[Expert consensus from the College of French Gynecologists and Obstetricians: Management of nausea and vomiting of pregnancy and hyperemesis gravidarum]. / Consensus formalisé d'experts du Collège national des gynécologues et obstétriciens français : prise en charge des nausées et vomissements gravidiques et de l'hyperémèse gravidique.

OBJECTIVE: To determine the management of patients with 1st trimester nausea and vomiting and hyperemesis gravidarum. METHODS: A panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds. RESULTS: Hyperemesis gravidarum is distinguished from nausea and vomiting during pregnancy by weight loss≥5 % or signs of dehydration or a PUQE score≥7. Hospitalization is proposed when there is, at least, one of the following criteria: weight loss≥10%, one or more clinical signs of dehydration, PUQE (Pregnancy Unique Quantification of Emesis and nausea) score≥13, hypokalemia<3.0mmol/L, hyponatremia<120mmol/L, elevated serum creatinine>100µmol/L or resistance to treatment. Prenatal vitamins and iron supplementation should be stopped without stopping folic acid supplementation. Diet and lifestyle should be adjusted according to symptoms. Aromatherapy is not to be used. If the PUQE score is<6, even in the absence of proof of their benefit, ginger, pyridoxine (B6 vitamin), acupuncture or electrostimulation can be used, even in the absence of proof of benefit. It is proposed that drugs or combinations of drugs associated with the least severe and least frequent side effects should always be chosen for uses in 1st, 2nd or 3rd intention, taking into account the absence of superiority of a class over another to reduce the symptoms of nausea and vomiting of pregnancy and hypermesis gravidarum. To prevent Gayet Wernicke encephalopathy, Vitamin B1 must systematically be administered for hyperemesis gravidarum needing parenteral rehydration. Patients hospitalized for hyperemesis gravidarum should not be placed in isolation (put in the dark, confiscation of the mobile phone or ban on visits, etc.). Psychological support should be offered to all patients with hyperemesis gravidarum as well as information on patient' associations involved in supporting these women and their families. When returning home after hospitalization, care will be organized around a referring doctor. CONCLUSION: This work should contribute to improving the care of women with hyperemesis gravidarum. However, given the paucity in number and quality of the literature, researchers must invest in the field of nausea and vomiting in pregnancy, and HG to identify strategies to improve the quality of life of women with nausea and vomiting in pregnancy or hyperemesis gravidarum.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) -- Text of the Guidelines (short text)]. / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège National des Gynécologues Obstétriciens Français (CNGOF) et du Collège National des Sages-Femmes de France (CNSF) ­ Texte des recommandations (texte court).

OBJECTIVE: The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. METHODS: These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. RESULTS: It is recommended to conduct a complete initial examination of the woman in labor at admission (consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30minutes but not more than 60minutes after delivery (consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2mg) of vitamin K (consensus agreement) be given systematically within two hours of birth. CONCLUSION: These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - - When and how to take medical action during labor?] / Accouchement normal : accompagnement de la physiologie et interventions médicales. Recommandations de la Haute Autorité de Santé (HAS) avec la collaboration du Collège national des gynécologues obstétriciens français (CNGOF) et du Collège national des sages-femmes de France (CNSF) ­ quand et comment intervenir médicalement au cours du travail ?

OBJECTIVE: The aim of this chapter is to provide recommendations for good practice regarding drug and technical interventions that may be considered during normal delivery. METHODS: These recommendations were established by an expert consensus based on an analysis of the scientific literature and the French and international recommendations available on the subject. RESULTS: Interventions during latent phase of the first stage of labor (up to 5-6cm) must be performed according to the fetal and maternal contraction tolerance (consensus agreement). In the active phase (from 5-6cm to full dilatation), dilation speed under 1cm/4h between 5 and 7cm or under 1cm/2h beyond 7cm is considered abnormal, it is then recommended to propose: an amniotomy if the membranes are intact and administration of oxytocin if membranes are already ruptured and uterine contractions are considered insufficient (consensus agreement). Intravenous (IV) antibiotic prophylaxis (at least four hours before birth) is recommended during labor in women at risk for group B streptococcal (GBS) maternofetal infection (GBS vaginal portage or GBS bacteriuria during pregnancy or history of maternofetal GBS infection) (grade B). In case of rupture of membranes after 37weeks of gestation without spontaneous labor, it is recommended: if the patient has GBS, to begin antibiotic prophylaxis immediately (consensus agreement); if delivery did not occur after 12hours, to start antibiotic prophylaxis (grade A), to set up dedicated patient monitoring (consensus agreement), to screen for an infection (at least a full blood count, a vaginal sample and a dipstick test) (consensus agreement). It is recommended not to start expulsive efforts as soon as a complete dilation is identified but to let the fetal presentation go down (grade A). The administration of oxytocin is recommended if the patient does not feel inclined to push and the presentation has not reached low-pelvic station after two hours of complete dilation in case of insufficient uterine activity (AE). There is no argument for recommending a push technique over another (grade B). It is recommended to inform the gynecologist-obstetrician in case of non-progression of the fetus after two hours of complete dilation with sufficient uterine activity (AE). Prophylactic administration of oxytocin at 5 or 10 IU is recommended to prevent postpartum hemorrhage after vaginal delivery (grade A). Administration could be performed intravenously (slow injection over about a minute) or intramuscularly (AE). In case of placental retention, manual removal of the placenta is recommended (grade A). In absence of bleeding, it must be performed after 30mins after birth, without exceeding 60mins (AE). CONCLUSION: These recommendations define indications and methods for drug and technical interventions during a normal delivery to prevent poor obstetrical outcomes.

[Retrospective study of the impact of training on the management of immediate post-partum hemorrhage]. / Impact d'une formation sur la prise en charge de l'hémorragie du post-partum.

OBJECTIVE: The aim of the study was to assess the impact of the introduction of training workshops on the quality of prevention and management of Post-Partum Hemorrhage (PPH) in a type III university center. METHODS: A clinical audit was carried out in our type III university center before and after the introduction of training workshops on the prevention and management of PPH, in two periods between January 1st to December 31st 2011 and March 1st and August 1st, 2015. Training workshops were according to the recommendations for clinical practice of the National College of Gynecologists-Obstetricians French published in 2014, and included a theoretical portion and a simulation of low fidelity manikin. Data on the management of patients presenting with PPH after vaginal birth of a singleton were retrospectively collected consecutively from medical records. Data were collected using a standardized analytical grid. Between the two data collections, some improvement actions were implemented. RESULTS: After implementation of training workshops, the proportion of patients with active management of the third stage of labor (prophylactic uterotonic after delivery) has significantly improved (72% before, vs. 92% after, P=0.001); time to PPH diagnosis has been significantly higher notified (40% before, vs. 94% after, P<0.001), as well as the quantification of bleeding at diagnosis (46% before, vs. 72% after, P<0.003) and total bleeding (68% before, vs. 92%, P<0.001). PPH-specific monitoring sheet was found to be used significantly more frequently (3 before, vs. 30 after, P=0.00015). Additionally, the Physician Anesthesiologist has been contacted significantly more often (34% before, vs. 53% after, P=0.002). CONCLUSION: Our study highlights a significant improvement in professional practices between 2011 and 2015 on PPH prevention and management in our type III university center.

[Human Resources for Unplanned Activities in Obstetrics and Gynecology. Consensus statements by the CNGOF, CARO, CNSF, FFRSP, SFAR, SFMP and SFN]. / Ressources humaines pour les activités non programmées en gynécologie-obstétrique. Propositions élaborées par le CNGOF, le CARO, le CNSF, la FFRSP, la SFAR, la SFMP et la SFN.

OBJECTIVE: To determine a minimum threshold of human resources (midwives, obstetricians and gynecologists, anesthesiology and intensive care units, pediatricians) to ensure the safety and quality of unplanned activities in Obstetrics and Gynecology. MATERIALS AND METHODS: Consultation of the MedLine database, the Cochrane Library and the recommendations of authorities. Meetings of representative members in different modes of practice (university, hospital, liberal) under the aegis of and belonging to the French College of Obstetricians and Gynecologists (CNGOF), the French Society of Anesthesia and Resuscitation (SFAR), the French Society of Neonatalogy (SFN), the French Society of Perinatal Medicine (SFMP), the French College of Midwives (CNSF), the French Federation of Perinatal Care Networks (FFRSP) with elaboration of a re-read text by external experts, in particular by the members of the Boards of Directors of these authorities and of Club of Anesthesiology-Intensive Care Medicine in Obstetrics (CARO). RESULTS: Different minimum thresholds for each category of caregivers were proposed based on the number of births/year. These proposed minimum thresholds can be modulated upwards according to the types (level I, IIA, IIB or III) or the activity (existence of an emergency reception service, maternal-fetal and/or surgical activity of resort or referral). Due to peak activity and the possibility of unpredictable concomitance of urgent medical procedures, it is necessary that organizations plan to use resource persons. The occupancy rate of the target beds of a maternity ward must be 85%. CONCLUSION: These proposed minimum thresholds are intended to help caregivers providing non-scheduled perinatal as well as Obstetrics and Gynecology care to make the most of the human resources allocated to institutional bodies to ensure their safety and quality.

[Evaluation of the impact and efficiency of high-fidelity simulation for neonatal resuscitation in midwifery education]. / Évaluation de la simulation haute-fidélité dans la formation initiale à la réanimation en salle de naissance chez les étudiants sages-femmes.

BACKGROUND: Prompt initiation of appropriate neonatal resuscitation skills is critical for the neonate experiencing difficulty transitioning to extra-uterine life. Expertise in neonatal resuscitation is essential for personnel involved in the care of newborns, above all for midwives who are sometimes alone to initiate the first resuscitation. The use of simulation training is considered to be an indispensable tool to address these challenges, not only in continuing education but also in midwifery education. OBJECTIVE: The aim of this study was to evaluate the impact and efficiency of high-fidelity simulation for neonatal resuscitation in midwifery education. METHODS: This was a prospective monocentric study conducted in the Angers university hospital between October and December 2012 and included two groups of midwifery students (n=40) who received high-fidelity simulation as part of their basic midwifery education. Participants' perceptions of the knowledge, skills, and confidence gained following training in high-fidelity simulation for neonatal resuscitation were determined using a pre-/post-test questionnaire design completed during the training and also several months after the course, as well as after the students had begun working. A satisfaction survey to evaluate this training was also completed at the same time. RESULTS: With a good participation rate (67.5%), the survey showed a high degree of satisfaction among the participants. This training was described as facilitating their hire in one third of cases. A significant increase in self-assessment of skills scores was observed between the pre-test and post-test (P<0.001), the pre-test and the distance test (P<0.001), and the post-test and distance test (P=0.007). Although a decrease in the median score was observed on the knowledge questionnaire given as a post-test, this median remained significantly higher than that obtained on the pre-test (P=0.03). CONCLUSION: The significant improvement in knowledge during the session and its preservation after a few months confirmed the efficacy of this teaching method. The simulation training increased the participants' perceptions of their knowledge, skills, and confidence in conducting neonatal resuscitation. These preliminary results are very encouraging and argue in favor of generalizing this teaching method. However, this training could be more profitable if it was proposed earlier in the midwifery curriculum and organized with a multidisciplinary team (pediatric and anesthesia residents).