Avenues for measuring and characterising violence in perinatal care to improve its prevention: A position paper with a proposal by the National College of French Midwives.

BACKGROUND: France is somewhat behind other countries in its consideration of the issue of violence in perinatal care. Its consequences on maternal, but also neonatal and infant health are recognised internationally. Nonetheless, research and data measuring its frequency and its determinants are inadequate, and the relevant definitions are not always consensual. In this context, we, as midwives and researchers in public health and as members of the National College of French Midwives, seek to propose a scientific and clinical contribution to this debate. AIM: We propose avenues for measuring and characterising violence in perinatal care. Our objective is to quantify and characterise the situations of violence in perinatal care in population-based studies and based on the perceptions of each woman questioned. DISCUSSION: This proposal for questions, simplified compared with those currently in used in the international scientific literature, has the advantage of focusing reflection around three categories: inappropriate medical care, inappropriate human behaviours in care, and sexual abuse. It should also allow the identification of the contexts of care during which violence may be experienced, as well as the categories of health-care workers concerned. CONCLUSION: It seems important to us to distinguish these situations, causal and context, for they require different responses if we hope to reduce the frequency and the effects of violence in perinatal care in the future. We propose questions that could also be used in clinical situations by midwives and other clinicians.

Barrier measures implemented in French maternity hospitals during the COVID-19 pandemic: A cross-sectional survey.

OBJECTIVES: The objectives of this survey were 1) to describe the changes over time of barrier measures in maternity units, specifically, co-parent visits and women wearing masks in birth rooms, and 2) to identify potential institutional determinants of these barrier measures. DESIGN: We used an online questionnaire to conduct a descriptive cross-sectional survey from May to July 2021. SETTING: All districts in mainland France. PARTICIPANTS: Midwife supervisor of each maternity unit. MEASUREMENTS: Primary outcomes were "banning of visits" in the postnatal department during the first lockdown (March-May 2020), and "mandated mask-wearing in birth rooms" during the survey period (May-July 2021); the independent variables were maternity unit characteristics and location in a crisis area. Co-parent visits were considered only during the first lockdown as they were mostly allowed afterwards, and the wearing of masks was studied only during the survey period, as masks were unavailable for the population during the first lockdown. RESULTS: We obtained 343 responses, i.e., 75.2% of French maternity units. Visits to the postnatal department were forbidden in 39.3% of the maternity units during the first lockdown and in none during the study period. Maternity hospitals with neonatal intensive care units were the most likely to ban co-parent hospital visits (adjusted OR 2.34 [1.12; 4.96]). However, those were the maternity units least likely to encourage or require women to wear masks while pushing (adjusted OR, 0.31; 95% confidence interval [CI], 0.11-0.77). Maternity units in crisis areas (i.e., with very high case counts) during the first lockdown banned visits significantly more often (adjusted OR, 1.68; 95% CI, 1.05-2.70). KEY CONCLUSIONS: Our study showed that barrier measures evolved during the course of the pandemic but remained extremely variable between facilities. IMPLICATIONS FOR PRACTICE: Maternity units implemented drastic barrier measures at the beginning of the pandemic but were able to adapt these measures over time. It is now time to learn from this experience to ensure that women and infants are no longer harmed by these measures.

Surgical management of a loss of pregnancy in the first trimester: Patient experience and influencing factors, a prospective observational study.

OBJECTIVE: Describe the "patient experience" regarding care provided during the surgical management of a loss of pregnancy in the first trimester and identify the factors influencing this experience. MATERIAL AND METHODS: It is an observational prospective study conducted in two type III, academic, maternity wards in Lyon, France, carrying out 8,500 deliveries per year. Adult female patients, having undergone a suction curettage for a loss of pregnancy in the first trimester from 24 December 2020 to 13 June 2021 were inculded. The "patient experience" was assessed using the 15 questions of the Picker Patient Experience (PPE-15) questionnaire, and research was conducted on factors influencing the patient experience. The main outcome was the percentage of patients reporting a problem in response to at least one of the PPE-15 questions. RESULTS: 58 out of 79 patients (73% CI [62-83]) reported at least one problem with their care. The largest proportion of problems was raised in question about "Opportunity for family/loved ones to talk to the doctor" (76% CI [61-87]). The lowest proportion of problems was raised in question about "Treated with respect and dignity" (8% CI [3-16]). No factors influencing the patient experience were identified. DISCUSSION: Almost three out of four patients reported a problem in the experience as a patient. The main areas of improvement reported by patients were the participation of their family/relatives and the emotional support provided by the healthcare team. TWEETABLE ABSTRACT: Better communication with patient families and emotional support could improve patient experience during the surgical management of a loss of pregnancy in the first trimester.

[Oxytocin administration during spontaneous labour: Guidelines for clinical practice. Guidelines short text]. / Recommandations pour l'administration d'oxytocine au cours du travail spontané. Texte court des recommandations.

OBJECTIVES: To define the different stages of spontaneous labour. To determine the indications, modalities of use and the effects of administering synthetic oxytocin. And to describe undesirable maternal and perinatal outcomes associated with the use of synthetic oxytocin. METHOD: A systematic review was carried out by searching Medline database and websites of obstetrics learned societies until March 2016. RESULTS: The 1st stage of labor is divided in a latence phase and an active phase, which switch at 5cm of cervical dilatation. Rate of cervical dilatation is considered as abnormal below 1cm per 4hour during the first part of the active phase, and below 1cm per 2hours above 7cm of dilatation. During the latent phase of the first stage of labor, i.e. before 5cm of cervical dilatation, it is recommended that an amniotomy not be performed routinely and not to use oxytocin systematically. It is not recommended to expect the active phase of labor to start the epidural analgesia if patient requires it. If early epidural analgesia was performed, the administration of oxytocin must not be systematic. If dystocia during the active phase, an amniotomy is recommended in first-line treatment. In the absence of an improvement within an hour, oxytocin should be administrated. However, in the case of an extension of the second stage beyond 2hours, it is recommended to administer oxytocin to correct a lack of progress of the presentation. If dynamic dystocia, it is recommended to start initial doses of oxytocin at 2mUI/min, to respect at least 30min intervals between increases in oxytocin doses delivered, and to increase oxytocin doses by 2mUI/min intervals without surpassing a maximum IV flow rate of 20mUI/min. The reported maternal adverse effects concern uterine hyperstimulation, uterine rupture and post-partum haemorrhage, and those of neonatal adverse effects concern foetal heart rate anomalies associated with uterine hyperstimulation, neonatal morbidity and mortality, neonatal jaundice, weak suck/poor breastfeeding latch and autism. CONCLUSION: The widespread use of oxytocin during spontaneous labour must not be considered as simply another inoffensive prescription without any possible deleterious consequences for mother or foetus. Conditions for administering the oxytocin must therefore respect medical protocols. Indications and patient consent have to be report in the medical file.

[Unexpected out-of-hospital deliveries: Management and risk factors]. / Accouchement inopiné extrahospitalier : prise en charge et facteur de risque.

OBJECTIVES: To estimate the frequency of accidental out-of-hospital deliveries (OHDs), to describe the home care and the complications occurred, and to identify risk factors. MATERIALS AND METHODS: A retrospective case-control study from 1st January 2012 to 31 December 2012 in Lyon urban area. Cases were identified from the Emergency Medical Aid Service 69 (SAMU 69) registry and control from the birth registry of the maternity corresponding to the case, recruiting two controls per case. RESULTS: The frequency of the OHDs was 0.3% [0.2-0.4]. At home, the prophylactic administration of oxytocin was performed in 18.3% [9.31-27.3] of cases and prevention of neonatal hypothermia was performed in 45.7% [34.1%-57.3%] of cases. Multiparity [OR: 3.43 (1.65-7.23)], a precarious situation [OR: 37.63 (5.02-7.81)], and lack of antenatal care [OR: 3.36 (2.72-4.15)] were OHDs' risk factors. CONCLUSION: The practical prevention of postpartum hemorrhage, and that of the home neonatal hypothermia could be improved. Points of vigilance for the medical teams to look for during the pregnancy monitoring are precariousness and less than 3 consultations scheduled.

[Saccular aneurysm of the superior vena cava]. / Anévrisme sacciforme de la veine cave supérieure.

The authors report a case of a saccular aneurysm of the superior vena cava in a 38 year old female. The diagnosis could only be made at thoracotomy because of the additional difficulty posed by a complete thrombosis of the aneurysmal pocket, which produced a particularly deceptive CT image. This type of lesion is exceptionally rare as a cause of a mediastinal "tumour" since only 24 cases of congenital aneurysm of the superior vena cava have been reported, of which only 4 were of the saccular type.

[Assessment of mortality morbidity conference in obstetrics: literature review]. / Évaluation de l'impact des revues de morbi-mortalité en obstétrique: revue de la littérature.

OBJECTIVES: To assess this effectiveness of morbi-mortality conference (MMC) in improving quality of care. MATERIALS AND METHODS: A review was carried out by searching Medline, Pascal and Cochrane databases, Google scholar and websites of French obstetrics professional societies, until July 2011. Search terms included morbidity, mortality, conference, and obstetrics. The eligible reports of assessment of MMC in obstetrics have been analysed by four reviewers with a standardized form. RESULTS: Among 319 records identified, four observational studies published between 2009 and 2011 were included. The objective of these MMC was students' training (n=2), quality of care improvement (n=1), or both (n=1). The MMC organization was heterogeneous. The impact of MMC was assessed using qualitative (n=2), semi-quantitative (n=1) or quantitative (n=1) method. None of these studies showed a significant impact of MMC on students' training or quality of care. CONCLUSION: Available evidence is insufficient to evaluate the effectiveness of MMC in improving quality of obstetrics care.

[Cell-mediated immunity studied by skin tests in patients receiving intensive care. Prognostic value of repeated tests. Study of some factors predisposing towards anergy (author's transl)]. / Etude de l'immunité cellulaire par la méthode des tests cutanés en réanimation.

Cell-mediated immunity was assessed by three skin tests (using tuberculin, candidin, and Varidase) in one-hundred patients in a medical intensive care unit. Anergy on admission was most often found after major blood loss and massive transfusion as well as in patients over sixty. For the 49 patients who were anergic on admission the mortality rate was 32%, against 12% for the 51 reactive subjects (p less than 0.01). Repetition of skin tests considerably improved their prognostic value. No deaths occurred among the 21 patients who were reactive on admission and throughout the course of their disease, or among the 16 patients who, after being anergic on admission, became reactive subsequently. Conversely, the survival rate was only 40% for the 22 patients who remained or became anergic. Our results confirm the value of skin tests for assessing cell-mediated immunity in patients receiving intensive care. Repeated tests allow early detection of high risk patients in whom fatal outcome, whether due to infection or not, is more frequent. Two factors which predispose to anergy are underlined: advanced age and massive transfusion after major blood loss.

[A rare tumor: benign sclerosing pneumocytoma with an intrascissural development]. / A propos d'un cas de tumeur rare: pneumocytome sclérosant bénin à développement intrascissural.

In 1956, LIEBOW and HUBBEL defined pulmonary fibrosing haemangioma as a marked vascular proliferation with a marked tendency to fibrosis, papillary vegetations, extensive histiocytic infiltration and haemorrhages at various stages of organisation. More than 70 cases have been reported since. This lesion occurs most often in the middle aged woman. It is usually asymptomatic or may present as haemoptysis. Radiologically, it takes the form of a well-limited round homogeneous opacity and the prognosis is excellent after excision. The case reported here fell fully within this context and had the special feature of intrascissural tumour development resulting in an unusual radiological appearance which initially suggested a diagnosis of encysted pleural effusion. However the solid nature of the opacity being confirmed by CT scan, it was excised surgically. Its nature was revealed by histological examination. A detailed review of the literature is undertaken and changes in the histopathological concept of this type of lesion discussed. Previously classified amongst inflammatory pseudo-tumours, it is now considered to be a tumour proliferation which, on the basis of current data from electron microscopy and histochemistry, is felt by some to be of vascular origin but by the majority to be of epithelial origin, apparently developing from immature type II pneumocytes. The name "benign fibrosing pneumocytoma" suggested by CHAN would seem now more appropriate.

[Clinical aspects of 27 cases of severe primary infectious lung diseases]. / Aspects cliniques de 27 cas de pneumopathies infectieuses graves primitives.

The authors report 27 cases of severe primary pulmonary infections which resulted in acute respiratory failure and which were treated in a Respiratory Medicine Intensive Care Unit. A bacteriological specimen (blood culture, transtracheal aspiration, fibroscopy, pleural tap) and/or a serological examination permitted the responsible agent to be identified in 20 of the 27 cases (74%). Apart from antibiotics and symptomatic treatments, 13 patients also received oxygen therapy and 14 other patients were intubated and ventilated. In the first group, 3 patients died (24%) and in the second group, the mortality was much higher, with 9 deaths out of 14 patients (64%). The authors present the clinical features, the frequency of the various micro-organisms isolated, the therapeutic modalities and various prognostic factors. Although repeated early specimens usually provide bacteriological diagnosis and therefore appropriate antibiotic therapy, the prognosis of these conditions, at the stage of acute respiratory failure remains serious and is probably related to risk factors linked with predisposition. The exact nature and the relative importance of these risk factors still needs to be determined.

[Oxygen enrichers and different ways of using them]. / Enrichisseurs d'oxygène et différents modes d'utilisation.

Different ways of using oxygen enrichers have been studied. First, the performances of two different devices were tested: the results were very similar to the constructors' previsions. Second, oxygen concentrations in venturi masks connected to enrichers were measured with a mass spectrometer. The authors suggest to adjust the flow delivered by enrichers at 3 liters/min for any type of venturi mask. Pharyngeal oxygen concentration curves show the reliability of masks connected to enrichers compared to other modes of administration (nasal cannulae, nasal catheter).

[Reliability of the transcutaneous PO2 measurement in the adult by the TCM 1 radiometer electrode]. / Fiabilité de la mesure de la PO2 transcutanée chez l'adulte par l'électrode radiometer TCM 1.

The accuracy of transcutaneous PO2 measurements (PtcO2; Radiometer TCM 1) was evaluated by comparison with arterial PO2 (PaO2) on 115 recordings in 35 patients: 20 during exercise testing (group I) and 14 during assisted ventilation at different FIO2 values (group II). The correlation coefficient between PaO2 and PtcO2 was satisfactory (r = 0.977; n = 115). However PaO2 and PtcO2 mean values were significantly different in group I, and in group II at 45% FIO2. The analysis of variance showed that the difference between PaO2 and PtcO2 was significant among the patients but did not vary with exercise and FIO2 changes (group I: F19 = 6.28, p less than 0.001; group II: F19(19) = 2.54, p less than 0.025). In the adult, transcutaneous PO2 measurement by TCM 1 radiometer electrode seems to be interesting in the context of monitoring blood gases with exercise and assisted ventilation. The significant variation with arterial PO2 sometimes registered should make one cautious in the interpretation of accurate measurements.

Effects of nifedipine on pulmonary arterial hypertension in patients with respiratory insufficiency without acute failure.

Permanent pulmonary arterial hypertension is a standard part of the prognosis for patients with chronic respiratory insufficiency. As a decrease of pulmonary arterial hypoxic vasoconstriction may be obtained by calcium antagonists, we studied the effects of nifedipine (10 mg sublingually) in 10 patients with chronic respiratory insufficiency without acute respiratory failure. Our results show that maximal expiratory air flow was not altered. The pulmonary antihypertensive action of this drug, which is less effective than oxygen breathing at low concentration, was associated with a constant decrease of arterial oxygen partial pressure; the oxygen transport was not sustained for every patient. This result suggests that considerable caution should be exercised in using this drug for the treatment of pulmonary arterial hypertension in patients with chronic respiratory insufficiency without acute failure.