Clinical profiles of placenta accreta spectrum: the PACCRETA population-based study.

OBJECTIVE: To describe and compare the characteristics of women with placenta accreta spectrum (PAS) and their pregnancy outcomes according to the presence of placenta praevia and a prior caesarean section. DESIGN: Prospective population-based study. SETTING: All 176 maternity hospitals of eight French regions. POPULATION: Two hundred and forty-nine women with PAS, from a source population of 520 114 deliveries. METHODS: Women with PAS were classified into two risk-profile groups, with or without the high-risk combination of placenta praevia (or an anterior low-lying placenta) and at least one prior caesarean. These two groups were described and compared. MAIN OUTCOME MEASURES: Population-based incidence of PAS, characteristics of women, pregnancies, deliveries and pregnancy outcomes. RESULTS: The PAS population-based incidence was 4.8/10 000 (95% CI 4.2-5.4/10 000). After exclusion of women lost to follow up from the analysis, the group with placenta praevia and a prior caesarean included 115 (48%) women and the group without this combination included 127 (52%). In the group with both factors, PAS was more often suspected antenatally (77% versus 17%; P < 0.001) and more often percreta (38% versus 5%; P < 0.001). This group also had more hysterectomies (53% versus 21%, P < 0.001) and higher rates of blood product transfusions, maternal complications, preterm births and neonatal intensive care unit admissions. Sensitivity analysis showed similar results after exclusion of women who delivered vaginally. CONCLUSION: More than half the cases of PAS occurred in women without the combination of placenta praevia and a prior caesarean delivery, and these women had better maternal and neonatal outcomes. We cannot completely rule out that some of the women who delivered vaginally had placental retention rather than PAS; however, we found similar results among women who delivered by caesarean. TWEETABLE ABSTRACT: Half the women with PAS do not have both placenta praevia and a prior caesarean delivery, and they have better maternal outcomes.

Tranexamic acid for the prevention and treatment of postpartum haemorrhage.

Postpartum haemorrhage (PPH) is a major cause of maternal mortality, accounting for one-quarter of all maternal deaths worldwide. Uterotonics after birth are the only intervention that has been shown to be effective for PPH prevention. Tranexamic acid (TXA), an antifibrinolytic agent, has therefore been investigated as a potentially useful complement to this for both prevention and treatment because its hypothesized mechanism of action in PPH supplements that of uterotonics and because it has been proved to reduce blood loss in elective surgery, bleeding in trauma patients, and menstrual blood loss. This review covers evidence from randomized controlled trials (RCTs) for PPH prevention after caesarean (n=10) and vaginal (n=2) deliveries and for PPH treatment after vaginal delivery (n=1). It discusses its efficacy and side effects overall and in relation to the various doses studied for both indications. TXA appears to be a promising drug for the prevention and treatment of PPH after both vaginal and caesarean delivery. Nevertheless, the current level of evidence supporting its efficacy is insufficient, as are the data about its benefit:harm ratio. Large, adequately powered multicentre RCTs are required before its widespread use for preventing and treating PPH can be recommended.

Outpatient balloon catheter versus expectant management for post-term labor induction in nulliparous women: A randomized trial.

BACKGROUND: Increased use of labor induction has renewed interest in outpatient cervical ripening. Post-term pregnancy (i.e., ≥41 weeks) is a specific situation of increased neonatal risk, including greater risk of perinatal death and adverse perinatal outcomes. While a high proportion of these patients will need induction, outpatient management of this specific population has never been studied. Therefore, our objective was to compare two policies of management of post term pregnancies: the use of a transcervical Foley catheter for outpatient cervical ripening compared with expectant management. METHODS: Multicenter, randomized controlled open-label study comparing home induction with a Foley catheter versus expectant management. Inclusion criteria were nulliparous, live singleton fetus in a vertex position, post-term (at 41 + 4 days), requiring cervical ripening (Bishop score <6), intact membranes, and distance home-hospital within 40 min. The primary endpoint was change in Bishop score beetween randomization (41 + 4 days) and consultation (41 + 5 days). RESULTS: Forty-five women were included: 21 in the home induction group and 24 in the control group. The study was stopped due to low recruitment. The difference in Bishop score increases one day after randomization approached significance (p = 0.055), with home induction showing a larger change compared with expectant management (Cohen's d = 0.60; 95 % confidence interval [CI] -0.002 to 1.21). Regarding change in Bishop score, 81 % of home induction group patients had a better score at 41 + 5 days versus 52.2 % in the control group (relative risk = 1.55; 95 %CI 0.99 to 2.15). CONCLUSION: By specifically evaluating home induction in nulliparous women with post term pregnancies, we observed a Bishop score improvement in the home induction group. These data support further evaluation of induction methods and birth experiences in a larger cohort of this population. TRIAL REGISTRATION: The study was registered under European policy (number EudraCT 2015-A01298-41) and on www.clinitrials.gov (number NCT02932319). Date of registration: 13/10/2016, Date of initial participant enrollment: 31/03/2017.

Comparative analysis of quality scores images between second- and third-trimester ultrasound scan.

OBJECTIVES: To evaluate whether the quality scores validated for second-trimester ultrasound scan can be used for third-trimester ultrasound scan. METHODS: Prospective multicenter ancillary study using data from the RECRET study. Nulliparous women, with no reported history, with second- and third-trimester ultrasound examinations performed by the same ultrasonographer and using the same ultrasound machine were recruited. The global score and the individual score of each ultrasound image were compared between second- and third-trimester ultrasound scan. The sample size was calculated for a non-inferiority (one-sided) paired Student t test. RESULTS: 103 women with 1606 anonymized ultrasound images were included. The median term at second- and third-trimester ultrasound scan was 22.2 weeks gestation (22.0-22.7) and 31.6 weeks gestation (30.7-34.7), respectively. The mean global score of ultrasound images was comparable between the second- and the third-trimester ultrasound examination (32.37 ± 2.62 versus 31.80 ± 3.27, p = 0.13). Means scores for each biometric parameters i.e. head circumference, abdominal circumference, and femur diaphysis length were comparable. The scores for the four-chamber view (5.11 ± 0.91 versus 5.36 ± 0.75, p = 0.02) and the spine (4.18 ± 1.17 versus 5.22 ± 1.02, p < 0.001) were significantly lower in the third trimester compared to the second trimester. The score for the kidney image was significantly higher for third trimester images compared to second trimester images (4.73 ± 0.51 versus 4.32 ± 0.67, p < 0.001. CONCLUSIONS: Biometrics parameters quality scores images previously validated for the second trimester ultrasound scan can be also used for the third trimester scan. However, anatomical quality scores images performances may vary between the second and the third trimester scan.

[Maternal deaths due to hypertensive disorders in France 2013-2015]. / Morts maternelles par complications hypertensives en France 2013­2015.

Between 2013 and 2015, six maternal deaths were due to hypertensive disorders. During this period, the maternal mortality ratio was 0.2/100,000 live births. Hypertensive disorders were responsible for 2% of maternal deaths in France and for 5% of direct maternal mortality. All these deaths happened after the delivery. Mode of delivery was a cesarean section when the hypertensive complication started before the delivery (4/6; 67%). Three had DIC during the immediate post-partum. Five women were under 35 years old. Only one had a BMI over 30. Four out of six patients were primiparous. One woman was Afro-Caribbean. Medical care was estimated non-optimal in 100% of the cases. In three cases, it was prenatal care and in three cases it was obstetrical care during delivery; anesthesia and intensive care were suboptimal in five cases. Eighty percent of these deaths seemed to be preventable. The main causes of suboptimal management were inappropriate or insufficient obstetrical and/or anesthetic treatments, and delayed optimal treatment. The analysis of these maternal deaths offers the opportunity to stress major points to optimize medical management in case of hypertensive disorders during pregnancy such as management of eclampsia (use of magnesium sulfate) or recognition of DIC when HELLP syndrome is diagnosed.

[Induced abortions for maternal indications: Retrospective study in Western Normandy between 2010 and 2019]. / Interruptions médicales de grossesse pour indications maternelles : analyse rétrospective en Normandie Occidentale (2010­2019).

INTRODUCTION: Termination of pregnancy for maternal reasons (MTOP) are authorized in France without limit of term when "the continuation of the pregnancy puts in serious danger the health of the woman". The literature on the subject is rare and we wanted to make an inventory in our region. METHODS: Retrospective observational study between 2010 and 2019 at the multidisciplinary center for prenatal diagnosis in Western Normandy. RESULTS: Thirty-one cases of MTOP were included (2.5% of all TOP). At the CHU de Caen, they represented one in 1200 births. Twenty-three percent of MTOP had a psychosocial or psychiatric indication (average term=22 SA) and 29% an obstetric indication due to severe preeclampsia (23 SA). Finally, 48% were linked to a non-obstetric somatic disorder including 46% pre-existing pathologies (average term=11 SA), most often cardiological or nephrological and 54% diagnosed during pregnancy (17 SA) dominated by neoplasias. They were more often (68%) performed in the second trimester. Vaginal births were more frequent (74% against 26% of endouterine aspirations). CONCLUSION: Strict medical contraindications to pregnancy are exceptional. Recourse to the medical termination of pregnancy within the framework of a preexisting pathology must remain rare, by systematizing of the preconception consultation.

[Maternal deaths due to haemorrhage in France 2013-2015]. / Mortalité maternelle par hémorragie en France 2013­2015.

Maternal death from haemorrhage is decreasing: in the last 15 years the number of deaths has been halved. This improvement demonstrates the progress made in hemorrhage management as a result of collective efforts. The number of deaths in this triennium is 22, representing 8.4% of maternal deaths and a maternal mortality ratio by haemorrhage of 1.0/100,000 live births. Nevertheless, there is a worrying proportion of deaths from occult haemorrhage. These occult haemorrhages most often occurred after caesarean sections. A lack of surveillance in the immediate follow-up was generally associated. One or more factors of sub-optimal care were present in 84% of the cases, and 88.9% of deaths were considered possibly or probably preventable. Delay in the diagnosis of haemorrhage, delay in surgical treatment, an insufficient transfusion strategy and inappropriate locations of care were the most frequently reported factors. The experts suggest that risk factors for haemorrhage should be identified in order to propose the most appropriate facility for childbirth. They encourage the strategies for early diagnosis of haemorrhage (attentive and regular monitoring, rapid haemoglobin measurement, abdominal ultrasound) and surgical intervention in case of hemoperitoneum.

[Propositions for perinatal care at extremely low gestational ages - Working group on "Extremely low gestational ages" for SFMP, CNGOF, and SFN]. / Propositions sur la prise en charge en cas d'extrême prématurité ­ Le groupe de travail « Extrême Prématurité ¼ pour la SFMP, le CNGOF et la SFN.

OBJECTIVES: International literature suggests that active perinatal management at extremely low gestational ages improves survival without increasing the risk of impairment in survivors, compared to less active management. Although these results are limited to a small number of countries, they question current practices in France. New propositions on perinatal management of extremely preterm infants have carried out by the French Society of Perinatal Medicine, the French Society of Neonatology and the National College of French Obstetricians and Gynecologists. METHODS: This group was set up in 2015 on the initiative of the professional societies and in collaboration with parents' and users' associations. The work was based on a review of the literature on the prognosis of extremely preterm children, as well as on recommendations by European societies. Based on this information, a text was produced, submitted to all members of the working group and definitively validated in April 2019. RESULTS: This text offers a decision-making guideline for the management at extremely low gestational ages. Its principles are: the administration of steroids independently of management (resuscitation or comfort care); a prognostic evaluation and a collegial decision, outside the context of the emergency; a consensus on the information to be given to parents before going to inform them and gather their opinion. CONCLUSIONS: These new propositions will contribute to modifying perinatal care at extremely low gestational ages in France.

Practices for prevention, diagnosis and management of postpartum haemorrhage: impact of a regional multifaceted intervention.

OBJECTIVE: To evaluate the effectiveness of a multifaceted intervention on practices for prevention, diagnosis and management of postpartum haemorrhage (PPH) and on the prevalence of major PPH in a French perinatal network. DESIGN: Quasi-experimental before-and-after survey. SETTING: All maternity units (n = 19) of a French administrative region, operating as a perinatal network. SAMPLE: One representative sample of all women delivering in the network, one representative sample of women with PPH deliveries and an exhaustive sample of women with major PPH. METHODS: The multifaceted intervention took place between February 2003 and March 2004. Information was retrospectively collected for two periods, 2002 (before the intervention) and 2005 (after). MAIN OUTCOME MEASURES: Practices for prevention, diagnosis and management of PPH and prevalence of major PPH. RESULTS: After the intervention, the pharmacological prevention of PPH increased from 58.8% to 75.9% of vaginal deliveries (P < 10(-4)), and the use of blood collecting bags from 3.9% to 76.3% (P < 10(-4)), but initial PPH management did not change significantly. However, the median delay for second-line pharmacological treatment was significantly shortened [from 80 min (35-130) in 2002 to 32.5 min (20-75) in 2005]. An increase was observed in the use of surgery for PPH (0.06% versus 0.12% of deliveries; P = 0.03) and in blood transfusions (0.18% versus 0.33%; P = 0.01). The prevalence of major PPH did not change (0.80% versus 0.86% of deliveries; P = 0.62). CONCLUSIONS: The intervention was effective at improving PPH-related preventive and diagnostic practices in a perinatal network. Improving management practices and reducing the prevalence of major PPH might require a different intervention design.

[Management of the first trimester miscarriages]. / Prise en charge des fausses couches spontanées du premier trimestre.

A first trimester miscarriage is most often painfully experienced by the patients. The practitioner should be able to offer appropriate, timely, efficient and safe medical management, allowing a shorter convalescence without effect on subsequent fertility. Each step of the process of the miscarriage results in clinical and ultrasonographic characteristics, and requires a specific therapeutic strategy. Vaginal ultrasound allows confirmation of early pregnancy failure (missed miscarriage) diagnosis and to estimate the complete or incomplete removal of trophoblastic material. However, the endometrial thickness does not appear to be predictive for the risk of persistent bleeding or secondary surgery. Surgical evacuation of the product of conception remains the most effective and the quickest method of treatment. Depending on the clinical situation, medical treatment with misoprostol (missed miscarriage) or expectative attitude (incomplete miscarriage) do not increase the risk of complications, particularly the infectious one. However, these alternatives generally require more prolonged outpatient follow-up leading to more frequent consultations and surgical emergencies.

[Impact of a new regional management for postpartum hemorrhages by an audit of severe cases: a before and after study (2002-2005)]. / Evaluation de la mise en place d'une prise en charge régionale des hémorragies du postpartum par un audit des cas graves : étude avant-après (2002-2005).

BACKGROUND: Postpartum haemorrhage (PPH) is still the first cause of maternal mortality in France. Most of these cases include inappropriate management. In 2004, regional guidelines were diffused to all the birthplaces in Basse-Normandie. To assess the impact of this regional management, an epidemiological study "before-after" (2002-2005) has been performed. Part of this study was the evaluation of the management of severe PPH. OBJECTIVE: This study assessed the quality of care for major PPH and the correct follow-up of the guidelines before and after 2004. MATERIAL AND METHODS: A clinical audit has been conducted in all the birthplaces from the region to assess the management of all severe PPH identified during 2002 and 2005. PPH were considered as severe when they presented one or more of the following: blood transfusion, uterine embolisation, hemostatic surgery, difference in hemoglobin rates greater than 4 g / dl, or maternal death. All of these cases have been analysed except those defined by hemoglobin difference. Assessment has been carried out by pairs of practitioners (obstetrician and anesthetist) blinded to the origin of the case. Criteria assessed were the quality of care for major PPH, the correct follow-up of the guidelines and the degree of severity of the PPH which was estimated as moderate or severe on clinical arguments. RESULTS: The number of severe PPH was 34 in 2002 and 63 in 2005. The quality of care was increased with rates of inadequate management falling from 32 to 13% (p < 0,02), respectively. The follow-up of the guidelines was correct in the whole area, most of the criteria having been respected in about 90% of cases in 2005. However, active management of the third stage of delivery was only conducted in 71% of cases. The rates of severe PPH were not significantly different between 2002 (44%) and 2005 (38%). CONCLUSION: The originality from this study is that the modifications of the practices were conducted at a regional level in order to enhance the management of PPH. The assessment which was performed showed that quality of care was improved all over the area but that there is still place to progress.

[Prospective evaluation of the knowledge of couples concerning the prenatal screening ultrasound]. / Évaluation prospective des connaissances des couples concernant l'échographie de dépistage prénatal.

OBJECTIVES: Evaluation of the knowledge of couples concerning the prenatal screening ultrasound in order to improve information. METHODS: This prospective, observational and comparative study was carried out in three maternal centers: a level III maternity, a level II private maternity, and a private gynecologist's office where prenatal screening ultrasounds were performed between the first of March 2018 and the 31th of April 2018. A questionnaire was given to all pregnant women coming to consult for a prenatal screening ultrasound. It included items on maternal characteristics, pregnancy characteristics, and screening ultrasound. RESULTS: One hundred and sixty-nine women answered the questionnaire. On the 138 participants who had consulted in the level III maternity, 42 % expected them to study fetal well-being, 38 % growth, and 13 % malformation. Forty-six percent attested to have received a request for consent, as well as information about these ultrasounds. The same is true for the 120 spouses in thelevel III maternity where only 7 % expected a malformation search to be carried out. The number of participants in the type II private maternity and the private gynecologist's office was insufficient. CONCLUSION: The information given and received, and the knowledge of couples in this level III maternity about the prenatal screening ultrasound seem to be insufficient. It is therefore important to inform the pregnant women and their spouse by giving consent before the first ultrasound and by a verbal message, simple and clear about what the professional is looking for in order to reduce this discrepancy, and thus prepare the couple in case of announcement of an anomaly.

T7 RNA polymerase studied by force measurements varying cofactor concentration.

RNA polymerases carry out the synthesis of an RNA copy from a DNA template. They move along DNA, incorporate nucleotide triphosphate (NTP) at the end of the growing RNA chain, and consume chemical energy. In a single-molecule assay using the T7 RNA polymerase, we study how a mechanical force opposing the forward motion of the enzyme along DNA affects the translocation rate. We also study the influence of nucleotide and magnesium concentration on this process. The experiment shows that the opposing mechanical force is a competitive inhibitor of nucleotide binding. Also, the single-molecule data suggest that magnesium ions are involved in a step that does not depend on the external load force. These kinetic results associated with known biochemical and mutagenic data, along with the static information obtained from crystallographic structures, shape a very coherent view of the catalytic cycle of the enzyme: translocation does not take place upon NTP binding nor upon NTP cleavage, but rather occurs after PPi release and before the next nucleotide binding event. Furthermore, the energetic bias associated with the forward motion of the enzyme is close to kT and represents only a small fraction of the free energy of nucleotide incorporation and pyrophosphate hydrolysis.

[Management of the HELLP syndrome]. / Prise en charge du HELLP syndrome.

Defined by the association of hemolysis, hepatic dysfunction and thrombocytopenia, the Hemolysis, Elevated Liver enzyme, Low Platelets (HELLP) syndrome can complicate preeclampsia and worsen maternal and fetal prognosis. It can be diagnosed in the immediate postpartum (30%) or in the absence of preeclampsia (10-20%). Clinical diagnosis can be difficult because there is no specific symptom. Abdominal pain or vomiting during the third trimester must lead to think about this diagnosis. Biological criteria are well defined: hemolysis by the presence of schistocytes, increased serum total bilirubin >12 mg/L or LDH >600 IU/L, hepatic dysfunction by increased transaminases and thrombocytopenia by a platelet count <100,000/microL. The evolution of those parameters is a major prognostic factor. With the HELLP syndrome, maternal morbidity is dramatically increased compared to isolated preeclampsia with complications such as eclampsia, placental abruptio, disseminated intravascular coagulation, pulmonary edema, acute renal insufficiency, subcapsular liver hematoma. The management of a HELLP syndrome requests level 3 hospital with intensive care units for neonate and mother. The treatment of this syndrome requires termination of the pregnancy as soon a possible, either by cesarean section or by vaginal delivery if cervical conditions are optimal (without any maternal or fetal complications). Before 32 weeks, a more expectative attitude could be acceptable with the prematurity permitting corticotherapy for fetal pulmonary maturation. This corticotherapy can improve temporary biological parameters but there are no proven benefits to consider improvement for long term maternal or fetal prognosis. During the postpartum, evolution is usually spontaneously favorable. Recurrences are not frequent.

[Management of postterm pregnancies]. / Prise en charge du dépassement de terme.

The classic pregnancy term is between 37 and 42 weeks of gestation and the perinatal mortality and morbidity rates increasing progressively during this period, it is difficult to decide of an "ideal" term above which a medical intervention (induction of labour) brings more benefits than risks linked to the natural evolution of pregnancy. There is a good scientific evidence for the induction of labour from 41 weeks of gestation, defined like "postdating" term, when the cervical conditions are favourable (Bishop score>5) and systematically from 42 weeks (significative reduction of perinatal mortality rate and not increased rate of cesarean delivery compared with expectant management). An intensive antenatal surveillance involving a nonstress test and an evaluation of amniotic fluid volume is an efficient alternative when the conditions of delivery are unfavourable between 41 and 42 weeks of gestation or when the woman does not wish induction.

[Atypical abdominal pain in the first trimester of pregnancy]. / Douleurs abdominales atypiques au premier trimestre de la grossesse.

We report the case of a 22-year-old woman who presented a violent epigastric pain at eight-weeks gestation. Superior mesenteric vein thrombosis was detected, with an extension to portal vein and remaining blood flow. Screening for thrombophilia revealed a heterozygote prothrombin gene mutation. Portal vein thrombosis is uncommon and difficult to diagnose. Diagnosis is made by Doppler ultrasound, a second intention test to be done in case of unusual upper abdominal pain during pregnancy.

[Fetal pulse oximetry: clinical practice]. / Oxymétrie de pouls foetal en pratique clinique.

OBJECTIVE: To assess in current practice the application of our protocol of using fetal pulse oximetry during labor, to evaluate whether fetal scalp blood sampling can be reduced and to determinate reliability of fetal pulse oximetry on the prediction of poor neonatal outcomes. STUDY DESIGN: Prospective observational unicenter cohort including 449 patients during two years. All pregnancies were singleton, greater than or equal to 37 weeks' gestation, cephalic presentation, and had non reassuring fetal heart rate. The poor neonatal outcome was defined by one of the followings: arterial umbilical cord pH

[Acute-placental dysfunction by villous-maturation defect and late-fetal mortality]. / Dysfonction placentaire aiguë par retard de maturation villositaire et décès foetal tardif.

INTRODUCTION: The placental histological examination is essential in the assessment of stillbirths, especially those of third trimester, which are often of placental origin by chronic placental dysfunction and sometimes by acute dysfunction. The physiopathogenesis of the latter remains obscure. MATERIAL AND METHOD: Three stillbirths, one per partum and two after 38 and 39 weeks gestation, caused by acute-placental dysfunction by villous maturation defect were studied. The maternal aetiological investigations and the fetal autopsies were normal. Placentas were pale. Villi were numerous, normal size but fibrous, showing a severely reduced vascularization and a lack of syncytium-capillary membranes. RESULTS: Only one author studied the villous maturation defect. He defines this entity by the same characteristics as that noted in our observations. Its incidence would be of 5.7% and would be associated with fetal death only after the eighth month in 2.3 % of cases, with a risk of recurrence estimated at 10%. CONCLUSION: This entity, probably underestimated, must be indexed systematically in any late fetal death and any unexplained per partum asphyxia, in order to help the couple overcome a fetal death and to give doctors a medicolegal support.

[Prevention and early management of immediate postpartum haemorrhage: policies in six perinatal networks in France]. / Politiques de prévention et de prise en charge précoce de l'hémorragie du post-partum immédiat dans six réseaux de maternités françaises.

OBJECTIVES: Postpartum haemorrhage (PPH) constitutes the leading cause of maternal deaths in France, and the majority of these deaths are preventable. The objective of this study was to ascertain policies for prevention and early management of PPH in maternity units, and to compare the results with scientific evidence. The survey was part of the Euphrates European project, and was conducted in France in 2003 before national recommendations for clinical practice related to PPH were launched. MATERIALS AND METHODS: A cross-sectional declarative survey was conducted in six perinatal networks representing 132 maternity units. A postal questionnaire was sent to all units. Main outcomes measured were stated policies for prevention, diagnosis and management of PPH. RESULTS: There was no definition of PPH in one out of four units, and no written protocol for PPH management in one out of six. Policies of using preventive uterotonics were widespread, but variation was observed concerning the timing of administration, and association with the other components of active management of the third stage of labour. Policies about drugs used for management of PPH also varied. CONCLUSION: Variations in policies show firstly that evidence-based improvement in practice is possible, and secondly that further research is needed on poorly documented aspects of PPH management.

[Length of pushing efforts: pushing is not playing. Reply to the article of C. Le Ray and F. Audibert]. / Durée des efforts expulsifs : pousser n'est pas jouer. Réponse à l'article de C. Le Ray et F. Audibert.

The aim of this work is to answer constructively to C. Le Ray and F. Audibert who were surprised that the French guidelines recommended an assisted delivery after 30 min pushing, even if the fetal heart rate is reassuring. We first resumed the definition of "second stage of labor", this word including the first phase with no pushing efforts and the second phase with active pushing of the mother. With that definition, the length of the second stage is around 60 min for the primipara and 20 min for the multipara, this length being modified by the use of peridural. We then specified the physiological mechanisms influencing the acidobasic equilibrium during the pushing time. Those mechanisms are difficult to consider because foetal heart rate monitoring is often "lost" during that phase. Altogether, these factors bring incertitude about progressive foetal acidosis and incapacity to diagnose it. Finally, the literature analysis teaches us that increasing the second stage of labor (inactive plus active phases) during the normal pregnancy seems to be at low risk for the foetus within the primiparas, but display a risk for the mother and so might be limited. Comparing the delayed pushing with the immediate pushing only lead us to conclude that delayed pushing is dangerous, as is prolonged second stage. In conclusion, we think that prolonging the second stage of labor is possible but must be by increasing the inactive first phase of the second stage, especially as long as we will not get a noninvasive and reliable method allowing assessing the well-being of the foetus.