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Aim: The first twin (T1) in breech position is at risk of complications during vaginal delivery, making the choice of the appropriate delivery route highly important. Although British and American practice guidelines recommend the cesarean section, the French National College of Obstetricians and Gynecologists concluded that there was not enough data to choose one delivery route or the other. In this context, we set out to describe practices in our centre., Material and Methods: Our retrospective study was conducted at a level III labor ward between January 1st, 1995 and December 31st, 2006. One hundred and thirty-seven twin pregnancies at more than 26 gestational weeks (GW), with T1 in breech and T2 in any position, were included., Results: A cesarean section was performed before labor in 60.6 % cases. Among the 54 (39.4 %) cases where a trial of labor was accepted, 29 patients (53.7 % success rate) delivered vaginally and 25 (46.3 %) had a cesarean section during labor. No statistical difference was observed between the neonatal outcomes after cesarean section as compared to vaginal birth. However, a significant relationship was found between delivery route and parity. Less than one-third of nulliparas versus two-third of patients with a history of at least one delivery, having trials of labor, ultimately gave birth vaginally. Thus, we observed a high rate of cesarean section during labor in nulliparas (68 % of the initially accepted trials of labor)., Conclusion: Our study is the first one that clearly shows that the success rate of the trial of labor is closely related to a history of vaginal birth. Following these results and because of more than two-third of cesarean section during labor in nulliparas, we subsequently plan an elective cesarean section at the 38th GW for nulliparas with twin pregnancies and T1 in breech position. Nevertheless, if any of these patients go in labor before the cesearean section, a careful trial of labor is offered., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)

Aim: To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears., Material and Methods: A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods., Results: In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001)., Conclusion: An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward., (Copyright 2009 Elsevier Masson SAS. All rights reserved.)

We describe the administration of antenatal corticosteroid therapy (ACT) for liveborn very preterm neonates in a population-based study. A total of 790 very preterm neonates (between 24 and 31 full weeks of gestation) were included in this regionally defined population of very preterm neonates in France. The main outcome measure was non-access to ACT. Data were analysed using logistic and polytomous models to control for neonatal and sociodemographic characteristics, mechanisms of very preterm birth and neonatal network organisation. As compared with level III, births in levels I-II maternity units were closely related to non-access to ACT (60.1% vs. 8.8%), but not to pregnancy follow-up (19.7% vs. 17.8%). Only 6.3% of very preterm neonates that benefited from antepartum referral did nor receive ACT. Births associated with rupture of membranes and gestational hypertension were significantly more often transferred to level-III units (73.8% and 68.3% respectively) than those due to maternal bleeding and spontaneous labour (57.0% and 50.7% respectively), and the neonates had a lower probability of not receiving ACT (8.5%, 11.5%, 23.0%, 31.2% respectively). Very preterm neonates referred in utero to a level-III unit came from a more favourable socio-economic environment. Non-access to ACT was more often observed in neonates born to 14- to 24-year-old mothers, smokers, of low socio-economic status, and preterm birth resulting from maternal bleeding or spontaneous labour. These data from a French regional study show that access to ACT is not only explained by practitioners' support of recommendations. In our population-based study, ACT access was related to socio-economic factors and to the mechanisms of very preterm birth. Improving the rate of access to ACT should take these organisational, medical and socio-economic dimensions into account.

Objective: The subjectivity and inter- and intra-observer variability of transvaginal (TV) digital examination in the diagnosis of fetal head engagement set a real problem in the strategic choice of the mode of delivery. We conducted a preliminary study on the feasibility of using ultrasound in the diagnosis of fetal head engagement during labour., Material and Method: From 3rd January to 20th February 2007, a prospective monocentered study was set up by comparing the fetal head position in the pelvic cavity obtained by TV digital examination with the ultrasound measurement of the perineum-fetal head distance. Sixty-five measurements were obtained from 45 patients (single pregnancies, cephalic presentations), during labour and/or at complete cervical dilatation, by a single operator., Results: Whenever the perineum-fetal head distance was greater than 60 mm, the fetal head was not engaged in the pelvic cavity, with a specificity of 89% and a negative predictive value of 94.1%. However, if the distance is less or equal to 60 mm, the fetal head was engaged with a sensitivity of 97.8% and a positive predictive value of 95.6%. It was even possible to define the fetal head station in the cavity as the distances are now known: high cavity : 50 mm, mid cavity : 38 mm, low cavity : 20 mm., Conclusion: This technique based on a single distance measurement is not difficult and the reference point is easily localized. An abdominal probe is sufficient, making the diffusion of this method quite easy. With its excellent negative predictive value, transperineal ultrasound would allow obstetricians avoid difficult vaginal extractions, localize correctly the fetal position in the cavity and obtain the exact fetal head orientation, even in case of scalp blood humps. The feasibility and relevance of this technique must be confirmed by larger studies.

Objective: To delineate the perinatal risk factors of neurodevelopmental disabilities in very preterm birth applying logistic regression analysis., Design: This prospective, geographically defined collaborative study was carried out in the Franche-Comté region of France., Subjects: From October 1, 1990 to September 30, 1992, perinatal and follow-up data were collected on 203 consecutive live-born singleton or twin non-malformed infants with strictly ascertained gestational ages of less than 33 weeks., Main Outcome Measure: The rate of cerebral palsy and/or severe mental retardation as diagnosed by a family physician or pediatrician with a screening-skill test performed at 2 years of age., Results: 167/171 (98%) survivors were evaluated. Twenty-two of the 167 examined infants (13%) showed signs of cerebral palsy, and 10 of these had severe cerebral palsy or mental retardation. Risk factors for disabilities were selected by a multivariate approach: premature rupture of membranes >/=48 h (OR 4.3, 95% CI 1.6-11.8); monochorionic twin placentation (OR 6.0, 95% CI 1.7-21.3), and respiratory distress syndrome (OR 2.8, 95% CI 1.1-7.1)., Conclusion: This geographically defined prospective study gives epidemiological data and highly suggests that there is a link between prenatal events (premature rupture of membranes, monochorionic twin placentation), postnatal events (respiratory distress syndrome), and neurological disabilities in former preterm infants.

Background: The goal of this study was to estimate direct costs induced by the first year of treatment of cervix cancers according to the stage at diagnosis., Methods: Fifteen patients of the Gynaecology Department of the Besançon hospital (Doubs, France) were involved in a prospective study to estimate the real cost of treatment of carcinomas in situ (CIS) by conization and of microinvasive carcinomas (MIC) by simple hysterectomy. Costs of invasive cancers were obtained from a retrospective analysis of 24 hospital records in the Radiotherapy Department., Results: The average real cost of treatment for the CIS was 5023 FF (1995 French Francs). Real treatment cost of the MIC was 15,867 FF. The average cost of treatment for the IB and IIA cancers stage (FIGO classification) was 61,540 FF and 145,314 FF for the IIB to IV stage cancers., Conclusions: Cost-estimation of cervix cancer treatment according to the stage of diagnosis has to be done before starting a cost-effectiveness analysis of mass screening for cervix cancers. This study will allow us to take into account changes in the stages distribution following on a screening campaign.

Many publications report the number of epidural analgesias carried out for the last years in English-speaking countries. On the other hand, very little information exists about the incidence of obstetrical epidural analgesia performed in South and Central Europe, particularly in France. A retrospective study within the regions of Bourgogne and Franche-Comté was carried out for the year 1993 firstly, to determine the number of obstetrical epidural analgesias performed and the drugs used; and secondly, to describe the organization and the problems encountered. The result of this study leads to one major question: what is the best type of organization in order to guarantee the highest safety, given the increasing demand for epidural analgesia in obstetrics?

Unregistered and unmonitored pregnancies account for 0.2 to 0.6 p. cent of all pregnancies. They essentially concern young, single, primiparous mothers from disadvantaged social backgrounds. Labour and delivery are generally without difficulty but the neonatal prognosis is impaired by a high proportion of premature and underdeveloped infants, often requiring a long stay in a pediatric unit.