[Impact of the healthcare pathway on the rate of obstetrical interventions in small for gestational age fetuses (IATROPAG Study)]. / Impact du parcours de soins sur le taux d'interventions obstétricales dans la prise en charge des fœtus petit pour l'âge gestationnel (Étude IATROPAG).

BACKGROUND: While previous studies have demonstrated an improvement in implementation of clinical practices and an improved neonatal prognosis when growth restricted fetuses were followed within a standardized healthcare pathway, the objective of this study was to assess the prevalence of obstetric interventions in small-for-gestational-age (SGA) fetuses followed within a standardized care pathway compared to a traditional care pathway. METHODS: We conducted a retrospective study between 2015 and 2017, in a type III maternity hospital in Lyon, in a population of SGA fetuses, considered as such in case of antenatal diagnosis of fetal weight<10th percentile but>3rd centile without umbilical Doppler abnormality during antenatal surveillance and without ultrasound argument suggesting intrauterine growth retardation (IUGR). We collected the gestational age at diagnosis, obstetrical events and prevention of preterm delivery (antenatal corticosteroids), gestation age at birth, the method of delivery (spontaneous or induced), indication of induction, the method of birth (spontaneous, instrumental extraction or caesarean section), and the immediate neonatal outcome including cord pH, Apgar score at 5minutes, birth weight and fetal sex. After diagnosis, the choice of the pathway was left to the practitioner depending on their habit, their ability to manage the follow-up and their organizational constraints. RESULTS: Over the study period, and after exclusion of IUGR, 96 SGA were followed up in the traditional pathway and 106 SGA were followed up in the standardized pathway P=0.75. The traditional pathway showed in multivariate analysis a higher prevalence of antenatal corticosteroid therapy for SGA (16,6%) between 2015 and 2017 with OR 7.3 95% CI [1.41-38.43] when compared to the standardized pathway (3,7%). Similarly, the traditional pathway proposes a higher prevalence of induction of labor (54,1%) than the standardized pathway (33,9%) between 2015 and 2017 with OR 3.19 95% CI [1.70-7.80]. The "a posteriori" post-hoc power of the study is 82.9%. CONCLUSION: This study confirms the absence of excessive obstetrical intervention in the SGA population when followed in a standardized healthcare pathway. The latter would reduce unnecessary obstetrical interventions while respecting the intrinsic neonatal prognosis of small for gestational age fetuses.

Adverse events related to ibuprofen treatment for patent ductus arteriosus in premature neonates.

OBJECTIVE: Our study aimed to review adverse drug reactions (ADRs) associated with ibuprofen treatment of patent ductus arteriosus (PDA) in premature neonates. METHOD: We retrospectively evaluated electronic patient records from neonates treated with ibuprofen for PDA during 5 years in a French neonatal intensive care unit. Full chart review and targeted triggers were used to detect ADRs. The causality between suspected ADRs and medication was evaluated using the WHO causality assessment method by pharmacovigilance experts. Categorical variables were compared using chi-square tests or Fisher's test. Quantitative variables were compared using the Student t test. We explored the risk factors associated with ADR using univariate model analysis. RESULT: Of 227 infants with a mean gestational age (GA) of 27 weeks (24-33), 12 (5%) developed intestinal perforation and seven, necrotizing enterocolitis (3%). The perforation occurred less frequently in infants older than 27 weeks GA (OR=0.14; 95% CI=0.03-0.66, P=0.01). Other observed ADRs were acute renal failure (25 infants, 11%) and thrombocytopenia (five infants, 2%). CONCLUSION: Gastrointestinal complications observed in infants treated with ibuprofen for PDA including gastrointestinal perforations occur in less mature infants. Active chart review of the patient's medical file with a trigger tool should be evaluated for routine ADR monitoring.

Clinical impact of vancomycin heteroresistance in staphylococcal strains involved in neonatal sepsis: Discussion of a case report.

Heteroresistance to vancomycin (HRV) represents a decreased susceptibility to vancomycin and is frequently observed in multidrug-resistant coagulase-negative staphylococci. The clinical significance of such heteroresistance is controversial, but several failures of vancomycin therapy have been related to HRV, especially in the neonatal population. Here we report the case of a preterm neonate, born at 26 weeks of gestation, who developed sepsis due to a multidrug-resistant HRV Staphylococcuscapitis isolate. Bacteremia persisted despite adequate vancomycin serum concentration and catheter removal. The patient finally recovered after replacing vancomycin by linezolid. Through this case report, we would like to alert clinicians of the potential clinical impact of HRV and to discuss the lack of therapeutic alternatives in neonates.

Postsurgery analgesic and sedative drug use in a French neonatal intensive care unit: A single-center retrospective cohort study.

OBJECTIVE: To describe pain assessment, the pattern of analgesic and sedative drug use, and adverse drug reactions in a neonatal intensive care unit (NICU) during the postsurgery phase. METHOD: Demographic characteristics, pain scores, and drug use were extracted and analyzed from electronic patient medical files for infants after surgery, admitted consecutively between January 2012 and June 2013. RESULT: One hundred and sixty-eight infants were included. Acute (DAN score) and prolonged (EDIN score) pain assessment scores were used in 79% and 64% of infants, respectively, on the 1st day. This percentage decreased over the 7 days following surgery. The weekly average scores postsurgery were 2/15 (±2.2) for the EDIN score and 1.6/10 (±2.0) for the DAN score. The rates of pain control were 88% for the EDIN and 72% for the DAN. The most prescribed opiate drug was fentanyl (98 patients; 58%) with an average dose of 1.8 (±0.6) µg/kg/h. Midazolam was used in 95 patients (56%), with an average dose of 35 (±14) µg/kg/h. A bolus was administered in 7% (±7.4) of the total dose for fentanyl and 8% (±9.3) for midazolam. Similar doses were used in term and preterm neonates. Of 118 patients receiving fentanyl and/or midazolam, 40% presented urinary retention, 28% a weaning syndrome. Paracetamol (155 patients; 92%) and nalbuphine (55 patients; 33%) were the other medications most often prescribed. CONCLUSION: The off-label use of fentanyl and midazolam was necessary to treat pain after surgery. Pain assessment should be conducted for all neonates in order to optimize their treatment. Research on analgesic and sedative medicine in vulnerable neonates seems necessary to standardize practices and reduce adverse drug reactions.

Idiopathic central diabetes insipidus in an extreme premature infant: A case report.

CONTEXT: Central diabetes insipidus (CDI) is a rare disease during the neonatal period, making it diagnosis difficult and delaying medical treatment. CASE REPORT: We report here a case of a premature infant born at 26 weeks gestation who, during his 1st month of life, presented persistent hypernatremia with polyuria despite increased fluid supply and low sodium intake. CDI diagnosis was suspected and then confirmed by the therapeutic test with vasopressin analog, in its oral form. Electrolyte disorders were normalized after treatment, which allowed normal weight and height growth with standard fluid supply. Biological and radiological tests were all normal; this CDI was considered idiopathic. CONCLUSION: Persistent hypernatremia with excessive diuresis should alert to CDI diagnosis.

[Neonatal intoxication to vitamin D in premature babies: A series of 16 cases]. / Intoxication néonatale à la vitamine D chez des anciens prématurés : une série de 16 cas.

INTRODUCTION: Preterm neonates are particularly at risk of vitamin D (25-D) deficiency. To prevent rickets and osteopenia in this population, international guidelines vary between 800 and 1000IU per day of vitamin D in Europe and recommend 400IU per day in the USA. Target levels of circulating 25-D are not well identified, with the lower target level 50-75nmol/L and the upper target level probably 120nmol/L. METHODS: Between 2013 and 2015, 16 premature infants (born<35WG) were referred to pediatric nephrology clinics because of symptoms secondary to 25-D overdose during the neonatal period. Clinical and biological data were retrospectively reviewed to better define this population. The results are presented as the median (range). RESULTS: Gestational age was 27 (24-35)WG with a birth weight of 810 (560-2120)g. Nephrocalcinosis was the initial symptom in 37% of cases, hypercalcemia in 44%, and hypercalciuria in 19%. Daily vitamin D doses were 333 (35-676)IU. Age and body weight at initial symptom were 36.6 (27.6-47.6)WG and 2300 (640-3760)g, respectively. The 25-D level at the time of the first dosage was 210 (119-350)nmol/L and the 1-25 vitamin D level was 370 (245-718)pmol/L (local normal values for age<240). During follow-up, 12 patients displayed nephrocalcinosis, ten hypercalciuria, and three hypercalcemia. The 25-D level normalized in ten patients within 10 (3-32)months after vitamin D withdrawal. Nephrocalcinosis improved in ten of 12 patients, within 12 (3-30)months. Vitamin D could be readministered in ten patients. When searched (n=3), no CYP24A1 mutation was identified in two patients, but was identified in the heterozygous state in one. CONCLUSION: A 25-D overdose should be systematically ruled out in the presence of nephrocalcinosis, hypercalcemia, and/or hypercalciuria during infancy in children born preterm. Studies are required to assess the exact frequency of 25-D deficiency and overdose in this population, as well as to evaluate the potential deleterious effects of this imbalance on bone, kidney, and brain development.

[Teaching pediatrics to residents via conventional lectures in France: A national survey from students]. / Enseignement théorique du Diplôme d'études spécialisées de pédiatrie en France : évaluation nationale par les internes.

OBJECTIVE: To assess the point of view of young physicians training in pediatrics in France on their theoretical courses during residency. METHODS: A free-access electronic anonymous survey was sent three times by e-mail to the 1215 residents in pediatrics, from July to October 2015. RESULTS: Fifty-seven percent of French residents in pediatrics responded to the survey. It was established that they took part in six (range, 3-10) half-days of specific theoretical teaching in pediatrics from November 2014 to mid-April 2015. Only 54% participated in more than 75% of regional theoretical training. The main self-declared reason for their absence was that they could not leave their clinical activities. Fifty-three per cent of the residents took part in additional training, 45% of them because they found the primary theoretical training insufficient. The overall quality of the theoretical teaching was rated 5 (range, 3-7) out of 10. Eighty-five percent of residents expected to be evaluated on their knowledge during their residency. CONCLUSION: In pediatrics, additional training is individually undertaken because they deemed their initial training insufficient during their residency. An evaluation of knowledge is requested by residents. The reform of the national residency program must take into account these results in redesigning the theoretical training in pediatrics, integrating innovative teaching techniques to daily practice, for example.

Evaluation of the quality of life of pregnant women from 2005 to 2015.

Over the past two decades, quality of life has become an essential preoccupation in the care of patients. Many measuring instruments are available to assess physical, psychological and social quality of life. These tools allow healthcare professionals to determine the best quality of their patients. However, the quality of life for the pregnant woman seems to be little studied. This article presents the results of a bibliographic review of publications between 2005 and 2015 - referenced in PUBMED and COCHRANE - on the quality of life of pregnant women giving birth after the 22nd week of amenorrhea. The articles were selected by a reading committee. 195 publications responding to keywords were identified. 75 articles on the problem were selected. The main countries that have published on this subject are Iran (n=11) and Brazil (n=9). France ranks 17th with only one publication. 74% of articles deal with quality of life for pathological pregnancies (gestational or pre-existing pathologies). 23 pathologies were identified, mainly depression (20% of items). This review reveals a growing global interest in quality of life in pregnant women. However, few studies evaluate the impact of care in terms of quality of life in pregnant women, contrary to the recommendations of different health authorities. Finally, the analysis of the various articles shows that, in general, few measurements are made to evaluate the quality of life, not requiring a standardized curve of quality of life during pregnancy. There is thus a significant lack of data to establish a standardized curve for the quality of life of pregnant women, which allows a simple comparison of quality of life measures according to the different clinical management.

Neonatal transient hypophosphatemic hypercalciuric rickets in dizygous twins: A role for maternal alendronate therapy before pregnancy or antireflux medications?

BACKGROUND: Bisphosphonates (BP) are sometimes used in children and young women, but their use requires expertise and caution due to the relative lack of long-term efficacy and safety data. CLINICAL CASES: We report on two dizygotic male twins with a past of mild prematurity who presented at the age of 2 months with moderate clinical craniotabes, hypophosphatemia, normal circulating calcium, severe hypercalciuria, and low parathyroid hormone levels. Following supplementation with oral phosphorus and native vitamin D, the clinical and biological abnormalities disappeared within 2 months. Since the twins were dizygotic and were identical in terms of clinical presentation and progression, the only likely explanation for these transient mineral abnormalities was prenatal or neonatal exposure to a toxic agent. Taking into account their medical past, two drugs were possibly involved: either oral alendronate that their mother had received before pregnancy for misdiagnosed osteoporosis or antireflux medications, or both. DISCUSSION: We believe that these two cases could correspond to the first description of a potential mother-to-fetus transmission of alendronate, inducing early and transient hypophosphatemic rickets, the clinical picture being worsened by the antireflux drugs impairing intestinal phosphate absorption. For pediatric rheumatologists, this raises the question of more clearly defining the indications for BP in female children and teenagers; for rheumatologists, this also demonstrates the importance of correctly diagnosing osteoporosis and not using BP off-label, especially in women of child-bearing age.

Wide geographical dissemination of the multiresistant Staphylococcus capitis NRCS-A clone in neonatal intensive-care units.

Nosocomial late-onset sepsis represents a frequent cause of morbidity and mortality in preterm neonates. The Staphylococcus capitis clone NRCS-A has been previously described as an emerging cause of nosocomial bacteraemia in French neonatal intensive-care units (NICUs). In this study, we aimed to explore the possible unrecognized dissemination of this clone on a larger geographical scale. One hundred methicillin-resistant S. capitis strains isolated from neonates (n = 86) and adult patients (n = 14) between 2000 and 2013 in four different countries (France, Belgium, the UK, and Australia) were analysed with SmaI pulsed-field gel electrophoresis (PFGE) and dru typing. The vast majority of NICU strains showed the NRCS-A pulsotype and the dt11c type (96%). We then randomly selected 14 isolates (from neonates, n = 12, three per country; from adult patients, n = 2), considered to be a subset of representative isolates, and performed further molecular typing (SacII PFGE, SCCmec typing, and multilocus sequence typing-like analysis), confirming the clonality of the S. capitis strains isolated from neonates, despite their distant geographical origin. Whole genome single-nucleotide polymorphism-based phylogenetic analysis of five NICU isolates (from the different countries) attested to high genetic relatedness within the NRCS-A clone. Finally, all of the NRCS-A strains showed multidrug resistance (e.g. methicillin and aminoglycoside resistance, and decreased vancomycin susceptibility), with potential therapeutic implications for infected neonates. In conclusion, this study represents the first report of clonal dissemination of methicillin-resistant coagulase-negative Staphylococcus clone on a large geographical scale. Questions remain regarding the origin and means of international spread, and the reasons for this clone's apparent predilection for neonates.

Adaptation to vancomycin pressure of multiresistant Staphylococcus capitis NRCS-A involved in neonatal sepsis.

OBJECTIVES: The Staphylococcus capitis clone NRCS-A has recently been described as a frequent cause of late-onset sepsis (LOS) in pre-term neonates worldwide. Representatives of this clone exhibit non-susceptibility to vancomycin, the first-line agent used in LOS. Cases of prolonged S. capitis LOS despite vancomycin treatment have been reported. We investigated whether NRCS-A strains exhibit faster adaptation to vancomycin pressure as compared with other staphylococci. METHODS: Strains of S. capitis NRCS-A, S. capitis non-NRCS-A and Staphylococcus epidermidis (n = 2 each, all with vancomycin MICs ≤2 mg/L) and the prototype vancomycin-heteroresistant Staphylococcus aureus Mu3 were subcultured daily for 15 days with 0.25-32 mg/L vancomycin. Regression coefficients of daily log2 MICs on time were used to estimate the kinetics of resistance development. Changes in bacterial cell-wall thickness were measured by transmission electron microscopy. To assess the stability of resistance and the emergence of cross-resistance, vancomycin, teicoplanin, daptomycin and linezolid MICs were measured before and after vancomycin treatment, as well as after nine additional subcultures without antibiotics. RESULTS: All strains developed a stable resistance to vancomycin, but this occurred significantly faster in S. capitis NRCS-A than in S. capitis non-NRCS-A (P < 0.001) and other species (P < 0.0001). Vancomycin resistance in S. capitis NRCS-A was associated with significant cell-wall thickening and an increase in MICs of daptomycin and teicoplanin, but not linezolid. CONCLUSIONS: S. capitis NRCS-A rapidly adapts to vancomycin pressure as compared with potential niche competitors, a feature that might contribute to its success in neonatal ICUs where vancomycin is widely prescribed.

[Advantages and special features of hospital preparations of parenteral nutrition in neonatalogy]. / Avantages et spécificités des préparations hospitalières de nutrition parentérale en néonatalogie.

INTRODUCTION: The care of premature infants requires specific, suitable parenteral nutrition, in which the dosage must be frequently adjusted. METHOD: A comparative analysis of four industrial standard parenteral nutrition formulations NP 100®, Pediaven AP-HP Nouveau-né 1®, Pediaven AP-HP Nouveau-né 2® and Numetah G13% E® and of two hospital preparations made specifically in hospital pharmacies produced by two separate university hospitals (Nutrine® HCL and Formule standardisée début de nutrition) was conducted. The comparison between the formulations focused on electrolytic compositions and protein/energy ratio. RESULTS: Formule standardisée début de nutrition and Pediaven AP-HP Nouveau-né 1® are free from (i) sodium and potassium, (ii) potassium respectively. Almost equivalent sodium concentration (19-27 mM) and more variable potassium concentration (∼9-26 mM) characterize the other formulations. Protein/energy ratio of Numetah G13% E®, Nutrine® HCL and Formule standardisée début de nutrition is 58% higher than that of NP 100®, Pediaven AP-HP Nouveau-né 1® and Pediaven AP-HP Nouveau-né 2®. DISCUSSION: Formule standardisée début de nutrition and Pediaven AP-HP Nouveau-né 1® are in accordance with the recommendations about hydro-electrolytic supplies during transition phase. Nutrine® HCL complies best to the recommendations about hydro-electrolytic account during stabilization phase. CONCLUSION: Hydro-electrolytic composition and protein/energy ratio of standard hospital parenteral nutrition formulations comply best to nutritional needs of premature infants.

[Nuclear magnetic resonance based metabolic phenotyping for patient evaluations in operating rooms and intensive care units]. / Phénotypage métabolique par résonance magnétique nucléaire pour l'évaluation périopératoire et en réanimation.

Metabolic phenotyping consists in the identification of subtle and coordinated metabolic variations associated with various pathophysiological stimuli. Different analytical methods, such as nuclear magnetic resonance, allow the simultaneous quantification of a large number of metabolites. Statistical analyses of these spectra thus lead to the discrimination between samples and the identification of a metabolic phenotype corresponding to the effect under study. This approach allows the extraction of candidate biomarkers and the recovery of perturbed metabolic networks, driving to the generation of biochemical hypotheses (pathophysiological mechanisms, diagnostic tests, therapeutic targets…). Metabolic phenotyping could be useful in anaesthesiology and intensive care medicine for the evaluation, monitoring or diagnosis of life-threatening situations, to optimise patient managements. This review introduces the physical and statistical fundamentals of NMR-based metabolic phenotyping, describes the work already achieved by this approach in anaesthesiology and intensive care medicine. Finally, potential areas of interest are discussed for the perioperative and intensive management of patients, from newborns to adults.

A report on the large measles outbreak in Lyon, France, 2010 to 2011.

In 2010 and 2011, the city of Lyon, located in the Rhône-Alpes region (France), has experienced one of the highest incidences of measles in Europe. We describe a measles outbreak in the Lyon area, where cases were diagnosed at Lyon University hospitals (LUH) between 2010 and mid-2011. Data were collected from the mandatory notification system of the regional public health agency, and from the virology department of the LUH. All patients and healthcare workers who had contracted measles were included. Overall, 407 cases were diagnosed, with children of less than one year of age accounting for the highest proportion (n=129, 32%), followed by individuals between 17 and 29 years-old (n=126, 31%). Of the total cases, 72 (18%) had complications. The proportions of patients and healthcare workers who were not immune to measles were higher among those aged up to 30 years. Consequently, women of childbearing age constituted a specific population at high risk to contract measles and during this outbreak, 13 cases of measles, seven under 30 years-old, were identified among pregnant women. This study highlights the importance of being vaccinated with two doses of measles vaccine, the only measure which could prevent and allow elimination of the disease.

[Does the regional health care organization impact the outcome of infants born with congenital diaphragmatic hernia?]. / Hernie diaphragmatique congénitale : le devenir des enfants est-il lié aux modalités de prise en charge ?

INTRODUCTION: Congenital diaphragmatic hernia (CDH) is a serious pathology that requires optimal management in very specialized health centers. French medical care organization is regionally based. Hence, evaluating local practices may help deliver clear information to parents before delivery. The aim of this study was to analyze the neonatal characteristics and the postnatal outcome of infants affected with CDH, treated within two different French perinatal health care networks. PATIENTS AND METHODS: Retrospective cohort study of infants with CDH, cared for in the Lorraine perinatal health care network (Réseau Périnatal Lorrain [RPL]) or at Édouard-Herriot Hospital (HEH) in Lyon, between 1997 and 2007. RESULTS: One hundred and twenty-seven newborns were included, 44 in the RPL and 83 in Lyon. Prenatal diagnosis of CDH was similar in RPL and at HEH; 47.7% of infants with CDH died in RPL vs 36.1% in HEH (P=0.2). Surgery delayed for more than 24h was more frequent in RPL (68.6% vs 31.7%; P<0.001), with a postoperative mortality rate of 31.4% vs 15.9%; P=0.08. In RPL, specialized medical follow-up was rare (33.3% vs 100%; P<0.001), while psychomotor retardation was more frequent (33.3% vs 5.7%; P=0.002). CONCLUSION: This study brings to light the diversity of care and outcome for infants affected with CDH in two French perinatal health care networks. These results may help improve both centers' practices. In Lorraine for instance, the follow-up of these vulnerable children can be improved.

[Is it possible to prevent preterm births outside of level-3 maternity wards? Experience of Greater Lyon perinatal network]. / Les naissances des grands prématurés en dehors des maternités de type III sont-elles évitables? Expérience du réseau Grand Lyon.

OBJECTIVE: The main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented. METHODS: This was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97(th) percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second. RESULTS: During the study period, 113 infants were born alive between 24 and 27 weeks GA+6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided. DISCUSSION AND CONCLUSION: Any time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.

[Audipog perinatal network 2004-2005. Part 2: assessment of medical practices]. / Réseau Sentinelle Audipog 2004-2005. Partie 2 : évaluation des pratiques professionnelles.

OBJECTIVE: To describe specific clinical practices in France in 2004-2005 based on data from the Audipog sentinel network. PATIENTS AND METHODS: The database for 2004 and 2005 covers 71406 pregnancies from 86 maternity units throughout the year. We constructed a random subsample each year by including only the births occurring during a single month for each maternity ward. Our study therefore analyzes 6987 pregnancies in 2004 and 7648 pregnancies in 2005. RESULTS: Among the very preterm (<33 weeks of gestation) infants from multiple pregnancies, 77.4% were born in level 3 hospitals in 2000-2001, and only 44.9% in 2004-2005 (p<0.0001). Among the very preterm infants from singleton pregnancies, the percentage born in level 3 maternity hospitals rose between 1996-1997 and 2004-2005 (55% versus 73%; p=0.001). The rate of corticosteroid therapy before delivery among very preterm infants did not change significantly between 2000 and 2005 (p=0.58). The cesarean rate rose from 14% in 1994 to 20.0% in 2005. The percentage of actively managed third stages of labor increased from 1994-1995 to 2005 (6.2% versus 31.3%). Fewer episiotomies were performed: 56% in 1994-1995 and 41.3% in 2005. Exclusive breast-feeding rose from 51.2% in 2000-2001 to 58.5% in 2005 (p<0.0001). Early discharge increased between 1994-1995 and 2005 (p<0.0001). DISCUSSION AND CONCLUSION: Indicators monitoring implementation of some of the national clinical practice guidelines have improved slightly over time, although most often before the publication of these guidelines.