Asymptomatic Short Cervix and Threatened Preterm Labor: A Comparative Study on Perinatal Outcomes.

OBJECTIVE: To determine the rate of delivery within 15 days of admission among patients with an asymptomatic short cervix (ASC) compared to those admitted for threatened preterm labor (TPL). MATERIAL AND METHODS: This retrospective study conducted in a tertiary maternity hospital, included patients with a singleton pregnancy admitted with a cervical length of less than 25 mm between 24 and 34 weeks. The population was divided into two groups, patients with ASC (i.e., with no contractions at admission) and patients with TPL. The primary outcome was the delivery rate within 15 days of admission. Secondary outcomes included gestational age at delivery, preterm delivery rate before 370/7 weeks and before 340/7 weeks, admission to delivery interval, 5 minutes Apgar score and transfer to neonatal intensive care unit rate. The characteristics of the two groups and the primary and secondary outcomes were compared between the two groups using univariate analysis. Two subgroup analysis were performed, one restricted to patients with a mildly modified CL (15 ≤ CL < 25 mm), and one excluding patients at high risk of preterm birth. RESULTS: Among the 247 included patients, 136 (55.1%) had TPL, and 111 (44.9%) ASC. There were no significant differences in the rate of patient who delivered within 15 days of admission between the groups, 13.2% in the TPL group vs 8.0% in the ASC group (p=0.22). Patients in the TPL group had a significantly higher frequency of delivery before 34 weeks compared to those in the ASC group (19.9% versus 9.0%, p=0.02 This finding persisted in the subgroup analysis excluding patients at high risk of preterm birth (16.5% in the TPL subgroup vs. 6.9% in the ASC subgroup, p=0.04). There were no significant differences in the rates of preterm delivery before 37 weeks, the admission-to-delivery interval, or neonatal outcomes between the two groups or within the subgroup analyses. CONCLUSION: The frequency of delivery within 15 days of admission was not statistically different between patients with an asymptomatic short cervix and those with TPL. Nevertheless, these asymptomatic patients delivered significantly later and less frequently before 34 weeks, with only one in ten requiring corticosteroids.

Re-evaluating fetal scalp pH thresholds: An examination of fetal pH variations during labor.

INTRODUCTION: Since the 1970s, fetal scalp blood sampling (FSBS) has been used as a second-line test of the acid-base status of the fetus to evaluate fetal well-being during labor. The commonly employed thresholds that delineate normal pH (>7.25), subnormal (7.20-7.25), and pathological pH (<7.20) guide clinical decisions. However, these experienced-based thresholds, based on observations and common sense, have yet to be confirmed. The aim of the study was to investigate if pH drop rate accelerates at the common thresholds (7.25 and 7.20) and to explore the possibility of identifying more accurate thresholds. MATERIAL AND METHODS: A retrospective study was conducted at a tertiary maternity hospital between June 2017 and July 2021. Patients with at least one FSBS during labor for category II fetal heart rate and delivery of a singleton cephalic infant were included. The rate of change in pH value between consecutive samples for each patient was calculated and plotted as a function of pH value. Linear regression models were used to model the evolution of the pH drop rate estimating slope and standard errors across predefined pH intervals. Exploration of alternative pH action thresholds was conducted. To explore the independence of the association between pH value and pH drop rate, multiple linear regression adjusted on age, body mass index, parity, oxytocin stimulation and suspected small for gestational age was performed. RESULTS: We included 2047 patients with at least one FSBS (total FSBS 3467); with 2047 umbilical cord blood pH, and a total of 5514 pH samples. Median pH values were 7.29 1 h before delivery, 7.26 30 min before delivery. The pH drop was slow between 7.40 and 7.30, then became more pronounced, with median rates of 0.0005 units/min at 7.25 and 0.0013 units/min at 7.20. Out of the alternative pH thresholds, 7.26 and 7.20 demonstrated the best alignment with our dataset. Multiple linear regression revealed that only pH value was significantly associated to the rate of pH change. CONCLUSIONS: Our study confirms the validity and reliability of current guideline thresholds for fetal scalp pH in category II fetal heart rate.

Assessing the external validity and clinical relevance of umbilical doppler resistance index references in daily practice.

OBJECTIVE: To assess the external validity and clinical relevance of current references for umbilical artery resistance index (UA RI) in daily practice. METHODS: Retrospective cross-sectional single center study including all UA RI measurements between 22 and 40 gestational weeks (GW) from distinct patients between 2014 and 2022. Patients with normal pregnancies and normal neonatal outcomes that had an UA RI measurement between 2014 and 2019 were used to calculate reference ranges. The established reference for the 95th centile was compared to two current references. The clinical relevance of the established reference was tested by comparing neonatal outcomes according to the 95th percentile among the consecutive distinct patients between 2020 and 2022. RESULTS: Among the 13342 consecutive distinct patients with a singleton pregnancy that had an UA RI measurement between 22 and 40 GW between 2014 and 2022, 5298 patients were included to establish the reference ranges, and 3634 patients to validate these ranges. For each gestational age, the established references were similar to current references. Using the established references, the proportion of patients presenting an UA RI>95th percentile among the patients with normal pregnancies in the validation population was comparable to the proportion when using the two current references. Among the validation population, 268 patients (7.4 %) (95%CI[6.5-8.2]) presented an UA RI ≥ 95th percentile. Of these 268 patients, 67.9% had a SGA newborn (versus 19.2%, p<0.001) and 59% a preterm birth (versus 13.9%, p<0.001). CONCLUSIONS: The reference range obtained from daily practice is clinically relevant and similar to current references.

Impact of discontinuing oxytocin in active labour on neonatal morbidity: an open-label, multicentre, randomised trial.

BACKGROUND: Oxytocin is effective in reducing labour duration but can be associated with fetal and maternal complications that could potentially be reduced by discontinuing the treatment during labour. We aimed to assess the impact of discontinuing oxytocin during active labour on neonatal morbidity. METHODS: STOPOXY was a multicentre, randomised, open-label, controlled, superiority trial conducted in 21 maternity units in France. Participants who received oxytocin before 4 cm dilation were randomly assigned 1:1 to either discontinuous oxytocin (oxytocin infusion stopped beyond a cervical dilation equal to or greater than 6 cm) or continuous oxytocin (administration of oxytocin continued until delivery). Randomisation was stratified by centre and parity. The primary outcome, neonatal morbidity, was assessed at birth using a composite variable defined by an umbilical arterial pH at birth less than 7·10, a base excess greater than 10 mmol/L, umbilical arterial lactates greater than 7 mmol/L, a 5-min Apgar score less than 7, or admission to the neonatal intensive care unit. Efficacy and safety was assessed in participants who were randomly assigned (excluding those who withdrew consent or were deemed ineligible after randomisation) and had reached a cervical dilation of at least 6 cm. This trial is registered with ClinicalTrials.gov, NCT03991091. FINDINGS: Of 2459 participants randomly assigned between Jan 13, 2020, and Jan 24, 2022, 2170 were eligible to receive the intervention and were included in the final modified intention-to-treat analysis. The primary outcome occurred for 102 (9·6%) of 1067 participants (95% CI 7·9 to 11·5) in the discontinuous oxytocin group and for 101 (9·2%) of 1103 participants (7·6 to 11·0) in the continuous oxytocin group; absolute difference 0·4% (95% CI -2·1 to 2·9); relative risk 1·0 (95% CI 0·8 to 1·4). There were no clinically significant differences in adverse events between the two groups of the safety population. INTERPRETATION: Among participants receiving oxytocin in early labour, discontinuing oxytocin when the active phase is reached does not clinically or statistically significantly reduce neonatal morbidity compared with continuous oxytocin. FUNDING: French Ministry of Health and the Département de la Recherche Clinique et du Développement de l'Assistance Publique-Hôpitaux de Paris.

Publication rate and factors associated with publication of research projects by obstetrics residents in an academic department over 10 years.

OBJECTIVES: To determine the publication rate of mandatory research projects conducted by obstetrics residents and to evaluate the publication-associated factors and reported obstacles. STUDY DESIGN: This retrospective cohort study included all consecutive residents in an academic obstetrics-gynecology department in Paris, France, between 2010 and 2020. All residents were required to conduct a research project. Information about publication was collected by searching PubMed. A closed-ended questions questionnaire was sent to former residents about their characteristics, subsequent professional development, and research project characteristics. Factors associated with publication were identified by univariable and multivariable analysis with logistic regression. RESULTS: During the study period, 156 residents trained in our obstetrics-gynecology department. The overall publication rate was 30.8% (48/156) and the median time to publication 27 months (IQR, 18-37). The resident was first author in 36 (75.0%) publications. Among the 130 (83.3%) residents who completed the questionnaire, 43 (33%) had published their research project. Overall, 74/130 (60.8%) residents used their project for their mandatory medical thesis. Factors associated with publication in univariable analysis were younger age (median), completion of a PhD, planned career in academic medicine, prospective study design, presentation at a conference or congress and use their project for their medical thesis. The only factors associated with publication in the multivariable analysis were planned career in academic medicine (aOR 5.62 95 %CI[1.84-17.19]) and the prospective study design of the research project (aOR 6.1 95 %CI[1.24-29.56]). The main reasons for nonpublication reported by resident were lack of time and failure to complete the project. CONCLUSION: Among the mandatory clinical research projects conducted by obstetrics residents over a decade in our department, 30.8% were published. The main factors associated with publication were planned career in academic medicine and a prospective design of the research project.

Oxytocin versus prostaglandins for labour Induction of women with an unfavourable cervix after 24 hours of cervical ripening (OPIC): protocol for an open multicentre randomised non-inferiority trial.

INTRODUCTION: It remains uncertain whether the most appropriate management for women with an unfavourable cervix after 24 hours of cervical ripening is repeating the ripening procedure or proceeding directly to induction by oxytocin. No adequately powered trial has compared these strategies. We hypothesise that induction of labour with oxytocin among women who have just undergone an ineffective first ripening procedure is not associated with a higher risk of caesarean delivery than a repeated cervical ripening with prostaglandins. METHODS AND ANALYSIS: We will conduct a multicentre, non-inferiority, open-label, randomised controlled trial aimed at comparing labour induction by oxytocin with a second cervical ripening that uses prostaglandins (slow-release vaginal dinoprostone; oral misoprostol 25 µg; dinoprostone vaginal gel 2 mg). Women (n=1494) randomised in a 1:1 ratio in 10 French maternity units must be ≥18 years with a singleton fetus in vertex presentation, at a term from ≥37+0 weeks of gestation, and have just completed a 24-hour cervical ripening procedure by any method (pharmacological or mechanical) with a Bishop score ≤6. Exclusion criteria comprise being in labour, having more than 3 contractions per 10 min, or a prior caesarean delivery or a history of uterine surgery, or a fetus with antenatally suspected severe congenital abnormalities or a non-reassuring fetal heart rate. The primary endpoint will be the caesarean delivery rate, regardless of indication. Secondary outcomes concern delivery, perinatal morbidity, maternal satisfaction and health economic evaluations. The nature of the assessed procedures prevents masking the study investigators and patients to group assignment. ETHICS AND DISSEMINATION: All participants will provide written informed consent. The ethics committee 'Comité de Protection des Personnes Ile de France VII' approved this study on 2 April 2021 (No 2021-000989-15). Study findings will be submitted for publication and presented at relevant conferences. TRIAL REGISTRATION NUMBER: NCT04949633.

Failed induction of labor in term nulliparous women with an unfavorable cervix: Comparison of cervical ripening by two forms of vaginal prostaglandins (slow-release pessary and vaginal gel).

OBJECTIVE: To compare the rate of failed induction after cervical ripening by two forms of vaginal prostaglandins. MATERIAL AND METHODS: This two-year retrospective study (January 1, 2016, through December 31, 2017) in two tertiary maternity units included nulliparous women with a singleton fetus in cephalic presentation and an unfavorable cervix requiring labor induction for prolonged pregnancy. The principal endpoint was the rate of failed induction, defined by the performance of a cesarean delivery before 6 cm of dilation. Cervical ripening was initiated by prostaglandins for 24 h, using a slow-release pessary (unit A) or a vaginal gel (unit B). The care protocol of the two groups after the first 24 h were similar. The women's individual characteristics were compared between the two units. The rates of failed induction were then compared between the two units, first by univariate and then by multivariable analysis adjusted for the characteristics that differed significantly between the units. RESULTS: Among the 17,217 women delivered in the two maternity units during the study period, 178 met our inclusion criteria (125 in unit A (slow-release pessary) and 53 in unit B (vaginal gel)). The rate of failed induction was similar: 21.6% in unit A (slow-release pessary) and 17.0% in unit B (vaginal gel) (P = 0.48). The multivariate analysis did not show any difference about failed induction, time from the onset of induction to delivery, and vaginal delivery rate within 24h. CONCLUSION: The rate of failed induction of labor did not differ between slow-release pessary and vaginal gel.

Implementation of glucose 5% supplementation protocol to reduce the duration of labor among women with cervical ripening by prostaglandins: The GLUCOSHORT before-and-after study.

INTRODUCTION: Previous publications have shown that glucose supplementation could reduce labor duration in women with induction of labor with a favorable cervix but none have shown it for women with an unfavorable cervix.  The purpose of our study was to assess the impact on labor duration of a protocol of glucose supplementation used for induction of labor in women with an unfavorable cervix. MATERIAL AND METHODS: The protocol implemented in November 2017 added glucose supplementation by 5% dextrose at 125 mL/h to Ringer lactate for women with an unfavorable cervix with labor induced with dinoprostone gel. The study included women who underwent this protocol with a singleton, term, cephalic fetus from June 2017 through April 2018. The primary outcome was the labor duration. The secondary outcomes were mode of delivery, postpartum hemorrhage rate, neonatal outcomes, and durations other stage of labor. These outcomes were compared between the pre-intervention (from June 1 to October 31, 2017) and post-intervention (from December 1, 2017 to April 30, 2018) periods. RESULTS: The pre-intervention period included 116 women, and the post-intervention period 123. The characteristics of women and the induction of labor were similar in the two periods. The median duration from induction to delivery was not significantly different between the two periods (13.2 h, IQR 9.1-18.6 versus 13.6 h IQR 9.3-18.3, P=.67). The secondary outcomes did not differ significantly between the two groups. DISCUSSION: Glucose supplementation administered to women with an unfavorable cervix undergoing induction does not appear to reduce the induction-delivery duration.

Neonatal outcomes for women at risk of preterm delivery given half dose versus full dose of antenatal betamethasone: a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial.

BACKGROUND: Antenatal betamethasone is recommended before preterm delivery to accelerate fetal lung maturation. However, reports of growth and neurodevelopmental dose-related side-effects suggest that the current dose (12 mg plus 12 mg, 24 h apart) might be too high. We therefore investigated whether a half dose would be non-inferior to the current full dose for preventing respiratory distress syndrome. METHODS: We designed a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial in 37 level 3 referral perinatal centres in France. Eligible participants were pregnant women aged 18 years or older with a singleton fetus at risk of preterm delivery and already treated with the first injection of antenatal betamethasone (11·4 mg) before 32 weeks' gestation. We used a computer-generated code producing permuted blocks of varying sizes to randomly assign (1:1) women to receive either a placebo (half-dose group) or a second 11·4 mg betamethasone injection (full-dose group) 24 h later. Randomisation was stratified by gestational age (before or after 28 weeks). Participants, clinicians, and study staff were masked to the treatment allocation. The primary outcome was the need for exogenous intratracheal surfactant within 48 h after birth. Non-inferiority would be shown if the higher limit of the 95% CI for the between-group difference between the half-dose and full-dose groups in the primary endpoint was less than 4 percentage points (corresponding to a maximum relative risk of 1·20). Four interim analyses monitoring the primary and the secondary safety outcomes were done during the study period, using a sequential data analysis method that provided futility and non-inferiority stopping rules and checked for type I and II errors. Interim analyses were done in the intention-to-treat population. This trial was registered with ClinicalTrials.gov, NCT02897076. FINDINGS: Between Jan 2, 2017, and Oct 9, 2019, 3244 women were randomly assigned to the half-dose (n=1620 [49·9%]) or the full-dose group (n=1624 [50·1%]); 48 women withdrew consent, 30 fetuses were stillborn, 16 neonates were lost to follow-up, and 9 neonates died before evaluation, so that 3141 neonates remained for analysis. In the intention-to-treat analysis, the primary outcome occurred in 313 (20·0%) of 1567 neonates in the half-dose group and 276 (17·5%) of 1574 neonates in the full-dose group (risk difference 2·4%, 95% CI -0·3 to 5·2); thus non-inferiority was not shown. The per-protocol analysis also did not show non-inferiority (risk difference 2·2%, 95% CI -0·6 to 5·1). No between-group differences appeared in the rates of neonatal death, grade 3-4 intraventricular haemorrhage, stage ≥2 necrotising enterocolitis, severe retinopathy of prematurity, or bronchopulmonary dysplasia. INTERPRETATION: Because non-inferiority of the half-dose compared with the full-dose regimen was not shown, our results do not support practice changes towards antenatal betamethasone dose reduction. FUNDING: French Ministry of Health.

Duration of second stage of labor and factors associated with prolonged second stage: A national population-based study in France.

OBJECTIVES: Prolonged second stage of labor could be associated with an increase in maternal and neonatal morbidity. However, in France, no consensual definition of prolonged 2nd stage of labor exists and therefore factors associated with prolonged second stage have not yet been studied. From national population-based data, we aimed at defining the prolonged 2nd stage of labor in France and identifying its associated factors for women with epidural. STUDY DESIGN: From the French national perinatal survey of 2016, we included all women who reached 2nd stage of labor and delivered at term of a singleton infant in cephalic presentation. We studied the distribution of the duration of the 2nd stage according to parity and defined prolonged 2nd stage as the 90th percentile. Among women with epidural, factors associated with a prolonged 2nd stage of labor were then explored by univariate and multilevel multivariable analysis, to take the cluster effect into account. The proportional change of variance was estimated for each multivariate model. RESULTS: Among the 8154 women included, 3574 were nulliparous and 4580 multiparous. Prolonged second stage was defined as a duration of more than 89.6 min and 30.6 min for nulliparous and multiparous women without epidural; and respectively 185.7 min and 120.1 min for women with epidural analgesia. The factors associated with prolonged 2nd stage of labor were respectively for nulliparous and multiparous women, macrosomia (aOR 1.74 [1.03-2.94] and ORa 2.52 [1.69-3.76]), prenatal preparation classes (aOR 1.47 [1.04-2.08] and aOR 1.56 [1.21-2.01]), a prolonged 1st stage (aOR 1.47 [1.14-1.87] and aOR 1.52 [1.19-1.95]) and delivery in a public maternity unit (aOR 2.68 [1.50-4.78] and aOR 3.12 [1.88-5.17]). Women's characteristics accounted for 3.4% of the variance and maternity organizational characteristics for 26.1%. CONCLUSION: In France, prolonged 2nd stage of labor can be defined as a 2nd stage exceeding 3 h in nulliparous and 2 h in multiparous women with epidural analgesia. The identification of its associated factors allows determining a target population of women at risk of prolonged 2nd stage and improve their 2nd stage's management.

Association between hospitals' cesarean delivery rates for breech presentation and their success rates for external cephalic version.

INTRODUCTION: Success rates of external cephalic version (ECV) are heterogenous in the published literature. Some individual factors are already known to be associated with ECV success but probably do not fully explain the differences. The objective of this review is to assess the association between hospitals' cesarean delivery rates for breech presentations after ECV failure and their ECV success rates. MATERIAL AND METHODS: We performed a review of the literature using the Medline and Cochrane Library computer databases and by searching on clinicaltrials.gov, from 1985 through 2020. This analysis included all studies reporting ECV success rates and cesarean delivery rates for breech presentations. The prognostic factors for successful ECV, such as rates of nulliparity, gestational age at ECV, BMI, and tocolysis use, were also collected and analyzed. Median ECV success rates from the included studies were compared according to these factors. The cesarean rate for persistent breech presentation after ECV failure reported in these studies was considered a proxy indicator of the unit's policy for breech presentations. The correlation between ECV success rates and cesarean delivery rates was analyzed and is presented as a scatter plot. RESULTS: This analysis included 22 studies reporting rates of both successful ECV and cesarean deliveries for persistent breech presentation after ECV failure. The ECV success rates ranged from 16.3% to 82.5% with a median of 48.8% (interquartile range: 36.9-62.9). The median ECV success rate was higher in the studies that used tocolysis than in those that did not (51.3% versus 22.0%, P = .001) and in the studies with the highest cesarean rates for breech presentations than in those with the lowest cesarean rates (57.9% versus 36.2%, P = .006). The ECV success rates were significantly correlated with cesarean delivery rates for persistent breech presentations (R = 0.67; P = .001). CONCLUSION: The likelihood of successful ECV appears higher in hospitals with policies that generally result in cesarean delivery for persistent breech presentation.

Cesarean delivery on maternal request: How do French obstetricians feel about it?

OBJECTIVE: The number of cesarean deliveries on maternal request (CDMR) is unknown in France. We aimed to evaluate the rate of obstetricians willing to perform a CDMR in 2020 in Paris and to compare OB/GYN seniors' and residents' points of view about CDMR using six hypothetical clinical scenarios. STUDY DESIGN: A survey was conducted between January to March 2020 with an anonymous self-administrated questionnaire sent by email to OB/GYN seniors working in 16 public and private maternity units and residents of Paris. Questionnaire was based on previous peer-reviewed literature. Socio professional characteristics were collected. OB/GYN seniors were asked if they agree to perform a CDMR and have already done one. OB/GYN seniors' and residents' points of view on six hypothetical clinical scenarios (CDMR, scarred uterus, breech presentation, multiple pregnancy, history of perineal tears or stillbirth) were compared. RESULTS: Eighty-three OB/GYN seniors and one hundred and fifteen residents answered to our questionnaire. Twenty-three (27,7%) OB/GYN seniors were ready to perform a CDMR, mostly because they think that mode of delivery is a woman's choice. Physicians working in a private maternity unit or having an exclusive private practice were significantly more willing to perform a cesarean delivery on maternal request. No differences were found between the OB/GYN seniors' and residents' point of view on the six hypothetical clinical scenarios. A third of OB/GYN seniors and residents reported having done at least one CDMR during their career or during their residency. CONCLUSION: One out of four OB/GYN senior interviewed is ready to perform a CDMR in Paris in 2020. OB/GYN seniors and residents share the same point of view concerning CDMR.

Term prelabor rupture of membranes: guidelines for clinical practice from the French College of Gynaecologists and Obstetricians (CNGOF).

OBJECTIVE: To determine the management of patients with term prelabor rupture of membranes. METHODS: Synthesis of the literature from the PubMed and Cochrane databases and the recommendations of French and foreign societies and colleges. RESULTS: Term prelabor rupture of membranes is considered a physiological process until 12 h have passed since rupture (professional consensus). In cases of expectant management and with a low rate of antibiotic prophylaxis, home care may be associated with an increase in neonatal infections (LE3), compared with hospitalization, especially for women with group B streptococcus (GBS) colonization (LE3). Home care is therefore not recommended (grade C). In the absence of spontaneous labor within 12 h of rupture, antibiotic prophylaxis may reduce the risk of maternal intrauterine infection but not of neonatal infection (LE3). Its use after 12 h of rupture in term prelabor rupture of the membranes is therefore recommended (grade C). When antibiotic prophylaxis is indicated, intravenous beta-lactams are recommended (grade C). Induction of labor with oxytocin (LE1), prostaglandin E2 (LE1), or misoprostol (LE1) is associated with shorter rupture-to-delivery intervals than expectant management; immediate induction is not, however, associated with lower rates of neonatal infection (LE1), even among women with a positive GBS vaginal swab (LE2). Thus, expectant management can be offered without increasing the risk of neonatal infection (grade B). Induction of labor is not associated with either an increase or decrease in the cesarean rate (LE2), regardless of parity (LE2) or Bishop score at admission (LE3). Induction can thus be proposed without increasing the risk of cesarean delivery (grade B). No induction method (oxytocin, dinoprostone, misoprostol, or Foley catheter) has demonstrated superiority over any another method for reducing rates of intrauterine or neonatal infection or of cesarean delivery or for shortening the rupture-to-delivery intervals, regardless of parity or the Bishop score. CONCLUSION: Term prelabor rupture of membranes is a frequent event. A 12-hour interval without onset of spontaneous labor was chosen to differentiate a physiological condition from a potentially unsafe situation that justifies antibiotic prophylaxis. Expectant management or induction of labor can each be proposed, even in case of positive screening for group streptococcus. The decision should depend on the woman's wishes and maternity unit organization (professional consensus).

Term prelabor rupture of the membranes with unfavorable cervix: Frequency and factors associated with spontaneous onset of labor after two days of expectant management.

INTRODUCTION: In case of term prelabor rupture of membranes (PROM), expectant management is a reasonable option. We aimed at assessing the frequency of spontaneous onset of labor after two days of term PROM and its associated factors. MATERIAL AND METHODS: Women delivering at a tertiary center of a singleton in cephalic presentation, after a term PROM with an unfavorable cervix and with an expectant management period of at least two days were included during a 2-year period. Women were excluded in case of induction of labor before or at day 2(D2) or of spontaneous labor before D2. The frequency of spontaneous labor was assessed, then maternal characteristics at admission and at D2 were compared between women with a spontaneous onset of labor before D3, and women with an induced labor at D3. The maternal and neonatal outcomes were compared between the two groups. The factors associated with spontaneous labor in univariate analysis were tested in multivariable analysis. RESULTS: Among the 11 608 women delivering at term, 933(8.4%) had a term PROM. Among them, 191 had an unfavorable cervix after D2 including 86(45%) women with a spontaneous labor onset between D2 and D3 and 105(55%) induced at D3. Maternal age below 35 years (reference ≥35years) and Bishop score of 3,4 and 5,6 at D2 (reference score 0-2) were significantly associated with spontaneous onset of labor, respectively aOR 2.62; 95%CI[1.26-5.45], aOR 2.38; 95%CI[1.18-4.78] and aOR 10.16; 95%CI[3.67-28.15]. DISCUSSION: In women with a term PROM and an unfavorable cervix, spontaneous labor still occurs in nearly half of women undelivered after two days of expectant management.

Nulliparous women with an unfavourable cervix at 41 weeks: Which women go into spontaneous labor during the expectant period?

CONTEXT: After 41 weeks, the labor induction term varies according to countries and obstetrical teams. The French recommendations are not to exceed 41 weeks 6 days. However, there are no data on the percentage of nulliparous women with an unfavorable cervix at 41 weeks going into spontaneous labor within five or six days. OBJECTIVE: The objective was to establish the rate of spontaneous labor within five days amongst nulliparous women with an unfavorable cervix at 41 weeks, and to identify the maternal and obstetrical factors associated with this spontaneous labor. MATERIALS AND METHODS: Retrospective study in a University Hospital Maternity between January 1st and December 31st 2017. All nulliparous women with a cephalic fetal presentation and unfavorable cervix at 41 weeks (Bishop ≤ 3) were included. The maximum term for induced labor was set at 41 weeks 5 days. The population was divided into two groups: spontaneous labor and induced labor (induction between 41 weeks and 41 weeks 4 days for medical indications or maternal wish and induction at 41 weeks 5 days for full term). The maternal and obstetrical characteristics of the two groups at 41 weeks were compared as well as the maternal and neonatal outcomes. RESULTS: The rate of spontaneous labor among the 269 women included was 38.3% (n = 103/269). At 41 weeks, the presence of painful uterine contractions and a Bishop score of 3 were associated with spontaneous labor within five days (p < 0.01). The Bishop score criteria most associated with spontaneous labor were cervical dilation and fetal station. The cesarean delivery rate was 20.4% in the group of women with spontaneous labor versus 41.0% in the group of induced labor (p < 0.01). There were no differences between the two groups in terms of neonatal outcome. CONCLUSION: Among nulliparous women with an unfavorable cervix at 41 weeks, almost 40 % will have a spontaneous onset of labor within five days. The only factors found to be associated with this onset of labor are the presence of painful uterine contractions and a higher Bishop score at 41 weeks.

Is duration of passive second stage associated with a risk of hysterotomy extension during cesarean?

OBJECTIVE: To assess obstetric factors associated with hysterotomy extension among women undergoing a second-stage cesarean. STUDY DESIGN: This 5-year retrospective cohort study (2013-2017) included all women with second-stage cesarean deliveries of live-born singleton fetuses in cephalic presentation at term. It took place at a tertiary center that practices delayed pushing. We performed univariable and multivariable logistic regression to assess the maternal, obstetric, and neonatal factors associated with hysterotomy extension mentioned in the surgical report. Operative time, postpartum hemorrhage, and maternal complications were also studied. RESULTS: Of the 3350 intrapartum cesareans, 2637 were performed at term for singleton fetuses in cephalic presentation: 747 (28.3%) during the second stage of labor, 83 (11.1%) of which were complicated by a hysterotomy extension. The median duration of the passive phase of the second stage did not differ between women with and without an extension (164 min versus 160 min, P = 0.85). No other second-stage obstetric characteristics, i.e., duration of the active phase, fetal head station, or fetal malposition, were associated with the risk of extension. Factors significantly associated with extension were the surgeon's experience and forceps use during the cesarean. Women with an extension, compared to women without one, had a longer median operative time (49 min versus 32 min, P<0.001) and higher rates of postpartum hemorrhage and blood transfusion (respectively, 30.1% versus 15.1%, p = 0.002 and 7.2% versus 2.4%, P = 0.03). CONCLUSION: The risk of a hysterotomy extension does not appear to be associated with second-stage obstetric characteristics, including the duration of the passive phase of this stage. In our center, which practices delayed pushing, prolonging this passive phase beyond 2 hours does not increase the risk of hysterotomy extension in second-stage cesareans.

Frequency and determinants of misuse of augmentation of labor in France: A population-based study.

INTRODUCTION: While use of augmentation of labor (AL) is appropriate for labor dystocia, it is frequently used inadequately and unnecessarily. The objective was to assess at a national level, the frequency and determinants of misuse of augmentation of labor (AL). MATERIAL AND METHODS: Women of the French perinatal survey of 2016 with a singleton cephalic fetus, delivering at term after a spontaneous labor were included. "Misuse of AL" was defined by artificial rupture of the membranes (ROM) and/or oxytocin within one hour of admission and/or duration between ROM and oxytocin of less than one hour. Women, labor and maternity unit's characteristics were compared between the "misuse of AL" and "no misuse of AL" groups by bivariate analysis. To identify the determinants of misuse of AL, a multivariable multilevel logistic regression was performed taking into account the data's hierarchical structure (first level: women, second level: maternity units). RESULTS: Among the 7196 women included, 1524 (21.2%) had a misuse of AL. The determinants of misuse of AL were middle school educational level (reference high school), aOR = 1.21; 95%CI[1.01-1.45], gestational age at delivery ≥41weeks (reference 39-40 weeks), aOR = 1.19; 95%CI[1.00-1.42], cervical dilation ≥6cm at admission (reference <3cm), aOR = 1.39; 95%CI[1.10-1.76], epidural analgesia aOR = 1.63; 95%CI[1.35-1.96], delivery in a private hospital (reference public teaching hospital), aOR = 2.25; 95%CI[1.57-3.23]; and maternity units with <1000 deliveries/year and 1000-1999 deliveries/year (reference ≥3000 deliveries/year), respectively aOR = 1.52; 95%CI[1.11-2.08] and aOR = 1.42; 95%CI[1.05-1.92]. Less than 3% of the variance was explained by women characteristics, and 24.17% by the maternity units' characteristics. CONCLUSIONS: In France, one spontaneous laboring woman among five is subject to misuse of AL. The misuse is mostly explained by maternity unit's characteristics. The determinants identified in this study can be used to implement targeted actions in small and private maternity units.

Fetal scalp blood sampling: Do pH and lactates provide the same information?

OBJECTIVE: Assess the discordance between scalp pH and lactates performed from the same sample during labor. METHOD: This single-center retrospective study included all women with a singleton fetus who had at least one fetal blood sample taken during labor. Some of them had up to seven samples. Scalp pH was the reference parameter for obstetric decision-making. The correlation between the pH and lactates was studied using Pearson coefficient. By categorizing the values as normal, pre-acidosis and acidosis, we were able to estimate agreement with Cohen's kappa coefficient. The frequency of discordance in the categorization and the factors related to it were studied with univariate and multivariable analyses. Cases of severe acidosis at birth (cord pH < 7.00) and cases with acidosis scalp lactates but normal scalp pH were analyzed. RESULTS: We analyzed 480 samples from 268 fetuses among the 2644 deliveries during the study periode. Fetal blood sampling represented 10 % of deliveries. The scalp pH and lactates results were strongly correlated (r=-0.83), but their agreement was only fair (K = 0.36). In 29.4 % of cases, pH and lactates were discordant. Factors related to discordance were meconium-stained fluid, sampling at full dilation and multiple sampling. Six infants (2.2 %) had severe acidosis at birth. Cases' analyses did not allow to conclude severe acidosis could have been avoided using scalp lactates for obstetric decision-making. CONCLUSION: For more than a quarter of the samples, results were discordant between scalp pH and lactates, especially when cervix was full dilated and when the amniotic fluid was meconium-stained. A randomized controlled trial comparing the relevance of each parameter according to the obstetrical situation would be necessary.