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Background: The French guidelines have recommended a restrictive policy of episiotomy since 2005. We aimed to assess variations in the prevalence of both episiotomy and obstetric anal sphincter injury (OASI) from the 2010, 2016, and 2021 National Perinatal Surveys., Methods and Findings: A total of 29,750 women who had given birth to a live infant by vaginal delivery were included. For instance, in 2021, 22.3% of women were over 35 years old, 17.7% were born outside of France, 11.3% had a body mass index (BMI) of 30 kg/m2 or higher, and 39.9% were primiparous. Episiotomy and OASI (third- and fourth-degree tears) were identified from medical records. We described the overall prevalence of outcomes, and then by obstetrical clinical contexts using a seven-group obstetric classification of women. Variations between 2010 (reference), 2016, and 2021 were analyzed by Cochran-Armitage tests and using Poisson regression models adjusted for maternal age, BMI, country of birth, antenatal classes, suspicion of fetal macrosomia, and neuroaxial analgesia during labor, the professional who attended the birth, the annual number of deliveries, and the maternity unit status to account for changes in women's characteristics and obstetric practices. The overall prevalence of episiotomy decreased significantly from 25.8% (95% confidence interval (CI) 25.0 to 26.7) in 2010, to 20.1% (95% CI 19.3 to 20.9) in 2016, and 8.3% (95% CI 7.8 to 8.9) in 2021 (adjusted risk ratio (aRR) 0.33, 95% CI 0.30 to 0.35). This reduction was observed in all groups of the classification (Cochran-Armitage tests P < 0.001), ranging from -33.0% in Group 2a [nulliparous term cephalic singleton with forceps delivery] to -94.0% in Group 7 [multiple pregnancy]. The difference in overall prevalence of OASI between 2010 (0.7%) and 2021 (1.0%) was not statistically significant after adjustment (aRR 1.24, 95% CI 0.91 to 1.68). By groups of classification, the prevalence of OASI increased significantly only in Group 2b [nulliparous term cephalic singleton with spatula delivery] from 2.6% (95% CI 1.2 to 5.6) in 2010 to 9.6% (95% CI 6.2 to 14.7) in 2021 (aRR 3.69, 95% CI 1.50 to 9.09), and did not differ statistically significantly in Group 2a [nulliparous term cephalic singleton with forceps delivery] from 3.2% (95% CI 1.8 to 5.7) in 2010 to 5.7% (95% CI 3.4 to 9.5) in 2021 (aRR 1.78, 95% CI 0.81 to 3.90). The main limitations of this study include the failure to take into account some potential confounding factors and the inability to analyze some groups of the studied population (8.5% of the sample) because of the very small number of events in these groups., Conclusions: The significant overall reduction in the prevalence of episiotomy in France has not been followed by an overall increase in OASI. However, subgroup analyses revealed a significant rise in OASI among nulliparous women giving birth by spatula (Group 2b), and a clinically relevant but statistically nonsignificant rise among nulliparous women delivering by forceps (Group 2a), while the prevalence of episiotomy significantly decreased. These results should be interpreted with caution given the low prevalence of OASI in some subgroups. Further research is needed to predict the optimal rate of episiotomy for instrumental deliveries. In hospitals with high episiotomy rates, our findings suggest that episiotomy could be safely reduced for spontaneous vaginal deliveries to comply with international guidelines and women's requests., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Houlbracq et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To assess the frequency and determinants of medical interventions during childbirth without women's consent at the population level., Methods: The nationwide cross-sectional Enquête Nationale Périnatale 2021 provided a representative sample of women who delivered in metropolitan France with a 2-month postpartum follow-up (n = 7394). Rates and 95% confidence intervals (CI) of interventions during childbirth (oxytocin administration, episiotomy or emergency cesarean section) without consent were calculated. Associations with maternal, obstetric, and organizational characteristics were assessed using robust variance Poisson regressions, after multiple imputation for missing covariates, and weighted to account for 2-month attrition., Results: Women reporting failure to seek consent were 44.7% (CI: 42.6-47.0) for oxytocin administration, 60.2% (CI: 55.4-65.0) for episiotomy, and 36.6% (CI: 33.3-40.0) for emergency cesarean birth. Lack of consent for oxytocin was associated with maternal birth abroad (adjusted prevalence ratio [aPR] 1.20; 95% CI: 1.06-1.36), low education level, and increased cervical dilation at oxytocin initiation, whereas women with a birth plan reported less frequently lack of consent (aPR 0.79; 95% CI: 0.68-0.92). Delivery assisted by an obstetrician was more often associated with lack of consent for episiotomy (aPR 1.46; 95% CI: 1.11-1.94 for spontaneous delivery and aPR 1.39; 95% CI: 1.13-1.72 for instrumental delivery, reference: spontaneous delivery with a midwife). Cesarean for fetal distress was associated with failure to ask for consent for emergency cesarean delivery (aPR 1.58; 95% CI: 1.28-1.96)., Conclusion: Women frequently reported that perinatal professionals failed to seek consent for interventions during childbirth. Reorganization of care, particularly in emergency contexts, training focusing on adequate communication and promotion of birth plans are necessary to improve women's involvement in decision making during childbirth., (© 2024 The Author(s). International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Introduction: The establishment of midwife-led birth centers (MLBCs) is still being debated. The study aimed to compare severe adverse outcomes and mode of birth in low-risk women according to their birth planned in MLBCs or in obstetric-led units (OUs) in France., Material and Methods: We used nationwide databases to select low-risk women at the start of care in labor in MLBCs (n = 1294) and in OUs (n = 5985). Using multilevel logistic regression, we compared severe adverse maternal and neonatal morbidity as a composite outcome and as individual outcomes. These include severe postpartum hemorrhage (≥1000 mL of blood loss), obstetrical anal sphincter injury, maternal admission to an intensive care unit, maternal death, a 5-minute Apgar score <7, neonatal resuscitation at birth, neonatal admission to an intensive care unit, and stillbirth or neonatal death. We also studied the mode of birth and the role of prophylactic administration of oxytocin at birth in the association between birth settings and severe postpartum hemorrhage., Results: Severe adverse maternal and neonatal outcome indicated a slightly higher rate in women in MLBCs compared to OUs according to unadjusted analyses (4.6% in MLBCs vs. 3.4% in OUs; cOR 1.36; 95%CI [1.01-1.83]), but the difference was not significant between birth settings after adjustment (aOR 1.37 [0.92-2.05]). Severe neonatal morbidity alone was not different (1.7% vs. 1.6%; aOR 1.17 [0.55-2.47]). However, severe maternal morbidity was significantly higher in MLBCs than in OUs (3.0% vs. 1.9%; aOR 1.61 [1.09-2.39]), mainly explained by higher risks of severe postpartum hemorrhage (2.4 vs. 1.1%; aOR 2.37 [1.29-4.36]), with 2 out of 5 in MLBCs partly explained by the low use of prophylactic oxytocin. Cesarean and operative vaginal births were significantly decreased in women with a birth planned in MLBCs., Conclusions: In France, 3 to 4% of low-risk women experienced a severe adverse maternal or neonatal outcome regardless of the planned birth setting. Results were favorable for MLBCs in terms of mode of birth but not for severe postpartum hemorrhage, which could be partly addressed by revising practices of prophylactic administration of oxytocin., (© 2024 The Author(s). Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: Shared decision-making is an important component of a patient-centered healthcare system. We assessed the prevalence of parturients with preferences for their labor and childbirth, expressed verbally in the birthing room or as a written birth plan, and studied maternal, obstetric, and organizational factors associated with their expression., Methods: Data came from the 2016 National Perinatal Survey, a cross-sectional nationwide population-based survey conducted in France. Preferences for labor and childbirth were studied in three categories: expressed verbally, in writing (birth plan), or unexpressed or nonexistent. Analyses used multinomial multilevel logistic regression., Results: The analysis included 11,633 parturients: 3.7% had written a birth plan, 17.3% expressed their preferences verbally, and 79.0% either did not have or did not express any preferences. Compared with the latter group, written or verbal preferences were both significantly associated with prenatal care by independent midwives (respectively, adjusted odds ratio (aOR) 2.19; 95% confidence interval (CI), [1.59-3.03], and aOR 1.43; 95% CI [1.19-1.71]) and with attendance at childbirth education classes (respectively, aOR 4.99; 95% CI [3.49-7.15], and aOR 2.27; 95% CI [1.98-2.62]). As years in traditional schooling increased, so did its association with preferences. Conversely, parturients from African countries were significantly less likely than French mothers to express preferences. A written birth plan was also associated with characteristics of maternity unit organization., Conclusion: Only one in five parturients reported having expressed preferences for labor and childbirth to healthcare professionals in the birthing room. This expression of preferences was associated with maternal characteristics and the organization of care., (© 2023 Wiley Periodicals LLC.)

Objective: The objective of this study was to compare two strategies for passive second stage management: three-hour vs two-hour delayed pushing after the diagnosis of full cervical dilation on mode of delivery and perinatal outcomes., Study Design: This retrospective observational study included low-risk nulliparous women who reatched full cervical dilation under epidural analgesia with a single term fetus in cephalic presentation and normal fetal heart rate, between September and December 2016. Mode of delivery (spontaneous vaginal delivery versus operative delivery including cesarean section and instrumental vaginal delivery) and perinatal outcomes (post-partum hemorrhage, perineal lacerations, 5-min Apgar score, umbilical cord pH and transfer to neonatal intensive care unit) were compared between two maternity units: maternity unit A, where women could have up to a three-hour delayed pushing period after full cervical dilation diagnosis, and maternity unit B, where the delayed pushing period was a maximum of 2 h. Outcomes were compared using univariate and multivariable analyses. Adjusted odds ratios (aOR) were estimated using a logistic regression multivariable model that included potential cofounders., Results: During the study period, 614 women were included, 305 in maternity unit A and 309 in maternity unit B. Women's pre-existing characteristics were comparable between the two maternity units. Women delivering in the maternity unit A had significantly lower risks of having an operative delivery compared to women delivering in the maternity unit B (respectively 18.4 vs 26.9%; aOR = 0.64; 95%CI [0.43 - 0.96]). Perinatal outcomes were comparable in the two maternity units, particularly in terms of post-partum hemorrhage rates (7.4 vs 7.8%; aOR = 1,19 [0.65 - 2.19])., Conclusion: Increasing the possible length of the delayed pushing period from 2 to 3 h after the diagnosis of full cervical dilation in low-risk nulliparous women appears to reduce operative deliveries without adverse effects on maternal or neonatal morbidity., Competing Interests: Declaration of Competing Interests The authors did not report any potential conflicts of interest., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Background: Knowledge of severe acute maternal morbidity (SAMM) and its risk factors is constantly growing, but studies have rarely focused on the specific population of low-risk women., Aim: To estimate the prevalence and to identify subgroups at risk of peripartum SAMM in low-risk women METHODS: From a population-based cohort-nested case-control study conducted in six French regions, i.e., 182 309 women who gave birth at ≥22 weeks in 119 maternity units, we selected women considered at low risk up to the end of pregnancy before labour according to the NICE guidelines and compared those experiencing peripartum SAMM (during birth and up to 7 days postpartum; n = 489) to a 2% random sample of women without peripartum SAMM from the same units (n = 1800). Risk factors for peripartum SAMM were identified by multivariable logistic regression., Findings: amongst low-risk women, the estimated rate of SAMM was 0.548/100 deliveries (95%CI 0.501-0.599). Severe obstetric haemorrhage was the main cause (83.6% of SAMM cases). Main risk factors for peripartum SAMM were primiparity (aOR 2.4, 95%CI 1.9-3.0), IVF pregnancy (aOR 1.8, 1.0-3.4), third-trimester anaemia (aOR 1.7, 1.3-2.3), being born out of Europe or Africa (aOR 1.9, 1.2-3.0)., Conclusion: amongst women considered at low risk up to the end of pregnancy before labour, peripartum SAMM is rare but still exists. Knowledge of risk factors of SAMM in this population will inform the discussion on peripartum risks and the most appropriate place of birth for each woman., Competing Interests: Declaration of competing interest All authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023. Published by Elsevier Ltd.)

Competing Interests: Conflict of interest statement All authors have disclosed that they do not have any potential conflicts of interest.

Background: France is somewhat behind other countries in its consideration of the issue of violence in perinatal care. Its consequences on maternal, but also neonatal and infant health are recognised internationally. Nonetheless, research and data measuring its frequency and its determinants are inadequate, and the relevant definitions are not always consensual. In this context, we, as midwives and researchers in public health and as members of the National College of French Midwives, seek to propose a scientific and clinical contribution to this debate., Aim: We propose avenues for measuring and characterising violence in perinatal care. Our objective is to quantify and characterise the situations of violence in perinatal care in population-based studies and based on the perceptions of each woman questioned., Discussion: This proposal for questions, simplified compared with those currently in used in the international scientific literature, has the advantage of focusing reflection around three categories: inappropriate medical care, inappropriate human behaviours in care, and sexual abuse. It should also allow the identification of the contexts of care during which violence may be experienced, as well as the categories of health-care workers concerned., Conclusion: It seems important to us to distinguish these situations, causal and context, for they require different responses if we hope to reduce the frequency and the effects of violence in perinatal care in the future. We propose questions that could also be used in clinical situations by midwives and other clinicians., Competing Interests: Declaration of Competing Interest None declared, (Copyright © 2022. Published by Elsevier Ltd.)

Objectives: This study's primary objective was to analyse the personal experience of different ultrasonographers during the announcement of suspected foetal abnormalities, seen either in screening or diagnostic ultrasound. The secondary objectives aimed to explore the factors influencing the announcement of the foetal abnormality, whether they complicated or facilitated the consultation. These also comprised the analysis of the knowledge, practice and attitudes of the healthcare professionals as well as the different techniques used during the consultation. Finally, this study aimed to analyse the various tools and skills used by ultrasonographers to improve the quality of their announcement of the diagnosis., Methods: This qualitative study was based on both the observation of consultations and the results of semi-structured interviews with ultrasonographers, in a maternity hospital in France., Results: The results highlighted feelings of great discomfort for the ultrasonographers on discovering an abnormality on the scan. The different perceptions and practices regarding the announcement of a diagnosis varied between screening ultrasonographers and specialist doctors. The uncertainty of foetal prognosis seemed to complicate the announcement for specialist doctors. Qualities that made the communication of the diagnosis easier included the ultrasonographer's availability and their attitude. Although professional experience was considered a very powerful skill, training for the communication of a diagnosis accelerates the development of good medical practice., Conclusions: The announcement of suspected foetal abnormalities is a difficult exercice, which impacts the ultrasonographer's personal experience and his attitude. Some professional practices are to be encouraged while others are to be put under question. A trust-based relationship between the healthcare professional and the patient is partly reinforced by the quality of the announcement and its follow-up, as well as the healthcare professional's thoroughness and humanity., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background: There is no consensus on an optimal strategy for managing the active phase of the second stage of labor. Intensive pushing could not only reduce pushing duration, but also increase abnormal fetal heart rate because of cord compression and reduced placental perfusion and oxygenation resulting from the combination of uterine contractions and maternal expulsive forces. Therefore, it may increase the risk of neonatal acidosis and the need for operative vaginal delivery., Objective: This study aimed to assess the effect of the management encouraging "moderate" pushing vs "intensive" pushing on neonatal morbidity., Study Design: This study was a multicenter randomized controlled trial, including nulliparas in the second stage of labor with an epidural and a singleton cephalic fetus at term and with a normal fetal heart rate. Of note, 2 groups were defined: (1) the moderate pushing group, in which women had no time limit on pushing, pushed only twice during each contraction, and observed regular periods without pushing, and (2) the intensive pushing group, in which women pushed 3 times during each contraction and the midwife called an obstetrician after 30 minutes of pushing to discuss operative delivery (standard care). The primary outcome was a composite neonatal morbidity criterion, including umbilical arterial pH of <7.15, base excess of >10 mmol/L, lactate levels of >6 mmol/L, 5-minute Apgar score of <7, and severe neonatal trauma. The secondary outcomes were mode of delivery, episiotomy, obstetrical anal sphincter injuries, postpartum hemorrhage, and maternal satisfaction., Results: The study included 1710 nulliparous women. The neonatal morbidity rate was 18.9% in the moderate pushing group and 20.6% in the intensive pushing group (P=.38). Pushing duration was longer in the moderate group than in the intensive group (38.8±26.4 vs 28.6±17.0 minutes; P<.001), and its rate of operative delivery was 21.1% in the moderate group compared with 24.8% in the intensive group (P=.08). The episiotomy rate was significantly lower in the moderate pushing group than in the intensive pushing group (13.5% vs 17.8%; P=.02). We found no significant difference for obstetrical anal sphincter injuries, postpartum hemorrhage, or maternal satisfaction., Conclusion: Moderate pushing has no effect on neonatal morbidity, but it may nonetheless have benefits, as it was associated with a lower episiotomy rate., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Disparities in access to pain management have been identified in several care settings, such as emergency departments and intensive care units, but with regard to labour analgesia, it remains poorly explored., Objectives: To determine the proportion of women without pain management during labour and its individual and organisational determinants., Design: Secondary analysis of a nationwide cross-sectional population-based study, the 2016 French National Perinatal Survey., Settings: All maternity units in France., Participants: Ten thousand and eleven women who attempted vaginal delivery with a labour duration at least 15 min., Main Outcome Measure: Absence of pain management, defined as absence of any pharmacological or nonpharmacological analgesic method during labour., Results: Among the 10 011 women included, 542 (5.4%) had no labour pain management: 318 (3.7%) of the 8526 women who initially preferred to use neuraxial analgesia and 222 (15.8%) of the 1402 who did not. Using generalised estimating equations stratified according to the maternal antenatal preference for neuraxial analgesia, the common determinants of no labour pain management in both groups were no attendance at childbirth education classes and admission to a delivery unit during the night. Among women who initially preferred to use neuraxial analgesia, those who delivered in units with <1500 annual deliveries compared with units with 2000 to 3499 annual deliveries, were more likely to do without pain management [adjusted odds ratio (OR) = 1.96; 95% confidence interval (CI), 1.39 to 2.78]; among those who did not prefer to use it, women born abroad were more likely to do without labour pain management (adjusted OR = 1.64; 95% CI, 1.12 to 2.40)., Conclusion: In France, 1 : 20 women had no labour pain management, and this proportion was three times higher among women who preferred not to use neuraxial analgesia. Enhancing maternal information on labour pain and its management, especially nonpharmacological methods, and rethinking care organisation, could improve access to analgesia of any kind., (Copyright © 2022 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.)

Background: Severe acute maternal morbidity (SAMM) accounts for any life-threatening complication during pregnancy or after delivery. Measuring and monitoring SAMM seem critical to assessing the quality of maternal health care. The objectives were to explore the validity of intensive care unit (ICU) admission as an indicator of SAMM by characterizing the profile of women admitted to an ICU and of their ICU stay, according to the association with other SAMM criterion., Methods: We performed a secondary analysis of the 2540 women with SAMM included in the epidemiology of severe acute maternal morbidity (EPIMOMS) multiregional prospective population-based study (2012-2013, n = 182,309 deliveries). The EPIMOMS definition of SAMM, based on national experts' consensus, is a combination of diagnosis, organ dysfunctions, and intervention criteria, including ICU admission. Among women with SAMM, we identified characteristics associated with maternal ICU admission with or with no other SAMM criterion compared with ICU admission, by using multivariable multinomial logistic regression models., Results: Overall, 511 women were admitted to an ICU during or up to 42 days after pregnancy, for a population-based rate of 2.8 of 1000 deliveries (511/182,309; 95% confidence interval [CI], 2.6-3.1); 15.5% of them (79/511; 95% CI, 12.4-18.9) had no other SAMM criterion compared with ICU admission. Among women with SAMM, the odds of ICU admission with no other morbidity criterion were increased in women with preexisting medical conditions (adjusted odds ratio (aOR), 2.13; 95% CI, 1.17-3.86) and cesarean before labor (aOR, 3.12; 95% CI, 1.47-6.64). Women admitted to ICU with no other SAMM criterion had more often decompensation of a preexisting condition, no interventions for organ support, and a shorter length of stay than women admitted with other SAMM criteria., Conclusions: Among women with SAMM, 1 in 5 is admitted to an ICU; 15.5% of those admitted in ICU have no other SAMM criterion and a less acute condition. These results challenge the use of ICU admission as a criterion of SAMM., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2021 International Anesthesia Research Society.)

Purpose: Neuraxial analgesia is effective and widely used during labour, but little is known about maternal satisfaction with its use. Our objectives were to assess the frequency of incomplete maternal satisfaction with neuraxial labour analgesia and its predictors., Methods: We extracted data from the 2016 National Perinatal Survey, a cross-sectional population-based study including all births during one week in all French maternity units. This analysis included all women who attempted vaginal delivery with neuraxial analgesia. Maternal satisfaction with analgesia was assessed by a 4-point Likert scale during a postpartum interview. Incomplete satisfaction grouped together women who were fairly, not sufficiently and not at all satisfied. We performed generalised estimating equations analyses adjusted for sociodemographic, obstetric, anaesthetic, and organisational characteristics to compare women with incomplete satisfaction to those completely satisfied., Results: Among the 8538 women included, 35.2% were incompletely satisfied with their neuraxial analgesia. The odds of incomplete satisfaction were higher among women who reported a prenatal preference not to use neuraxial analgesia but subsequently did (adjusted odds ratio 1.21; 95% confidence interval 1.05-1.39) and among those who did not use patient-controlled neuraxial analgesia (1.20; 1.07-1.34); the odds were lower among women who used combined spinal epidural analgesia (0.53; 0.28-0.99) than among those with epidural analgesia., Conclusion: Incomplete maternal satisfaction with neuraxial analgesia is a frequent concern in France. Increasing the use of patient-controlled neuraxial analgesia and combined spinal-epidural analgesia, as well as consistency between prenatal preference and actual use of neuraxial analgesia may improve maternal satisfaction., (Copyright © 2021 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objective: To determine the rate and profile of repeated maternal ICU admissions during or after pregnancy and to compare the characteristics of these women's first and second ICU admissions., Methods: A descriptive analysis from the French national hospital discharge database that included all women admitted to an ICU during pregnancy or within 42 days after delivery, between 2010 and 2014., Results: During the 5-year study period, there were 371 women with more than one maternal ICU admission, representing 2.5% of all women admitted during or after pregnancy (371/15,096) and a 0.9 per 10,000 deliveries (371/4,030,409) rate of repeated maternal ICU admission. Compared with women with only one maternal ICU admission, those with repeated maternal ICU admissions were more often admitted during the pregnancy rather than during or after the delivery stay (P < 0.001), for organ failure or sepsis (P < 0.001), and with a SAPS-II score > 25 (P < 0.001). Women with repeated admissions were usually readmitted for the same indications and had similar SAPS-II scores. Half of ICU readmissions occurred within 72 h of first ICU discharge, with similar causes and levels of severity for both stays., Conclusion: Although the rate of women with repeated maternal ICU admissions was low, their initial stay had a specific profile of causes of admission and greater severity compared with the stay of women admitted only once. The pattern and similar characteristics of both first and second ICU admission and the short interval for readmission suggests that some ICU discharges may have been potentially premature., (Copyright © 2021 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objectives: Despite the guidelines in effect, too few women in France receive folic acid supplementation. The principal objective of this study was to identify the factors associated with the inadequacy of this supplementation in the periconceptional period. The secondary objective was to assess women's knowledge about the prevention of neural tube defects (NTDs)., Methods: This study included 400 women and took place in 8 Parisian maternity. Folic acid supplementation was inadequate when started after the beginning of the pregnancy., Results: Among the women questioned, 68% had inadequate folic acid supplementation. They were significantly younger (ORa= 1,8; 95% IC [1,1-2,8]), didn't had health insurance (ORa=3,9; 95% IC [1,5-10,1]), had not studied after high school (ORa=2,9; 95% IC [1,2-6,9]) and had regular gynecological care less often than the women with adequate supplementation (ORa=3,0; 95% IC [1,6-5,6]). More than half (55.5%) had insufficient knowledge of the benefits of folic acid; the factors related to this lack of knowledge were the absence of regular gynecological care and of health insurance., Conclusion: Individual factors associated with a lack of supplementation have been identified. These results provide health professionals and supervisors with useful information for developing strategies adapted to certain subgroups of women for better prevention of AFTN in these populations., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Besides neuraxial analgesia, nonpharmacological methods are also proposed to help women coping with pain during labor. We aimed to identify the individual and organizational factors associated with the use of nonpharmacological analgesia for labor pain management. Women who attempted vaginal delivery with labor analgesia were selected among participants included in the 2016 National Perinatal Survey, a population-based cross-sectional study. Labor analgesia was studied as neuraxial analgesia alone, nonpharmacological analgesia alone, and neuraxial and nonpharmacological analgesia combined. The associations were studied using multilevel multinomial logistic regression. Among the 9231 women included, 62.4% had neuraxial analgesia alone, 6.4% had nonpharmacological analgesia alone, and 31.2% had both. Nonpharmacological analgesia alone or combined with neuraxial analgesia were both associated with high educational level (adjusted odds ratio 1.55; 95% confidence interval [CI], 1.08-2.23 and 1.39; 95% CI, 1.18-1.63), antenatal preference to deliver without neuraxial analgesia, and public maternity unit status. Nonpharmacological analgesia alone was more frequent among multiparous women, and in maternity units with an anesthesiologist not dedicated to delivery unit (1.57; 95% CI, 1.16-2.12) and with the lowest midwife workload (2.15; 95% CI, 1.43-3.22). Neuraxial and nonpharmacological analgesia combined was negatively associated with inadequate prenatal care (0.70; 95% CI, 0.53-0.94). In France, most women who had nonpharmacological analgesia during labor used it as a complementary method to neuraxial analgesia. The use of nonpharmacological analgesia combined with neuraxial analgesia mainly depends on the woman's preference, but also on socioeconomic factors, quality of prenatal care, and care organization.

Background: Monitoring severe acute maternal morbidity (SAMM) appears essential for optimising care and informing health care policies, especially given changes in obstetric practices and mother profiles. International comparisons can identify areas where improvement is needed, but the comparability of indicators must be evaluated., Objective: To assess the feasibility of monitoring SAMM using common definitions from hospital discharge databases across Europe., Methods: We used hospital discharge data in eight countries (2 826 868 deliveries) to identify women with SAMM among all hospitalisations of women of reproductive age admitted for antenatal or delivery care. Five SAMM indicators were investigated: eclampsia, septicaemia, hysterectomy, hysterectomy associated with a diagnosis of obstetric haemorrhage, and red blood cell (RBC) transfusion associated with a diagnosis of obstetric haemorrhage. Between-country variation was described, by the ratio of the highest to lowest rates, while external validation was assessed by comparing with population-based studies on maternal morbidity., Results: Ratios for hysterectomy and red blood cell (RBC) transfusion in the context of obstetric haemorrhage were 1:2.1 and 1:3.5, respectively. High values of hysterectomy and low values of transfusion were both consistent with high maternal mortality from haemorrhage (France, Italy, Portugal). Ratios across countries were relatively low for eclampsia (1:3.4) but very high for septicaemia (1:22.5). Compared to population-based morbidity estimates, eclampsia was over-reported in hospital databases whereas the two indicators of severe haemorrhage had good external validity., Conclusions: In association with diagnosis codes indicating obstetric haemorrhage, hysterectomy and RBC transfusion appear to be good candidates for surveillance of maternal morbidity in Europe., (© 2019 John Wiley & Sons Ltd.)

Introduction: Maternal intensive care unit admission is an indicator of severe maternal morbidity. The objective of this study was to estimate rates of maternal intensive care unit admission during or following pregnancy in France, and to describe the characteristics of women concerned, the severity of their condition, associated diagnoses, regional disparities, and temporal trends between 2010 and 2014., Methods: Women hospitalised in France in intensive care units during pregnancy or up to 42 days after pregnancy between January 2010 and December 2014 were identified using the national hospital discharge database (PMSI-MCO). Trends in incidence rates were quantified using percentages of average annual variation based on a Poisson regression model., Results: In total, 16,011 women were admitted to intensive care units, representing an overall incidence of 3.97‰ deliveries. This number decreased significantly by 1.7% on average per year. For women who gave birth (60.5% by C-section), 62.5% of admissions occurred during their hospitalisation for delivery. The SAPS II score, an indicator of severity, significantly increased from 18.4 in 2010 to 21.5 in 2014. Obstetrical haemorrhage (39.8%) and hypertensive complications during pregnancy (24.8%) were the most common reasons for admission. In mainland France, the Ile-de-France (i.e., greater Paris) region had the highest rates of intensive care units admission (5.05‰) while the Pays-de-la-Loire region had the lowest (2.69‰)., Conclusion: The rate of maternal intensive care unit admission decreased from 2010 to 2014 in France, with a concomitant increase in case severity. In-depth studies are needed to understand the territorial disparities identified., (Copyright © 2019 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objective: To investigate the association between in vitro fertilisation IVF and severe maternal morbidity (SMM) and to explore the role of multiple pregnancy as an intermediate factor., Design: Population-based cohort-nested case-control study., Setting: Six French regions in 2012/13., Population: Cases were 2540 women with SMM according to the EPIMOMS definition; controls were 3651 randomly selected women who gave birth without SMM., Methods: Analysis of the associations between IVF and SMM with multivariable logistic regression models, differentiating IVF with autologous oocytes (IVF-AO) from IVF with oocyte donation (IVF-OD). The contribution of multiple pregnancy as an intermediate factor was assessed by path analysis., Main Outcome Measures: Severe maternal morbidity overall and SMM according to its main underlying causal condition and by severity (near misses)., Results: The risk of SMM was significantly higher in women with IVF (adjusted OR = 2.5, 95% CI 1.8-3.3). The risk of SMM was significantly higher with IVF-AO, for all-cause SMM (aOR = 2.0, 95% CI 1.5-2.7), for near misses (aOR = 1.9, 95% CI 1.3-2.8), and for intra/postpartum haemorrhages (aOR = 2.3, 95% CI 1.6-3.2). The risk of SMM was significantly higher with IVF-OD, for all-cause SMM (aOR = 18.6, 95% CI 4.4-78.5), for near misses (aOR = 18.1, 95% CI 4.0-82.3), for SMM due to hypertensive disorders (aOR = 16.7, 95% CI 3.3-85.4) and due to intra/postpartum haemorrhages (aOR = 18.0, 95% CI 4.2-77.8). Path-analysis estimated that 21.6% (95% CI 10.1-33.0) of the risk associated with IVF-OD was mediated by multiple pregnancy, and 49.6% (95% CI 24.0-75.1) of the SMM risk associated with IVF-AO., Conclusion: The risk of SMM is higher in IVF pregnancies after adjustment for confounders. Exploratory results suggest higher risks among women with IVF-OD; however, confidence intervals were wide, so this finding needs to be confirmed. A large part of the association between IVF-AO and SMM appears to be mediated by multiple pregnancy., Tweetable Abstract: The risk of severe maternal morbidity is higher in IVF-conceived pregnancies than in pregnancies conceived by other means., (© 2019 Royal College of Obstetricians and Gynaecologists.)

Objectives: Most indicators proposed for assessing quality of care in obstetrics are process indicators and do not directly measure health effects, and cannot always be identified from routinely available databases. Our objective was to propose a set of indicators to assess the quality of hospital obstetric care from maternal morbidity outcomes identifiable in permanent hospital discharge databases., Methods: Various maternal morbidity outcomes potentially reflecting quality of obstetric care were first selected from a systematic literature review. Then a three-round Delphi consensus survey was conducted online from 11/2016 through 02/2017 among a French panel of 37 expert obstetricians, anesthetists-critical-care specialists, midwives, quality-of-care researchers, and user representatives. For a given maternal outcome, several definitions could be proposed and the indicator (i.e. corresponding rate) could be applied to all women or restricted to specific subgroup(s)., Results: Of the 49 experts invited to participate, 37 agreed. The response rate was 92% in the second round and 97% in the third. Finally, a set of 13 indicators was selected to assess the quality of hospital obstetric care: rates of uterine rupture, postpartum hemorrhage, transfusion incident, severe perineal lacerations, episiotomy, cesarean, cesarean under general anesthesia, post-cesarean site infection, anesthesia-related complications, postpartum pulmonary embolism, maternal readmission and maternal mortality. Six were considered in specific subgroups, with, for example, the postpartum hemorrhage rate assessed among all women and also among women at low risk of PPH., Implications: This Delphi process enabled us to define consensually a set of indicators to assess the quality of hospital obstetrics care from routine hospital data, based on maternal morbidity outcomes. Considering 6 of them in specific subgroups of women is especially interesting. These indicators, identifiable through codes used in international classifications, will be useful to monitor quality of care over time and across settings., Competing Interests: The authors have declared that no competing interests exist.

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., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

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 women's 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 women's 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 woman's active choice., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To study the association between the duration of oxytocin augmentation intervals and the risk of postpartum haemorrhage (PPH) among primiparous women in spontaneous labour., Materials and Methods: Retrospective cohort including primiparous women in spontaneous labour who received oxytocin during labour (n=454). Oxytocin augmentation intervals were dichotomized in intervals<20minutes and≥20minutes. Obstetrical and neonatal issues were analyzed according to the duration oxytocin augmentation intervals. The association between oxytocin augmentation intervals and PPH was analyzed using univariate and multivariate analysis., Results: Oxytocin augmentation intervals were shorter than 20minutes for 43.8% of the study population. The rate of PPH was higher (9.1% vs 3.5%; P=0.014), and the use of sulprostone was more frequent (6.5% vs 3.5%; P=0.013) if oxytocin augmentation intervals were shorter than 20minutes in comparison with intervals≥20minutes. The association between oxytocin augmentation intervals and PPH remains significant after adjustment on other PPH risk factors (adjusted OR=3.48, 95% CI [1.45-8.34]). The rate of adverse neonatal issue, defined by arterial pH at birth≤7.10 and/or 5minutes score d'Apgar≤7, was higher if oxytocin augmentation intervals were<20minutes (12.1% vs 4.3%; P=0.002)., Conclusion: Our study demonstrated an increased risk of PPH for primiparous women in spontaneous labour who received oxytocin with augmentation intervals shorter than 20minutes., (Copyright © 2016. Published by Elsevier Masson SAS.)

Objective: Provide guidelines for clinical use of non-pharmacological and pharmacological treatments of inhibition of lactation and the management of the weaning., Materials and Methods: Systematically review of the literature between 1972 and May 2015 from the databases Medline, Google Scholar, Cochrane Library, and the international recommendations about inhibition of lactation with establishment of levels of evidence (LE) and grades of recommendation., Results: The available data on the effectiveness of non-pharmacological measures are limited, with very low levels of evidence that fail to make recommendations (Professional consensus). Pharmacological treatments for inhibition of lactation should not be given routinely to women who do not wish to breast-feed (Professional consensus). For women aware of the risks of pharmacological treatments of inhibition of lactation, lisuride and cabergolin are the preferred drugs (Professional consensus). Because of potentially serious adverse effects, bromocriptin is contraindicated in inhibiting lactation (Professional consensus). Available data on management of lactation weaning fail to provide recommendation and no treatment is recommended (Professional consensus)., Conclusion: Bromocriptin is contraindicated in the treatment of inhibiting lactation. Women who do not wish to breast-feed have to be informed of the benefits and disadvantages of the pharmacological treatment for inhibition of lactation., (Copyright © 2015. Published by Elsevier Masson SAS.)

Objective: To describe the practical aspects of the use of the most commonly prescribed drugs during the postpartum period, the dietetic measures and the management of breast-feeding in case of addictive behaviors., Methods: Review of the literature between 1972 and May 2015 from the databases Medline, Google Scholar, Cochrane Library, and international recommendations of learned societies., Results: The precaution to stop breast-feeding when drugs are necessary is not justified in many situations (professional consensus). Aspirin at antiaggregant dose is allowed during breast-feeding while high doses are not recommended; NSAIDs with short half-life can be used (professional consensus). Precautions are needed in cases of use of morphonics (professional consensus). There is no justification to delay the initiation of breast-feeding in case of locoregional or general analgesia or for caesarean section. Antibiotic treatment does not justify discontinuing breast-feeding (professional consensus). Anxiolytics of the class of antihistaminic sedating H1 such as hydroxyzine (Atarax®) should not be prescribed in case of breast-feeding (professional consensus). Imaging does not justify to stop breast-feeding (professional consensus). Tobacco consumption is discouraged but is not a contraindication to breast-feed (professional consensus). It is recommended to avoid the consumption of alcohol (professional consensus). In case of occasional and moderate consumption of alcohol, delaying breast-feeding for a minimum of two hours is recommended (professional consensus). Cocaine consumption is a contraindication of breast-feeding (professional agreement), and breast-feeding is not recommended in case of cannabis use (professional consensus)., Conclusion: Few drug treatments are not compatible with breast-feeding that can be continued in most of the cases., (Copyright © 2015. Published by Elsevier Masson SAS.)

Objective: Provide guidelines for management of breastfeeding complications., Materials and Methods: Systematically review of the literature between 1972 and May 2015 from the database Medline, Google Scholar, Cochrane Library, and the international recommendations about inhibition of lactation with establishment of levels of evidence (EL) and grades of recommendation., Results: Nipple stimulation preparation techniques or antenatal correction an anatomical variation of the nipple are not recommended to decrease nipple complications or improve the success of breastfeeding (grade B). The use of lanolin and application of breast milk may have an interest in diseases of the nipple (EL4). The current published data are insufficient to conclude on the effectiveness of nipple shield, (professional consensus). Manual breast expression or using a breast pump may have an interest in preventing breast engorgement (professional agreement). A bacteriological sample of milk for mastitis is necessary to decide an antibiotic and interrupt breastfeeding with breast infected while continuing its drainage with a breast pump (professional consensus). Incision and drainage of breast abscess are recommended (professional consensus) and iterative puncture is an alternative to surgical drainage in the moderate forms (professional consensus). Breastfeeding is not contraindicated for women with a past history of esthetic breast surgery or breast cancer (professional consensus). There is no scientific justification to recommend the use of breast pumps to improve breastfeeding (grade B). Because of the potential side effects, the use of domperidone and metoclopramide are not recommended in the stimulation of lactation (grade C)., Conclusion: Breastfeeding exposes women to specific complications, which may impede the continuation of breastfeeding. Prevention of mastitis is essential., (Copyright © 2015. Published by Elsevier Masson SAS.)

Objectives: The objectives were to on assess the frequency and the duration of breastfeeding in France. On the other hand, the objectives were to identify its benefits and drawbacks, and to study the factors influencing its initiation and its extension., Material and Methods: Bibliographic research in Medline, Google Scholar and in the Cochrane Library., Results: Breastfeeding concerns in France about 70% of children at birth (EL2). Its median duration is about 15 weeks and 3 weeks ½ for exclusive breastfeeding. At three months, only one third of children breastfed at birth are still being breastfed (EL2). Whether this is due to the composition of breast milk or the behavior of mothers with their children or their socio-cultural level, or even by all these components at once, breastfeeding is associated with better cognitive development children (EL2). This effect is even more reinforced that mothers breastfeed exclusively and prolonged (EL2). As part of the prevention of many diseases (ear infections, gastrointestinal infections, atopic diseases, obesity and cardiovascular diseases…), exclusive and prolonged breastfeeding (grade B) between 4 to 6 months is recommended (professional consensus). Breastfeeding is not a means of preventing postpartum depression (professional consensus). To reduce the incidence of breast cancer, prolonged breastfeeding is recommended (grade B). In order to increase the rate of initiation of breastfeeding as well as its duration, it is recommended that health professionals work closely with mothers in their project (grade A), the breastfeeding promotion messages include message to husbands (grade B), and to promote breastfeeding on demand without fixed interval between feedings (grade B). However, there is not enough data to recommend the use of a specific position during breastfeeding, or the use of one or two breast or to early start breastfeeding or not (professional consensus)., Conclusion: Exclusive and extended breastfeeding is recommended (grade B) between 4 to 6 months (professional consensus)., (Copyright © 2015. Published by Elsevier Masson SAS.)

Objective: To determine the national rate per delivery of pregnancy-related ICU admissions of women in France, the characteristics and severity of these cases, and their trends over the 4-year study period., Design: Descriptive study from the national hospital discharge database., Setting: All ICUs in France., Patients: All women admitted to an ICU during the pregnancy, the delivery, or the postpartum period from January 1, 2006, to December 31, 2009., Interventions: None., Measurements and Main Results: Of 3,262,526 deliveries, 11,824 women had pregnancy-related ICU admissions, for an overall rate of 3.6 per 1,000 deliveries. The conditions reported most frequently were obstetric hemorrhages (34.2%) and hypertensive disorders of pregnancy (22.3%). Case severity was assessed with four markers: case-fatality rate (1.3%), length of ICU stay (mean, 3.0 ± 0.1 d), Simplified Acute Physiology Score II score (mean: 19.7 ± 0.1), and a SUP REA code, which indicates the combination of a Simplified Acute Physiology Score II score more than or equal to 15 and at least one specific procedure related to life support or organ failure (23.0%). The most frequent causes of ICU admission were those associated with the least severity in the ICU. During the study period, the rate of pregnancy-related ICU admissions decreased from 3.9 to 3.4 per 1,000 deliveries (p < 0.001), whereas the overall severity of cases increased with longer stays, higher Simplified Acute Physiology Score II scores, and a greater proportion of SUP REA codes (all p < 0.001). Analysis by principal diagnosis showed that the severity of the condition of women admitted to ICU significantly increased over time for hemorrhages and hypertensive complications., Conclusions: The rate of women with pregnancy-related ICU admissions decreased and the severity of their cases increased. Most ICU admissions remained related to the least severe conditions. This raises the issue of the most appropriate organization of care for women with pregnancy-related conditions who require continuous surveillance but not necessarily intensive care.

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., (© 2014 John Wiley & Sons Ltd.)

Introduction: Diagnostic accuracy of first-line sonographic evaluation by obstetrics/gynecology residents in determining the need for emergency surgery in women with acute pelvic pain is unknown. Aim of this study was to evaluate the diagnostic accuracy of routine ultrasound evaluation by obstetrics/gynecology residents, available 24 hours a day, in patients with acute pelvic pain., Methods: A cross-sectional retrospective study included consecutive patients who underwent emergency laparoscopy for acute pelvic pain at a teaching hospital gynecologic emergency unit, between January 1, 2004, and December 31, 2006. The laparoscopic diagnosis was the reference standard. Gynecologic and nongynecologic conditions requiring immediate surgery to avoid severe morbidity or death were defined as surgical emergencies. In all patients, obstetrics/gynecology residents routinely performed clinical examination and standardized ultrasonography was routinely recorded. Sonograms were re-interpreted for the study, blinded to physical examination and laparoscopic findings, according to evidence-based predetermined criteria. Sensitivity, specificity, and likelihood ratios were computed for clinical data alone, sonographic data alone, and the combination of both., Results: Emergency laparoscopy was performed in 234 patients, diagnosing 139 (59%) surgical emergencies. Clinical and sonographic examinations performed by the residents each independently predicted a need for emergency surgery. Combining both examinations was superior over each examination alone and had an acceptable false-negative rate of 1%., Conclusions: First-line combined clinical and sonographic examination by obstetrics/gynecology residents is effective in ruling out surgical emergencies in patients with acute pelvic pain.

Background: The organization of obstetric care in France brings all women in contact with the hospital system. Thus, hospital discharge data from the Program of Medicalization of the Information System (PMSI) constitute a potentially valuable source of information, particularly regarding rare events such as severe maternal morbidity. These data cover a large population but their quality has not been assessed in that field. Our objectives were to study the processes of production and the validity of PMSI data related to severe maternal morbidity., Methods: The study was conducted in four French tertiary teaching hospitals (Caen, Cochin [AP-HP, Paris], Grenoble and Lille). First, the organization of each step of the medical information process -production, formatting, verification and processing- was detailed in each center with a standardized form. Second, the validation study was based on the comparison of data related to severe maternal morbid events in the PMSI from these centers for 2006 and 2007, with the content of medical records which constituted the gold standard. Indicators of sensitivities and positive predictive values of PMSI were calculated., Results: The processes of PMSI data production showed major differences between the four centers. In hospital discharge data, diagnoses (eclampsia and pulmonary embolism) had a high proportion of false-positives (68%). Inversely, procedures (four procedures for management of severe haemorrhage) had less than 1% of false-positives, but a low sensitivity with 37% false-negatives which could be corrected in 95%. Regarding intensive care provision, all indicators of hospital data quality were very high. In addition, the validity of hospital data in centers 1 and 2 was higher for all events., Conclusion: The heterogeneity of the process of PMSI data production is associated with a variable quality of these data. Intensive care provision can be used in the PMSI, as well as procedures after correction. For diagnoses, the quality of the PMSI data is better in centers having both computerized medical records and steps for verification of medical information., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Objective: To identify routine clinical, ultrasound, and biologic criteria to assess the volume of hemoperitoneum in women with ectopic pregnancy (EP)., Methods: Except for patients with hemodynamic shock, all women assigned to surgical laparoscopic treatment for confirmed EP at Poissy Saint Germain en Laye Hospital between January 2004 and December 2007 were included in the study. The patients underwent abdominal and digital pelvic examination, and standardized ultrasonography. Ordered logistic regression analysis was performed to select criteria associated with an increase in hemoperitoneum. The diagnostic accuracy of each variable was then calculated for different hemoperitoneum cut-off values., Results: The study included 215 patients. Pelvic pain of 4 or above on a numeric rating scale (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.1), abdominal guarding or rebound tenderness (OR, 4.6; 95% CI, 2.0-10.8), hemoglobin under 10 g/dL (OR, 12.2; 95% CI, 4.2-35.8), presence of fluid at transvaginal ultrasound (OR, 3.6; 95% CI, 1.4-9.2), and fluid in Morison pouch at abdominal ultrasound (OR, 5.6; 95% CI, 2.0-15.9) were found to be independently associated with hemoperitoneum., Conclusion: Both clinical examination and standardized ultrasonography were found to be useful for accurate evaluation of hemoperitoneum in patients presenting with EP., (Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Objective: To evaluate fetal and neonatal outcomes related to prolonged pregnancy., Methods: This study is based on Pubmed search, Cochrane library and HAS recommendations., Results: The risk of fetal complications including macrosomia (6 %), oligohydramnios (10 %-15 %), abnormal fetal heart rate pattern and meconium-stained fluid is increased in prolonged pregnancy (≥ 41(+0) weeks). The rate of stillbirth was estimated between 1.6 ‰ and 3.0 ‰ live births according to countries in post-term pregnancies (≥ 42(+0) weeks). The risk of umbilical cord pH less than 7.10, Apgar score at five minutes inferior to 7, ICU admissions and perinatal asphyxia is increased in post-term infants (≥ 42(+0) weeks) compared with term infants. The risk of neurologic complications including neonatal convulsion, hypoxic ischemic encephalopathy, cerebral palsy, developmental deviations and epilepsy in childhood is increased in post-term infants. The risk of meconium aspiration syndrome, neonatal sepsis, and birth trauma including shoulder dystocia and bone fracture is increased in post-term infants. The rate of perinatal mortality increases in post-term infants. The perinatal mortality in post-term infants could be explained by perinatal asphyxia and meconium aspiration syndrome., Conclusions: The risk of perinatal complications and mortality are increased in prolonged pregnancy., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: To estimate the frequency of prolonged pregnancy and study its associated maternal morbidity., Methods: Abstracts and articles were searched using Pubmed and Cochrane Library., Results: Nearly 15% of pregnant women in France are concerned by prolonged pregnancy (≥41(+0) weeks), whereas post-term pregnancy (≥42(+0) SA) only concern 1% of them. The post-term pregnancy frequency is heterogeneous between Europe and United States. It varies between 0.5% and 10% (EL2). In Europe, Scandinavian countries present discrepancies with high proportions of post-term pregnancies between 5 and 7%. These observations identified time variations and variations between countries. They can be explained by two factors: pregnancy datation by ultrasound and the evolution of labor induction practices. Moreover, post-term pregnancy constitute a risk factor of maternal complications as: cesarean section, postpartum haemorrhages, infections and perineum lacerations (EL2). On the contrary, limited conclusions about associations between prolonged pregnancies and labor inductions are due to insufficient data and the lack of high quality studies. Nowadays, we still ignore if labor inductions in the particular context of prolonged pregnancies are associated or not to an increase of maternal morbidities., Conclusion: Prolonged pregnancy is associated with an excess of maternal morbidity., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Objective: To estimate the accuracy and reliability of the reporting of diagnoses and procedures related to severe acute maternal morbidity in French hospital discharge data., Study Design and Setting: The study, conducted in four French tertiary teaching hospitals, covered the years 2006 and 2007 and 30,607 deliveries. We identified severe maternal morbid events-eclampsia, pulmonary embolism, procedures related to postpartum hemorrhages, and intensive care-in administrative hospital discharge data and medical records and compared their recording. Information from medical records was the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value of the hospital discharge data for these events were calculated. False positives and false negatives were examined to identify the reasons for misrecorded information., Results: The PPV of the hospital discharge data was 20% for eclampsia. For procedures related to postpartum hemorrhages, the PPVs were high, but sensitivities were lower; however, 95% of recording errors could be corrected. All indicators for intensive care exceeded 98%., Conclusion: Intensive care and procedures seem reliably reported in the hospital administrative database, which, therefore, can be used to monitor them. Using these data for monitoring diagnoses will require a greater investment by clinicians in the accuracy of their reporting., (Copyright © 2011 Elsevier Inc. All rights reserved.)