 0.14-0.90), direct OP position (aOR: 0.24, 95% CI: 0.09-0.65), and prelabor rupture of membranes (aOR: 0.40, 95% CI: 0.19-0.86). Oxytocin administration was the only factor positively associated with fetal head rotation (aOR: 2.17, 95% CI: 1.20-3.91). DISCUSSION Oxytocin administration may affect rotation of OP positions during the first stage of labor. Further studies should be performed to assess the risks and benefits of its utilization for managing labor with a fetus in OP position.