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Objective: The primary objective was to describe the evolution of the prevalence of maternal obesity in France. The secondary objectives were to assess changes in the French regions and the place of birth according to type (public/private) and level of care., Material and Methods: Study based population of all births between 1999 and 2009 included in the AUDIPOG database. Our judgment criterion was the body mass index (BMI) divided into classes., Results: Seventy-four thousand and forty-six pregnancies were included. The mean BMI was 22.9±4.5kg/m(2) with an increase between 1999-2001 and 2008-2009 (22.6±4.3kg/m(2) versus 23.1±4.7kg/m(2), P<10(-4)). North was the first region in terms of overweight patients (18%) and obese (10.2%). There was an increase of the birth rate in public maternity, and level II and III regardless of BMI class. Only the class of patients with a BMI ≥40kg/m(2) delivered more frequently in level III with an increase between the first and the last period of the study (20.8% versus 36.8%, P=0.02)., Conclusion: The BMI is still increasing with more and more patients with a BMI ≥40kg/m(2) referred to level III. This raises the question of the organization of care and follow-up of these patients., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objective of the Review: To identify predictors of preterm delivery in the context of threatened preterm labour., Main Points: Tobacco use and previous history of preterm delivery are the main anamnestic elements to predict preterm birth. High positive predictive value of vaginal examination is restricted to cases with strong cervical alterations like dilatation over 4 cm. In case of discrete cervical alterations, literature confirms the great interest for cervical length ultrasonographic measurement as it reduces false positive cases. Absence of fetal respiratory movements appears to be as sensitive as cervical length and could be more specific but its clinical use remains rare. Vaginal detection of fetal fibronectin is the most useful biomarker with high negative predictive value (>90%). Fibronectin quantitative test seems to enhance the positive predictive value. No other biomarker is currently used in clinical practice. Electromyography and elastography of the cervix appear to be promising approaches., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Objectives: Study of epidemiology of pregnancy loss., Materials and Method: A systematic review of the literature was performed using Pubmed and the Cochrane library databases and the guidelines from main international societies., Results: The occurrence of first trimester miscarriage is 12% of pregnancies and 25% of women. Miscarriage risk factors are ages of woman and man, body mass index greater than or equal to 25kg/m(2), excessive coffee drinking, smoking and alcohol consumption, exposure to magnetic fields and ionizing radiation, history of abortion, some fertility disorders and impaired ovarian reserve. Late miscarriage (LM) complicates less than 1% of pregnancies. Identified risk factors are maternal age, low level of education, living alone, history of previous miscarriage, of premature delivery and of previous termination of pregnancy, any uterine malformation, trachelectomy, existing bacterial vaginosis, amniocentesis, a shortened cervix and a dilated cervical os with prolapsed membranes. Fetal death in utero has a prevalence of 2% in the world and 5/1000 in France. Its main risk factors are detailed in the chapter., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Objectives: To determine if perinatal and neonatal morbidity and mortality is improved by a planned caesarean section for twins before and at term., Methods: A systematic search was conducted in Medline between May 2001 and December 2008. Randomised controlled studies and meta-analysis were researched at first., Results: There is no evidence to support a policy of planned caesarean section or vaginal delivery for twins before term or at term whatever the presentation of the first twin. There is also no evidence to support a policy of caesarean section or vaginal delivery for a patient with a history of prior caesarean section. Vaginal delivery must be made in the presence of an obstetrician, an anaesthesiologist, and a paediatrician in a level maternity adapted to the risks of the future newborn., Conclusion: Otherwise, there is no evidence to support a policy of planned caesarean delivery for twins but the type of delivery has to be decided with the informed patient., (Copyright © 2009 Elsevier Masson SAS. All rights reserved.)

Objective: To describe invasive diagnostic procedures (amniocentesis/choriocentesis) and subsequent risks in twin pregnancies., Material and Methods: PubMed and Cochrane database investigations were conducted using following key words: twin gestation, amniocentesis, chorionic villous sampling, karyotype. Guidelines for twin management edicted by different societies were reviewed., Results: Risk of pregnancy loss after invasive diagnostic procedure in twin pregnancies seems to be slightly higher to singletons, i.e about 1.5-2% after mid-trimester amniocentesis and about 2% after first trimester choriocentesis. Dual sampling is not always mandatory but can be performed on parent's request. Specific risks are associated with twins: redundant sampling, permutation or misidentification of affected twin in case of discordant status. Procedures should be performed by highly-skilled operators under permanent ultrasound-guidance. A scheme describing placental locations and funicular insertions appears to be useful for correct identification. If foeticide can be anticipated, diagnostic procedure and foeticide should be performed by the same operators. For amniocentesis, one or two needles can be used except for cases with infectious disease (two needles and two separate insertions required). For choriocentesis, sampling should be performed close to funicular insertions., Conclusion: First-trimester choriocentesis makes earlier diagnosis and earlier foeticide possible compared with mid-trimester amniocentesis. Both techniques require highly-skilled operators to reduce subsequent risks in the context of twin pregnancies., (Copyright © 2009 Elsevier Masson SAS. All rights reserved.)

Objectives: Our goal was to evaluate the level of integration of general practitioners within the perinatal network in the Auvergne., Materials and Methods: A cross-sectional study was realized. The questionnaire was sent by post to the 1346 general practitioners who were members of the "Union régionale des médecins libéraux" (Regional association of private doctors in the Auvergne). Follow-up phone calls were also made., Results: The overall response to the questionnaire was 29.8%. Of those who replied, 76.3% were involved in the care of pregnant women or newly born babies. Among them, 51.2% had a consultation with a pregnant woman less than once a week and 53,5% had a consultation with a newly born more than once a week. A third were aware of the network and 25.7% had knowledge of the medical record provided by the network. Among them, 91.3% thought that a common medical record was necessary to improve the coordination of care. The answers differed according to age, area of responsibility, the administrative geographic position in the Auvergne, type of practise (hospital, private), and the sex of those who replied., Conclusion: Despite a high a priori agreement, we must improve the level of information and training given to general practitioners within our perinatal network.

Objectives: The aim of this study was to assess the lurning curve of young residents for vacuum extraction., Materials and Methods: All vacuum extractions performed in our department by five residents (< or =5th semester) during a study period of nine months were systematically supervised by a senior who fulfilled an assessment questionnaire from which was calculated a score reflecting the quality of the extraction., Results: Fifty-four vacuum extractions were assessed with a mean of 10.8+/-2.9 (range, 10-13) procedures by resident. We compared the group including the six first procedures performed by each resident (group 1, n = 30) with the group including the following procedures (group 2, n = 24). We observed in the group 2 compared to the group 1, a significant improvement of the scores mean (12.3+/-5.4 vs 8.4+/-6.2, p = 0.016) and a significant reduction of the need for manual assistance by the senior (12.5% vs 40%, p = 0.034)., Conclusion: We report a method for the learning and assessment of vacuum extraction feasible at "the bed" of the patient. This approach allows to observe a significant progression of the resident for the technique of vacuum extraction on a dozen of procedures.

Objectives: The objective of this work was to determine the principal axes for measuring the satisfaction of women transferred within a perinatal network., Material and Methods: We began with two successive qualitative sociological approaches (18 semi-structured interviews of women and of couples in 2004 and 2006-2007) and one quantitative approach (questionnaire survey of 583 women hospitalized in 15 of the 16 maternity units in the Auvergne network during a two-week period in 2004)., Results: The qualitative surveys show that the procedures at arrival at the new establishment and the feeling of consistency that they did or did not induce, the identification of the participants, an understanding of their role, and the objectives of the new examinations were all important dimensions. During hospitalization, explanations of who does what and the consistency of the information provided also played a role in this satisfaction. The quantitative survey (participation rate=89%) showed that 77% of the women were aware of the possibility of an in utero transfer. Nonetheless, most of them had very little information about the network., Conclusion: It is possible to identify specific themes associated with women's satisfaction about in utero transfers that are useful for constructing a questionnaire that must, in turn, be validated.

Medical practice assessment is mandatory in France. The goal of this article is to explain to perinatal care providers the concept and the process, which do not seem simple, given the multitude of possible ways to evaluate and validate its medical practices. Concrete examples help to illustrate the process. French regulations now link medical practice assessment with continuing medical education (CME) for physicians. While certification is voluntary, a practice assessment conducted during hospital certification processes and during CME is required for all French physicians.

Objectives: Description of episiotomy rates and current trends in France. Description of episiotomy variation according to medical situations and inter or intra country in obstetrical variation practices., Materials and Methods: We analyzed the AUDIPOG Perinatal network. The medical literature review used Pubmed and the Cochrane Library databases., Results: The episiotomy rate has decreased, in France, from 1996-97 to 2002-03. The percentage of episiotomies among nulliparae is 68% and 31% among multiparae. The episiotomy rate increases with maternal age. The risk of perineal traumatism is variable according to women's ethnic background. The risk of episiotomy is linked to obstetrical situations. It remains an international variation of the global episiotomy rate. However, national rates include regional and hospital variations. French data do not find important variations according to hospital administrative status. We found inter professional variations in the literature., Conclusion: Episiotomy is a frequent obstetrical intervention in the world and in France. This intervention is linked with variations in obstetrical practice and with other medical factors at the time of delivery. We note a reduction of episiotomy rate in western countries but this reduction is not the same in these countries.

Objectives: Determine whether scientific evidence supports an "appropriate" episiotomy rate - and whether this rate can be reduced via medical intervention and or preventive actions during pregnancy or at the time of delivery., Material and Methods: A survey of the literature available on Medline and the Cochrane Library between 1980 and 2005 and dealing with the objectives of the present study was undertaken., Results: In France, the national episiotomy rate should not reach 30%. A program aiming at continuous improvement in quality-of-care after episiotomy and including various actions - training courses, audits, presence of a staff leader, episiotomy rate feedback per midwife or obstetrician - could help reduce the use of episiotomies (grade B). There is insufficient scientific data available to recommend perineal massaging or pre-birth perineal physiotherapy (grade B), and the benefits of a pre-birth training course on the perineum are still to be assessed (grade C). A pregnancy-long support provided to a woman by the same professional could reduce the use of episiotomies but not resorting to perineum repair (grade B). The effects of various types of pre-birth training courses on the perineum are unknown (grade C). We lack scientific data to promote perineal massaging during labor (grade B). Some studies show that an upright position during the second stage of labor is less harmful to the perineum than the classical dorsal reclining position, however it can increase the possibility of post-partum hemorrhage (grade B). Scientific proof is not sufficient to advise favoring a particular type of pushing or a specific manner to release the baby's head (grade B)., Conclusion: More randomized studies are necessary to assess the relevance of all these preventive measures as regards the use of episiotomies.

Objectives: 1- In order to define a "consensual attitude" in case of breech presentation, we queried the AUDIPOG network on obstetrical practice in search for the more frequently accepted criteria for normal delivery. 2- For consensual practices that could be identified, early neonatal complications were compared between women cared for in maternity wards applying these practices and those cared for in maternity wards not applying these practices., Materials and Methods: 1- A confidential survey was sent to participating obstetrics units to determine their practical attitude in case of breech presentation. A consensual attitude was established on the basis of their responses. 2- Crude and adjusted comparisons were made concerning neonatal results between the consensual and non consensual groups of obstetrics units., Results: Response rate was 85% for 175 obstetrics departments consulted. Six criteria were identified leading to classification of 42% of the units as consensual obstetrics units. The risk of major neonatal complications was lower in the consensual group than in the non-consensual group: adjusted OR=0.27 (95% CI: 0.09-0.85)., Conclusion: A questionnaire on obstetrical practice can help define consensual attitudes associated with lower risk of neonatal complications.

Objectives: To describe the evolution of medical practices in breech presentation at term and to compare early neonatal complications according to initial obstetrical decision on the type of delivery., Methods: 71919 pregnancies are included in the AUDIPOG Database from 1994 to 2000. Among this cohort, pregnant women with a singleton in breech, at term were selected which represented 2136 women after the exclusion of in utero deaths and medical abortions. The first outcome was global criteria of severe early neonatal complications ("death during per or immediate post partum or transfer of the newborns to an intensive care or surgery unit"). The size of the sample authorized a power of 90%., Results: The rate of cesarean section before labor was 40%. We found 2.3% of early neonatal complications in the group in which labor was accepted vs. 1.9% in the group with cesarean section performed before labor (p>0.05). After having taken into account prognostic factors, we do not see a significant difference for the risk of neonatal complications between the two groups (OR=1.33; 95% CI: 0.63-2.80)., Conclusion: The analysis of the AUDIPOG Database describes the French obstetrical practice in breech presentation at term. We do not find a different risk in morbi-mortality as regards to the initial obstetrical choice regarding the type of delivery, but the absence of randomization in our study does not authorize a strong medical evidence to guide national recommendations.

The latest changes in French law concerning induced abortion as well as comments from healthcare providers are discussed here. The new articles of the French law are explained. Some of the changes are to be applied immediately: limit set at 14 weeks amenorrhea, non-mandatory psychological consultation, referent adult. Other modifications are pending, including ambulatory induced abortion. These different changes raise many questions.

Objective: To assess the effectiveness of ante partum perineal massage to reduce the number of perineal injuries and episiotomies through a survey of the existing literature., Material and Methods: [corrected] A search both in English and French on randomized clinical trials using the Medline and Cochrane Library databases. The key words: "Perineum", "massage", "perineum injuries", "randomized controlled trial" were selected from the years 1966 to November 2000., Results: Four randomized controlled trials were found. The definition of the selected issues, as well as the included and excluded criteria varied according to the authors. Perineal massages seemed to reduce the occurrence of perineal injuries and episiotomies, mostly among primipara: Labrecque et al. in 1999, noted an OR of 0.56; 95% CI: 0.61-1.31 and at the opposite an increased rate of intact perineum in the massage group (OR = 1.79; 95% CI 1.27-2.52]; and Shipman et al. in 1997 stressed among women of > or = 30 years old an augmentation of intact perineum in the intervention group (OR = 1.93; 95% CI 1.08-3.48), and in the logistic regression taking into account age and birth weight they found a reduction of episiotomies and important perineal injuries (p = 0.02)., Conclusion: Ante partum perineal massages would seem valid but further studies would be necessary to evaluate the utility of this intervention in the avoidance of serious perineal injuries and the women's satisfaction.

The objective of this work was to improve physician's knowledge concerning medical and laboratory screening practices for pregnant women in France. We used the French legislation and the French guidelines on pregnancy screening.

Objective: To assess a policy of early discharge from hospital after a vaginal birth., Data Sources: Reports of studies on this topic were identified in Medline and Cochrane Collaboration database (from 1985 to the beginning of 1995, in english or latin publications). This search was supplemented by referenced studies in book chapters and in other published bibliographies. Key words were: early discharge or ambulatory care and mother or infant or post-partum or obstetrics., Study Selection: One hundred and ten articles have been retrieved. We have included in the meta-analyse the randomized clinical trials comparing a group of women discharged early (less than 48-72 hours after delivery) with a control group leaving hospital after an usual stay (more than 48-72 hours). Quality of the studies was analysed through the Chalmers et al. recommendations., Data Extraction: Data were retrieved independently by two authors, and results were compared. Selected outcomes were: hyperbilirubinemia, infant feeding problems and skin rashes; breast feeding; maternal satisfaction on the hospital stay; readmission and non-routine clinics for both the mother and her child., Data Synthesis: Data from five included studies were pooled by the Peto method. There are no significant modifications of the risks of re-admission to hospital. The frequency of non-routine clinics and the risk of skin rash are not different in the two groups. The risk of hyperbilirubinemia and infant food problems are not different. The frequency of breastfeeding one month after delivery was higher in the early discharge group (OR = 1.88; 95% CI: 1.09-3.23), but this difference decreased over time. Women satisfaction on hospital stay was lower in case of early discharge (OR = 0.56; 95% IC: 0.44-0.72)., Conclusion: The meta-analysis suggests an advantage of early discharge policy on breastfeeding at one month after the delivery, but mothers seem to prefer longer hospital stays. These results must be cautiously interpreted as included studies are of small sample size or rather old. This policy remains to be evaluated more thoroughly before recommendations could be made.

Decision making analysis is a probability-based quantitative method used for decision making in particularly uncertain circumstances. Such analysis can be used to develop a model for medical decision making and help to determine the best strategy for a given clinical situation. A decision tree includes all the necessary choices and the corresponding consequences. Statistical analysis of the decisional tree orients the decision to the one with the smallest risk and the greatest advantages. This work describes the basis of the methodology and the decision analysis using a simple example in obstetrics: repeat cesarean or uterus trial in women with a history of cesarean section. The analysis of the decision, based on data in the literature, demonstrates the choice for the uterin trial because of the lower maternal morbidity.

We studied the different motivations mothers had for choosing a particular mode of nursing at the University Hospital in Limoges. An anonymous questionnaire was distributed to all mothers who hat delivered between January 1 and April 30, 1992. It was apparent that the medical team did little to promote breast-feeding or to counteract negative attitudes. The results of this study, together with a review of the literature were used to determine conditions for encouraging breast feeding.