Twin pregnancies: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF).

The rate of twin deliveries in 2008 was 15.6 per 1000 in France, an increase of approximately 80% since the beginning of the 1970s. It is recommended that chorionicity be diagnosed as early as possible in twin pregnancies (Professional Consensus). The most relevant signs (close to 100%) are the number of gestational sacs between 7 and 10 weeks and the presence of a lambda sign between 11 and 14 weeks (Professional Consensus). In twin pregnancies, nuchal translucency is the best parameter for evaluating the risk of aneuploidy (Level B). The routine use of serum markers during the first or the second trimester is not recommended (Professional Consensus). In the case of a choice about sampling methods, chorionic villus sampling is recommended over amniocentesis (Professional Consensus). Monthly follow-up by a gynaecologist-obstetrician in an appropriate facility is recommended for dichorionic pregnancies (Professional Consensus). A monthly ultrasound examination including an estimation of fetal weight and umbilical artery Doppler is recommended (Professional Consensus). It is recommended to plan delivery of uncomplicated dichorionic diamniotic twin pregnancies from 38 weeks and before 40 weeks (Level C). Monthly prenatal consultations and twice-monthly ultrasound are recommended for monochorionic twins (Professional Consensus). It is reasonable to consider delivery from 36 weeks but before 38 weeks+6 days, with intensified monitoring during that time (Professional Consensus). Prenatal care of monochorionic pregnancies must be provided by a physician working in close collaboration with a facility experienced in the management of this type of pregnancy and its complications (Professional Consensus). The increased risk of maternal complications and the high rate of medical interventions justify the immediate and permanent availability of a gynaecologist-obstetrician with experience in the vaginal delivery of twins (Professional Consensus). It is recommended that the maternity ward where delivery takes place have rapid access to blood products (Professional Consensus). Only obstetric history (history of preterm delivery) (Level C) and transvaginal ultrasound measurement of cervical length (Level B) are predictive factors for preterm delivery. No study has shown that the identification by transvaginal sonography (TVS) of a group at risk of preterm delivery makes it possible to reduce the frequency of such deliveries in asymptomatic patients carrying twins (Professional Consensus). It is important to recognize signs of TTTS early to improve the management of these pregnancies (Professional Consensus). Treatment and counseling must be performed in a center that can offer fetoscopic laser coagulation of placental anastomoses (Professional Consensus). This laser treatment is the first-line treatment (Level B). In the absence of complications after laser treatment, planned delivery is recommended from 34 weeks and no later than 37 weeks (Professional Consensus). For delivery, it is desirable for women with a twin pregnancy to have epidural analgesia (Professional Consensus). The studies about the question of mode of delivery have methodological limitations and lack of power. Active management of the delivery of the second twin is recommended to reduce the interval between the births of the two twins (Level C). In the case of non-cephalic presentation, total breech extraction, preceded by internal version manoeuvres if the twin's position is transverse, is associated with the lowest cesarean rates for second twins (Level C). In the case of high and not yet engaged cephalic presentation and if the team is appropriately trained, version by internal manoeuvres followed by total breech extraction is to be preferred to a combination of resumption of pushing, oxytocin perfusion, and artificial rupture of the membranes, because the former strategy appears to be associated with fewer cesareans for the second twin (Level C).

[Management of twin pregnancy]. / Organisation pratique du suivi des grossesses gémellaires.

The epidemic of multiple pregnancies continues albeit in a different form with twin pregnancies predominating. Determination of chorionicity is the key to management and regular monitoring by ultrasound is a hallmark of quality care. All multiple pregnancies should be offered first trimester screening by nuchal translucency for aneuploidy. Monochorial twins should be scanned at fortnightly intervals to allow complications such as twin-twin transfusion or IUGR to be detected and referral made to a fetal medicine centre.

[Twin delivery]. / Accouchement des grossesses gémellaires.

The number of twin pregnancies is still increasing. This should not be assessed only as therapeutic success but also as complex obstetrical challenges. The main difficulties encountered are dystocic presentations, dystocic labours, and cord prolapses. Specific multiple pregnancy dystocias as chin-to-chin interlocking twins and conjoined twins are very rare. Twin delivery is substantially worse when compared with singleton delivery, with increased morbidity and mortality principally involving the second twin. Labour induction is possible, and should be indicated between the 38th and 39th weeks of gestation. Caesarean section should be done easily, especially in case of prematurity or in case of breech presentation for the first twin. Excepting these cases and the usual caesarean section indications, there is no demonstrated superiority of the caesarean section delivery compared to the vaginal delivery. When needed, internal version and/or breech extraction should be done with intact membranes. Active management of the third stage is necessary, due to uterine surdistension easily leading to uterine atonia.

Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs.

BACKGROUND: Despite growing evidence of the benefits of prolonged breastfeeding for mother and infant health, the rate of breastfeeding at infant age of 6 months remains below the Healthy People 2010 goal. The greatest decrease in the breastfeeding rate occurs during the first 4 postpartum weeks. Mothers who discontinue breastfeeding early are more likely to report lack of confidence in their ability to breastfeed, problems with the infant latching or suckling, and lack of individualized encouragement from their clinicians in the early postdischarge period. Observational studies suggest that primary care physicians can increase breastfeeding rates through specific advice and practices during routine preventive visits. However, robust scientific evidence based on randomized, controlled trials is currently lacking. OBJECTIVE: The purpose of this study was to determine whether attending an early, routine, preventive, outpatient visit delivered in a primary care physician's office would improve breastfeeding outcomes. DESIGN: The study was a prospective, randomized, parallel-group, open trial. SETTING: Participants were recruited at a level 3 maternity facility, with an average of 2000 births per year, in France. PARTICIPANTS: A total of 231 mothers who had delivered a healthy singleton infant (gestational age: > or =37 completed weeks) and were breastfeeding on the day of discharge were recruited and randomized (116 were assigned to the intervention group and 115 to the control group) between October 1, 2001, and May 31, 2002; 226 mother-infant pairs (112 in the intervention group and 114 in the control group) contributed data on outcomes. INTERVENTION: Support for breastfeeding in the control group included the usual verbal encouragement provided by the maternity ward staff members, a general health assessment and an evaluation for evidence of successful breastfeeding behavior by the pediatrician working in the obstetrics department on the day of discharge, provision of the telephone number of a peer support group, mandatory routine, preventive, outpatient visits at 1, 2, 3, 4, 5, and 6 months of infant age, and 10 weeks of paid maternity leave (extended to 18 weeks after the birth of the third child). In addition to the usual predischarge and postdischarge support, the mothers in the intervention group were invited to attend an individual, routine, preventive, outpatient visit in the office of 1 of the 17 participating primary care physicians (pediatricians or family physicians) within 2 weeks after the birth. The participating physicians received a 5-hour training program on breastfeeding, delivered in 2 parts in 1 month, before the beginning of the study. OUTCOME MEASURES: The primary outcome was the prevalence of exclusive breastfeeding reported at 4 weeks (defined as giving maternal milk as the only food source, with no other foods or liquids, other than vitamins or medications, being given). The secondary outcomes included any breastfeeding reported at 4 weeks, breastfeeding duration, breastfeeding difficulties, and satisfaction with breastfeeding experiences. Classification into breastfeeding categories reported at 4 weeks was based on 24-hour dietary recall. RESULTS: Ninety-two mothers (79.3%) assigned to the intervention group and 8 mothers (7.0%) assigned to the control group reported that they had attended the routine, preventive, outpatient visit in the office of 1 of the 17 primary care physicians participating in the study. Mothers in the intervention group were more likely to report exclusive breastfeeding at 4 weeks (83.9% vs 71.9%; hazard ratio: 1.17; 95% confidence interval [CI]: 1.01-1.34) and longer breastfeeding duration (median: 18 weeks vs 13 weeks; hazard ratio: 1.40; 95% CI: 1.03-1.92). They were less likely to report any breastfeeding difficulties (55.3% vs 72.8%; hazard ratio: 0.76; 95% CI: 0.62-0.93). There was no significant difference between the 2 groups with respect to the rate of any breastfeeding at 4 weeks (89.3% vs 81.6%; hazard ratio: 1.09; 95% CI: 0.98-1.22) and the rate of mothers fairly or very satisfied with their breastfeeding experiences (91.1% vs 87.7%; hazard ratio: 1.04; 95% CI: 0.95-1.14). CONCLUSIONS: Although we cannot exclude the possibility that findings might differ in other health care systems, this study provides preliminary evidence of the efficacy of breastfeeding support through an early, routine, preventive visit in the offices of trained primary care physicians. Our findings also suggest that a short training program for practicing physicians might contribute to improving breastfeeding outcomes. Multifaceted interventions aiming to support breastfeeding should involve primary care physicians.

Effect of a training program for maternity ward professionals on duration of breastfeeding.

BACKGROUND: Training programs are commonly viewed as an effective way to improve breastfeeding-related practices of health professionals. The objective of this study was to determine whether a 3-day training program for maternity ward professionals was followed by an increase in duration of any breastfeeding. METHODS: A before-and-after study was conducted involving two retrospective random samples of 308 mothers who had delivered a healthy singleton infant of 37 weeks' or more gestation and 2,500 g or more birthweight in a level 3 maternity ward in a university hospital in France. Data were gathered from medical records and postal questionnaire. RESULTS: Study participants included 169 mothers (54.9%) in the pre-intervention sample and 178 (57.8%) in the post-intervention sample. The prevalence of any breastfeeding at birth was 77.5 percent (70.5%-83.6%) in the pre-intervention sample and 82.6 percent (76.2%-87.8%) in the post-intervention sample(p=0.24); the median duration of any breastfeeding was 13 weeks and 16 weeks, respectively(chi2 log-rank test=5.8, p=0.02). The decreased risk of weaning in the post-intervention sample persisted after adjustment for baseline characteristics (adjusted hazard ratio=0.70 [0.54-0.91]). It was paralleled by significant improvement in maternity ward practices that are known to affect the duration of breastfeeding. CONCLUSION: An intensive 3-day training program for maternity ward professionals can be followed by a significant but moderate increase in the duration of any breastfeeding. Multifaceted interventions involving prenatal components and community support should be planned in Western countries with low to intermediate prevalence of breastfeeding.

Assessment of a structured in-hospital educational intervention addressing breastfeeding: a prospective randomised open trial.

OBJECTIVE: To determine whether a single one-to-one in-hospital education session could increase the rate of breastfeeding at 17 weeks. DESIGN: A prospective, randomised, parallel group, open trial. SETTING: A level two maternity hospital in France. SAMPLE: Breastfeeding mothers who were employed outside the home prenatally and were delivered of a healthy singleton. INTERVENTION: A structured one-to-one in-hospital education session. METHODS: One hundred and six mother-infant pairs were allocated to the intervention group and 104 to the control group (receiving usual verbal encouragement). A total of 93 mother-infant pairs in the intervention group and 97 in the control group provided complete data for final evaluation of efficacy. MAIN OUTCOME MEASURE: Rate of breastfeeding at infant age of 17 weeks. RESULTS: There was no significant difference between the two groups in the rate of any breastfeeding (34.4% in the intervention group vs 40.2% in the control group, relative risk = 0.86 [0.52-1.40]), and in the rate of exclusive breastfeeding (14.0% in the intervention group vs 14.4% in the control group, relative risk = 0.97 [0.42-2.22]). CONCLUSION: Our findings suggest that a single in-hospital educational intervention has no effect on the breastfeeding rate at four months. Guidance provided by maternity staff should be reinforced by a long term multifaceted support programme in countries with a low to intermediate rate of breastfeeding.

Evaluation of a training program for healthcare professionals about breast-feeding.

OBJECTIVE: To assess the impact of a continuing medical education program based on the WHO's 10 steps to successful breast-feeding. STUDY DESIGN: An observational before-and-after study at a teaching hospital. Data for two random samples of 50 women before and 50 after the intervention were collected from medical records and completed by a mail questionnaire. RESULTS: Seventy-six percent of mothers initiated breast-feeding in the two samples. The median duration of breast-feeding was 12 weeks and did not differ between the before and after groups. The percentage of newborns separated from their mother more than 4h a night decreased substantially after the intervention (13% versus 52% before the intervention, P<0.01). In-hospital formula provision also decreased after the intervention (63% of newborns versus 82% before intervention, P=0.07). CONCLUSION: This pilot study has enabled authors to document the feasibility of evaluating the impact of continuing education of maternity ward staff.

Fetal heart rate and survival of the very premature newborn.

OBJECTIVE: Our purpose was to study the likelihood of survival of infants who are born before 28 weeks of gestation and to examine the influence of fetal heart rate findings on neonatal death. STUDY DESIGN: In this retrospective study, we analyzed the mortality rate of infants at 2 months of age as a function of various obstetric and prenatal indicators. RESULTS: At 2 months, 207 of 325 children were still alive. The survival rate was also a function of gestational age, birth weight, the administration of corticosteroids, multiple pregnancies, and fetal heart rate. Fetal heart rate had the greatest effect on the mortality rate. Children with a reactive rate were 4 times more likely to survive than children with a flat tracing (P =.003; odd ratio, 4; 95% CI, 12.1; 39.8). CONCLUSION: The results in our study lead us to think that recording the fetal heart rate before and during labor may be useful in the prediction of perinatal death and may help obstetric decision-making.

Three-dimensional ultrasonographic reconstruction of the uterine cavity: toward virtual hysteroscopy?

The aim of this study was to evaluate the possibility of diagnosing intrauterine abnormalities, using a "virtual endoscopy" technique based on 3D hysterosonographic data. Five patients who presented intrauterine abnormalities (polyps, n=2; leiomyomas, n=3) underwent 3D transvaginal hysterosonography. The 3D data set was subsequently processed by using a proper software that creates virtual endoscopy images. After ultrasonographic examination, patients had a conventional hysteroscopy. In all patients intrauterine lesions were easily and reliably detected by computer-reconstructed 3D hysterosonography. Images obtained by this "virtual hysteroscopy" technique, including fine intrauterine details, were remarkably comparable to those obtained by conventional hysteroscopy. The results of this pilot study indicate that computerized reconstruction of 3D hysterosonography offers adequate visualization and characterization of intrauterine lesions.

Delivery of the second twin: comparison of two approaches.

OBJECTIVE: To compare two obstetrical approaches toward delivery of the second twin: one of expectant management, and the other, active; to compare the neonatal and maternal results and thereby identify, if possible, the optimal approach. STUDY DESIGN: This retrospective study looked at twin births in two maternity units in the Paris, France metropolitan region: Antoine Béclère (AB) in Clamart, and Port-Royal (PR) in Paris and concerned 113 deliveries of pairs of twins at AB and 78 at PR. RESULTS: The mean duration of the interbirth interval was 9 min at AB and 5 min at PR (P < 0.001). The characteristics of the pregnancies and the deliveries of twin A were comparable. Spontaneous birth accounted for 51% of twin A births at AB and 27% at PR (P < 0.001). Intrauterine manipulation of twin B occurred in 2% of the births at AB and 43% at PR (P < 0.001). At AB, there were five cesareans to deliver the second twin, but none at PR. The Apgar scores at AB and PR were identical, at 1 and 5 min, and for births before 32 weeks' gestation as well as for those afterwards. At AB, 19% (n = 21) of second twins were transferred to the neonatal intensive care unit, and at PR, 18% (n = 14). CONCLUSION: The neonatal results were similar in both groups, even though both the rate of obstetric maneuvers and the interbirth interval differed significantly. The two methods therefore appear to be equivalent when judged by the second twin's neonatal indicators. Our data suggest that an active approach diminishes the likelihood of cesarean delivery for the second twin, without increasing the neonatal risk.