Mortality in out-of-hospital premature births.

AIM: To determine whether the mortality for out-of-hospital (OOH) premature births was higher than for in-hospital premature births and identify additional risk factors. PATIENTS AND METHODS: A historical cohort study of a consecutive series of live-born, OOH, births of 24-35 weeks gestation cared for by two Transport Teams working in and around Paris, France 1994-2005. Matching with in-hospital births was according to gestational age, antenatal steroid use, the mode of delivery and nearest year of birth. RESULTS: Eighty-five OOH premature births were identified, of whom 83 met inclusion criteria, and 132 matching in-hospital premature births were selected. There was 18% mortality in the OOH group compared with 8% for the in-hospital group [p = 0.04, OR 2.9, (CI 95% 1.0-8.4)]. Variables significantly associated (p < 0.05) with the OOH birth were HIV infection, lower maternal age and endo-tracheal intubation, lack of medical follow-up during pregnancy, low temperature and low birth weight. CONCLUSIONS: Mortality was more than twice as high in out-of-hospital deliveries than for in-hospital matched controls. Hypothermia was an important associated risk factor. Measures such as oxygen administration to maintain an appropriate saturation for gestational age, the provision of polyethylene plastic wraps and skin-to-skin contact are recommended.

Pediatric victims involved in urban fires in Paris and its suburbs: Epidemiology, prehospital care, and lessons learned.

AIM: The literature includes few reports on the prehospital care of pediatric casualties of urban house fires. Here we aimed to describe the epidemiology of pediatric fire victims, focusing on their injuries, prehospital care, and survival. METHODS: This retrospective study included children under 15 years of age who were victims of urban house fires and who received care from prehospital medical teams. The variables analyzed included epidemiology, specific care provided by prehospital emergency services, the number of cardiac arrests, and survival rates. RESULTS: Over the 15-month study period, 365 house fires required the presence of at least one prehospital medical team. Casualties of these fires included 121 pediatric victims (median age, 4 years [interquartile range: 2-9 years]). All children were initially treated by a prehospital medical team that was not specialized in pediatrics. Six children (4.9%) received secondary treatment from a pediatric support team. Of the 121 children, 114 (94.2%) suffered from smoke inhalation and seven (5.8%) from burns. Two patients who were in cardiac arrest at their initial medical care did not survive. CONCLUSION: Pediatric fire casualties were initially managed by prehospital medical teams that were not specialized in pediatrics. As in adults, the main injuries were secondary to smoke inhalation, but this has increased toxicity in children. Prehospital teams not specialized in pediatrics can optimize their practice via the sharing of experiences, team training, and cognitive aid checklist for pediatric fire victims.

Obstetric interventions for babies born before 28 weeks of gestation in Europe: results of the MOSAIC study.

OBJECTIVE: To describe obstetric intervention for extremely preterm births in ten European regions and assess its impact on mortality and short term morbidity. DESIGN: Prospective observational cohort study. SETTING: Ten regions from nine countries participating in the 'Models of Organising Access to Intensive Care for Very Preterm Babies in Europe' (MOSAIC) project. POPULATION: All births from 22 to 29 weeks of gestation (n = 4146) in 2003, excluding terminations of pregnancy. METHODS: Comparison of three obstetric interventions (antenatal corticosteroids, antenatal transfer and caesarean section for fetal indication) rates at 22-23, 24-25 and 26-27 weeks to that at 28-29 weeks and the association of the level of intervention with pregnancy outcome. MAIN OUTCOME MEASURES: Use of antenatal corticosteroids, antenatal transfer and caesarean section by two-week gestational age groups as well as a composite score of these three interventions. Outcomes included stillbirth, in-hospital mortality and intraventricular haemorrhage (IVH) grades III and IV and/or periventricular leucomalacia (PVL) and bronchopulmonary dysplasia (BPD). RESULTS: There were large differences between regions in interventions for births at 22-23 and 24-25 weeks. Differences were most pronounced at 24-25 weeks; in some regions these babies received the same care as babies of 28-29 weeks, whereas elsewhere levels of intervention were distinctly lower. Before 26 weeks and especially at 24-25 weeks, there was an association between the composite intervention score and mortality. No association was observed at 26-27 weeks. For survivors at 24-25 weeks, the intervention score was associated with higher rates of BPD, but not with IVH or PVL. CONCLUSIONS: There are large differences between European regions in obstetric practices at the lower limit of viability and these are related to outcome, especially at 24-25 weeks.

[Intrapartum and postdelivery management of infants born to mothers with meconium-stained amniotic fluid]. / Prise en charge périnatale des enfants nés avec un liquide méconial.

Since a decade, some studies had discussed preventive and curative treatment of infants born to mothers with meconium-stained amniotic fluid. Today amnio-infusion, formerly proposed, is reconsidered in countries where midwives and obstetricians carefully monitor the fetal heart rate tracing during labor. Actually routine intrapartum oropharyngeal and nasopharyngeal suctioning, before and after shoulders delivery, followed by tracheal suction, are not recommended for infants born to mothers with meconium stained amniotic fluid.

[Revelation of the circumstances of the accident vascular arterial ischemic brain in at term or near-term and referral]. / Circonstances de révélation de l'accident vasculaire cérébral ischémique artériel chez le nouveau-né à terme ou proche du terme et orientation des patients.

The neonatal arterial ischemic stroke is an emergency. Recurrent focal seizures, generally occurring in the first 24-72 hours after birth, are the commonest first clinical signs. When neonatal arterial ischemic stroke is suspected, optimal initial management involves careful supportive care including treatment of clinical and frequent or prolonged subclinical seizures, correction of the possible metabolic disorders and their prevention. Contrary to hypoxic ischemic encephalopathy, therapeutic hypothermia is not indicated. This newborn requires emergent transfer to a neonatal intensive care unit for the confirmation of the diagnosis by means of a specialized neonatal transport team.

[Neonatal arterial ischemic stroke: Review of the current guidelines]. / Accidents vasculaires cérébraux ischémiques artériels néonatals : synthèse des recommandations.

Neonatal arterial ischemic stroke (NAIS) is a rare event that occurs in approximately one in 5000 term or close-to-term infants. Most affected infants will present with seizures. Although a well-recognized clinical entity, many questions remain regarding diagnosis, risk factors, treatment, and follow-up modalities. In the absence of a known pathophysiological mechanism and lack of evidence-based guidelines, only supportive care is currently provided. To address these issues, a French national committee set up by the French Neonatal Society (Société française de néonatologie) and the national referral center (Centre national de référence) for arterial ischemic stroke in children drew up guidelines based on an HAS (Haute Autorité de santé [HAS]; French national authority for health) methodology. The main findings and recommendations established by the study group are: (1) among the risk factors, male sex, primiparity, caesarean section, perinatal hypoxia, and fetal/neonatal infection (mainly bacterial meningitis) seem to be the most frequent. As for guidelines, the study group recommends the following: (1) the transfer of neonates with suspected NAIS to a neonatal intensive care unit with available equipment to establish a reliable diagnosis with MRI imaging and neurophysiological monitoring, preferably by continuous video EEG; (2) acute treatment of suspected infection or other life-threatening processes should be addressed immediately by the primary medical team. Persistent seizures should be treated with a loading dose of phenobarbital 20mg/kg i.v.; (3) MRI of the brain is considered optimal for the diagnosis of NAIS. Diffusion-weighted imaging with apparent diffusion coefficient is considered the most sensitive measure for identifying infarct in the neonatal brain. The location and extent of the lesions are best assessed between 2 and 4 days after the onset of stroke; (4) routine testing for thrombophilia (AT, PC PS deficiency, FV Leiden or FII20210A) or for detecting other biological risk factors such as antiphospholipid antibodies, high FVIII, homocysteinemia, the Lp(a) test, the MTHFR thermolabile variant should not be considered in neonates with NAIS. Testing for FV Leiden can be performed only in case of a documented family history of venous thromboembolic disease. Testing neonates for the presence of antiphospholipid antibodies should be considered only in case of clinical events arguing in favor of antiphospholipid syndrome in the mother; (5) unlike childhood arterial ischemic stroke, NAIS has a low 5-year recurrence rate (approximately 1 %), except in those children with congenital heart disease or multiple genetic thrombophilia. Therefore, initiation of anticoagulation or antithrombotic agents, including heparin products, is not recommended in the newborn without identifiable risk factors; (6) the study group recommends that in case of delayed motor milestones or early handedness, multidisciplinary rehabilitation is recommended as early as possible. Newborns should have physical therapy evaluation and ongoing outpatient follow-up. Given the risk of later-onset cognitive, language, and behavioral disabilities, neuropsychological testing in preschool and at school age is highly recommended.

[Effects of nasal continuous positive airway pressure ventilation in infants with severe acute bronchiolitis]. / Place de la ventilation non invasive nasale dans la prise en charge des broncho-alvéolites sévères.

OBJECTIVE: Usefulness of nasal continuous positive airway pressure (NCPAP) in severe acute bronchiolitis has been checked. The objective of this descriptive study was to evaluate the feasibility, safety and risk factors of NCPAP failure. POPULATION AND METHODS: One hundred and forty-five infants were hospitalised in our intensive care unit during the 2 last epidemics (2003-2004, 2004-2005). Among them, 121 needed a respiratory support, either invasive ventilation (N=68) or NCPAP (N=53). RESULTS: General characteristics were similar during the 2 periods. Percentage of NCPAP failure, defined by tracheal intubation requirement during the stay in paediatric intensive care unit, was quite similar during the 2 periods (25%), but number of NCPAP increased twofold. Whatever the evolution was in the NCPAP group, we observed a significant decrease in respiratory rate (60+/-16 vs 47.5+/-13.7 cycle/min., P<0.001) and PaCO2 (64.3+/-13.8 vs 52.6+/-11.7 mmHg, P=0.001) during NCPAP. Only PRISM calculated at day 1 and initial reduction of PaCO2 were predictive of NCPAP failure. Percentage of ventilator associated pneumonia was similar (22%) between the invasive ventilation group and infants who where intubated because of failure of NCPAP. Duration of respiratory support and stay were reduced in the NCPAP group (P<0.002). CONCLUSION: NCPAP appears to be a safe alternative to immediate intubation in infants with severe bronchiolitis.

[Neonatal resuscitation in delivery room: new advances]. / Aspects récents de la prise en charge du nouveau-né en salle de naissance.

The need for resuscitation of a distressed newborn in delivery room is more and more easily predictable. The two principal reasons are improvement of obstetrical survey and best perinatal regionalisation. Perinatal asphyxia and premature labour, especially before 32 weeks of gestational age, are the more frequent situation needing resuscitation at birth. A good survey of pregnancy and labor, verification of availability and efficiency of care devices and material in the delivery room are essential. In all guidelines respiratory resuscitation is today the priority in the first minutes. Non invasive positive pressure ventilation and early use of exogenous surfactant are the recent advances for the care of very premature baby in delivery room. Having a neonatal ventilator and pulse oximetry monitoring is recommended and can improve results. For the pregnant woman and the baby, maternal transfer if no contra-indications exist and when it is possible, is preferred to postnatal transportation in case of very premature labor or high risk pregnancy. In all the other situations neonatal transport must be strictly organised and realised by well-trained pediatric team, with adapted material and in the best conditions for security and comfort. The goal is to prevent any rupture until arrival in the referring neonatal intensive car unit.

[Air or oxygen for neonatal resuscitation in the delivery room?]. / Air ou oxygène pour le nouveau-né en salle de naissance?

Most of the contemporary guidelines on newborn resuscitation are based on experience but lack scientific evidence. The use of 100% oxygen is one of the more evident. Today, these practices are questioned, particularly for the resuscitation of moderately depressed full term or near term newborns. Results of recent meta-analysis of trials that compared ventilation with air versus pure oxygen at birth suggests current practices should be revisited. On the basis of these data, air can be the initial gas to use for these babies. Large scale trials, including preterm and cause and/or severity of initial asphyxia, must now be undertaken before the publication of new guidelines for these populations. Particularly severely asphyxiated infants might require supplemental oxygen with titration of oxygen delivery and continuous monitoring of oxygen saturation.

[Platelet transfusions in neonatology]. / Transfusions plaquettaires en néonatalogie.

Thrombocytopenia occurs in 20% to 40% of infants admitted to a neonatal intensive care unit. Approximately 30% of the newborns with severe thrombocytopenia below 50.10(9)/l platelets receive platelet transfusions. The etiology may be: bacterial infection, DIC and immune mediated thrombocytopenia. The consequences of thrombocytopenia are significant risks of severe intracranial hemorrhage and neurologic morbidity. Therapeutic platelet transfusions are given to actively bleeding neonates with less than 50.10(9)/l platelets. Prophylactic platelet concentrates are usually given to infants with platelets counts below 20.10(9)/l. The standard platelet concentrate (CMV-negative donor) is the product of choice for newborns. Fetal intracranial hemorrhage is possible as soon as 20 weeks of gestation in allo-immune thrombocytopenia. Actually percutaneous umbilical blood sampling is very useful to measure fetal platelets count in order to decide in utero maternal platelet transfusion. Maternal irradiated plateletpheresis concentrates are preferentially infused in this indication. At the end of pregnancy, cesarean section is preferred to normal vaginal delivery if fetal thrombocytopenia below 100.10(9)/l is observed. In pregnant women with auto-immune thrombocytopenia, the decision to carry out percutaneous umbilical blood samples should be weigh relatively to the 3-5% estimated risk of serious consequences. Platelets transfusions are particularly successful in immune thrombocytopenia but less effective in other clinical circumstances.

[Cardiorespiratory arrest in full term newborn infants: six case reports]. / Malaises graves et morts subites après une naissance normale à terme: à propos de six cas.

Cardiorespiratory arrest occurring within the first two hours of life of a perfectly normal newborn is a very seldom event hitherto unreported. Six infants born after an uneventful pregnancy by normal vaginal delivery, with a normal Apgar score and physical examination, were found with unexpected cardiorespiratory arrest requiring cardiac and respiratory resuscitation early after birth. All were lying in the prone position, their face covered up while facing mother's abdomen, breast or neck. All mothers were primipara. All newborns but one died. Biological and bacteriological samples were normal and early onset neonatal sepsis was ruled out. Autopsy, performed in five infants, was not contributive. We hypothesize that the sudden and unexpected cardiorespiratory arrest occurring in these normal newborns was secondary to acute upper airway obstruction. To prevent this life threatening post-natal asphyxic episode, it is essential to ensure that the face of a newborn lying down upon mother's breast and abdomen is properly and continuously cleared.

[Maternofetal disseminated candidiasis and high-grade prematurity]. / Infection maternofoetale disséminée a Candida albicans et grande prématurite.

BACKGROUND: Despite the frequency of vaginal yeast colonization, serious candidiasis infections in pregnant patients or neonates remain rare. Four cases of disseminated congenital candidiasis in very preterm infants are reported. CASE REPORTS: Congenital Candida albicans infection has been diagnosed in four very preterm infants. In three cases, the mothers had intrauterine devices in place throughout pregnancy. A careful macroscopic examination of the umbilical cord and placenta after birth has allowed an early management strategy in three cases. In all cases, a serious infectious alveolitis occurred. A pronounced increase in white blood cells (> 50,000/mm3) and high levels of both segmented neutrophil and band cells, despite the frequent normality of the CRP, constituted other features. Infection was controlled by parenteral amphotericin B or fluconazole. In one case, serious thrombocytopenia occurred after the first amphotericin B injection requiring substitution for fluconazole. The outcome was unfavourable in two cases with an extensive periventricular leukomalacia. CONCLUSION: Congenital candidiasis in these four very preterm neonates has several features in common: intrauterine contraceptive device during pregnancy, characteristic chorioamnionitis and funisitis, high WBC count, infectious alveolitis. Fluconazole as alternative to amphotericine B therapy is proposed.

[Severe bacterial infections in children. Survey by the pediatric mobile intensive care unit AP/HP in the Ile-de-France area]. / Infections bactériennes graves de l'enfant. Enquête des SMUR pédiatriques AP/HP de l'Ile-de-France (de 1998 au 1er quadrimestre 2001).

This study involves 106 infants (neonatal period ruled out), victims of severe bacterial infections managed from 1st january 1998 to 30 April 2001 by the four paediatric Mobile Intensive Care Unit (P.M.I.C.U.) teams AP-HP in Ile-de-France area. 46.2% of the whole infants are primary interventions (home, medical room, airport) and primary-secondary interventions (hospital emergencies) whereas 53.8% are related to secondary transports of infants who have been hospitalized and suffered from severe bacterial disorders complicating their original disease. 51% are meningitidis infections, rather due to streptococcus pneumoniae and meningococcis, associated with severe infectious purpura. 20.75% are toxic shock syndromes in patients suffering from chronic affections (sickle cell anemia), acquired or congenital immunodeficiencies; 19.8% of the cases are severe bacterial pneumonia (staphylococcal pleuro-pneumopathies, bordetella pertussis cough) or surinfected viral infections (VRS bronchiolitis, pneumonia due to mycoplasma pneumoniae and para-influenzae III). Authors study various characteristics of the two patient's groups, their immediate management by local medical team and by the P.M.I.C.U. team, their early term outcome. 65% of children recovered apparently without sequelae, 19% died, and 16% healed but with significant sequelaes, notably neurological damage. Meningitidis due to Streptococcus pneumoniae are particularly severe, because of their prognostic (10 deaths, 8 severe sequelae among the 26 cases). These observations prompted us to recommend early immunization of infants at 2-3 months post natal age by the new vaccine conjugated up to 7 valences such as "Prevenar". If this vaccine have been available for this patient series, may be avoided 8 deaths, 7 severe sequelae, with 1 septic shock syndrome due to streptococcus pneumoniae and another serious infection in a homozygous sickle cell disease.

[Assessment by a national survey of needs for NICU and intermediate NICU in France]. / Evaluation nationale des besoins en lits de réanimation et soins intensifs néonatals.

UNLABELLED: The setting up of the so-called "decrees on perinatal safety" on October 1998 has been associated with many difficulties which were apparently related to the lack of beds for intensive care units, special care units and neonatal medicine. This led to a national survey. OBJECTIVES: The aim of the survey was : (1) to collect the number of neonates requiring hospitalization in NICU and special care units over a 1-week period in metropolitan France and overseas departments and territories; (2) to assess the needs in equipments and care-givers. METHODS: The writs to be included in the survey were previously identified. Each day of hospitalization was classified as needing an intensive care unit, a special care unit or a neonatal unit. Then it was classified as well fitted or badly fitted. RESULTS: Two hundred and forty units (90% of the French units) from 204 hospitals participated in the survey and 3678 neonates were included and accumulated 17 583 days of hospitalization (NICU: 2728; special care: 5047; neonatal medicine: 9808). One thousand and five hundred and ninety hospitalization days did not fit well either with the technical level required by the neonate or/and with the location of the parents' home (9.2%): 23.1% in overseas departments and territories; 12% in metropolitan France. The main reasons for maladjustment were: a too high technical level: (59%); an insufficient technical level: (21%) (19 neonates could not be admitted in a NICU as they needed). The survey included 158 NICU and special care units. Taking into consideration the French law: the lack in equipment was: 294 ventilators, 231 cardio-respiratory monitors, 116 pulse oxymeters and 513 blood pressure monitors; 561 additional pediatricians were needed to allow a medical night duties including seven doctors in each NICU and each special care unit; 1878 additional nurses were also needed. Making the assumption that the mean occupation rate of the neonatal beds should be 70%, the needs were calculated for 1000 live births: metropolitan France: 0.76 (0.74; 0.78) in NICU; 1.45 (1.43-1.47) in special care units; overseas departments and territories: 2 (1.8-2.5) in NICU; 3.5 (3.2-3.8) in special care units. CONCLUSION: Finally, the main deficit was not related to the number of beds but to the equipment and number of care-givers. The status of overseas departments and territories was particularly worrying.

[Pediatric emergency department policy. Implementation and management of the resuscitation room]. / Recommandations concernant la mise en place, la gestion, l'utilisation et l'évaluation d'une salle d'accueil des urgences vitales pédiatriques.

The pediatric resuscitation room is the place where children suffering from vital distress are cared for in the emergency unit. Recommendations for its organization, functioning and evaluation have been ruled on by experts from six medical societies involved in these emergencies. They concern all the hospital's physicians, nurses and administrative directors.

[Newborn asphyxia at term during delivery]. / Volume de recrutement, charge de travail et morbidité liés aux asphyxies per-partum à terme pour les services mobiles d'urgence et de réanimation (SMUR) pédiatriques.

UNLABELLED: Recruitment, work load and morbidity linked to newborn asphyxia during delivery at term: a study from Pediatric Mobile Intensive Care Units. OBJECTIVE: In a population of term neonates transported by the mobile intensive care units (MICU), we aimed to determine the incidence of neonates with anoxic-ischemic encephalopathy related to asphyxia, to analyze in this population the difficulties of management, and to try to identify which of these newborns require new therapeutic strategies. METHODS: This retrospective study was performed over a 2-year period (2000 and 2001) in 3 paediatric MICU from the Ile de France area. During this period, 7,648 infants were transported including 3,301 newborns of more than 36 weeks of gestational age and less than 72 hours of life. These neonates came from 73 different hospitals. Among these 3,301 infants, 237 neonates (124 boys and 113 girls) with anoxic-ischemic encephalopathy related to asphyxia were selected in the present study. Inclusion criteria were association of one obligatory criterion of fetal distress during delivery and at least one criterion of neonatal asphyxia or one criterion of anoxic-ischemic encephalopathy. Data were compiled and analyzed with Epidata package and Epi info package, respectively. RESULTS: These 237 neonates with anoxic-ischemic represented 12% of MICU activity at the same gestational and postnatal ages. The mean gestational age was 39.5 + 1.5 weeks. The mean birth weight was 3,188 + 559 g. More than 50% of these neonates were born in level I maternities. Fifty-three percent of the infants were born by caesarean section. Eighty-three percent of the neonates had an Apgar score at 1 minute <3. Eighty-eight percent of the neonates received resuscitation care at 5 minutes of life and 34% of these had an Apgar score at 10 minutes <5. In 50% of the cases, the MICUs arrived at the maternity of delivery within 1 h 45 min of life and transportation of the neonates was completed after 3 hours of life. The neonates were transported to an intensive care unit in 88% of the cases (half to a polyvalent intensive care unit and half to a neonatal intensive care unit). Forty-four percent of transported neonates had no encephalopathy, 30% had a severe encephalopathy or seizures, 27% had multiple organ failure. Mortality reached 28% and encephalopathy accounted for two thirds of these deaths. Neonates who arrived in pediatric care units after 3 hours of life had more severe morbidity than neonates who arrived before 3 hours of life. CONCLUSION: Pediatric MICUs transport the most severely affected neonates. The initial clinical state is critical, and systemic and neurological complications are frequent and severe. Calls to the MICU should be made earlier in order to enable a better impact of new neuroprotective strategies.

[Regionalization of very preterm birth care sites in Ile-de France in 1998]. / Action de régionalisation des sites de naissance des grands prématurés en Ile-de-France en 1998.

The objective of this article is to describe the conditions under which very premature babies were born in the Paris region between June 1 and December 31, 1998, that is to say those born prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams. The study looked at all pre-term births, including medical terminations of pregnancy (TOP), occurring in one of the 135 maternity units in the Paris region. Between June 1 and December 31, 1998, 1337 mothers gave birth to babies prior to reaching 33 weeks of term (SA) and/or having a birth weight less than 1500 grams in 84 maternity units in the Paris region, 263 of which had a medical termination of pregnancy (20%). These mothers were older than average for the region (25% were 35 years old or older); 4.3% of them do not have social insurance coverage. The remaining 1074 mothers (excluding TOP) gave birth to 1290 children, of which 202 were stillbirths, 46 died in the labor ward and 1042 were admitted to a neo-natal unit. Of the same group of 1074 mothers, 195 (18%) had a multiple pregnancy--175 twins, 19 triplets, and 1 quadruplet 60% of them (599 women) who had very premature or low birth weight babies (excluding TOPs) delivered them in a tertiary perinatal centre (TPC). This proportion varies according to two variables: 1) the community in which the family lives (40% in the Seine-et-Marne department, the eastern region of Paris and a district without TPCs, to 70% in the Hauts-de-Seine, a northern district), and 2) whether the pregnancy is single (58.8%), twin (72.6%) or triple (84.2%). In utero transfer accounts for 62.7% of the mothers who delivered in TPC, who were transferred prior to delivery. This type of study is useful for measuring the implementation of the regionalisation high-risk perinatal care and access to adequate services. It clearly demonstrates that inequities in access to care exist for women by district of residence.

[Accidental out-of-hospital deliveries]. / Accouchements inopinés extrahospitaliers.

Unexpected out-of-hospital delivery accounts for 0.5% of the total number of delivery in France. The parturient is placed under constant multiparametric monitoring. Fetus heart rate is monitored thanks to fetal doppler. A high concentration mask containing a 50-to-50 percent mix of O(2) and NO performs analgesia. Assistance of mobile pediatric service can be required under certain circumstances such as premature birth, gemellary pregnancy, maternal illness or fetal heart rate impairment. Maternal efforts should start only when head reaches the pelvic floor, only if the rupture of the membranes is done and the dilation is completed. The expulsion should not exceed 30 min. Episiotomy should not be systematically performed. A systematic active management of third stage of labour is recommended. Routine care such as warming and soft drying can be performed when the following conditions are fulfilled: clear amniotic liquid, normal breathing, crying and a good tonus. Every 30 seconds assessment of heart rate, breathing quality and muscular tonus then guide the care. The redaction of birth certificate is a legal obligation and rests with the attending doctor.