[Induction of labor in women with previous caesarean delivery with balloon catheter: Is it worth it?] / Déclenchement par ballonnet en cas d'utérus cicatriciel et col défavorable : la tentative en vaut-elle la chandelle ?

OBJECTIF: Balloon catheters for labor induction at term after previous cesarean section is an alternative option to iterative cesarean section. The aim of this study was to analyze the maternal and neonatal outcomes of the trial of labor after cesarean (TOLAC) in women with unfavorable cervix and balloon catheter induction, 2 years after introduction of this process. METHODS: Unicentric observational study of women with term cephalic singleton, unfavorable cervix (simplified Bishop score<5) after TOLAC using double-balloon catheter. Were analyzed the mode of delivery and severe maternal (uterine rupture, post-partum hemorrhage, severe perineal tears) and neonatal (neonatal unit admission, APGAR<7 at 5minutes, pH<7.1) outcomes. Predictive factors for failed TOLAC were analyzed by using multivariate logistic regression. RESULTS: Between 2016-2017, 455 (75.4%) women had TOLAC, whose 59 (13%) women with balloon catheter. The overall vaginal delivery (VD) was 73.9%. After Balloon catheter, the VD rate was 50.8%, versus 79.1% after spontaneous labor, and 68.2% after alone oxytocin/artificial membrane rupture induction (P<0.05). Previous VD (aOR 0.176 CI-95% [0.048-0.651]) and prior sweeping membrane (aOR 0.161 CI-95% [0.034-0.761]) was protective for cesarean section after TOLAC. Severe maternal and neonatal morbidities were observed in 10 (17%) and 8 (13.6%) cases, respectively. CONCLUSION: Double-Balloon catheter is an option for unfavorable cervix and term induction after previous cesarean section. However, the TOLAC in women whose unfavorable cervix is not without maternal and neonatal risk, especially due to its failure.

Is episiotomy worthwile to prevent obstetric anal sphincter injury during operative vaginal delivery in nulliparous women?

OBJECTIVES: Episiotomy is a marker of Obstetric Anal Sphincter Injury (OASIS) condition, therefore, unmeasured factors could have biased the strength of the association between episiotomy and reduced OASIS during Operative Vaginal Delivery (OVD). The aim of this study was to compare the OASIS rate during OVD according to episiotomy practice. STUDY DESIGN: Retrospective cohort study of all nulliparous pregnant women attempting an OVD between 2014-2017. To avoid unmeasured bias, all maternal and delivery data were prospectively captured after the birth. The strong relationship between parity and episiotomy practice (indication bias) lead to analyze only nulliparous women. Association between mediolateral episiotomy and OASIS following OVD was performing by using multivariate logistic regression analysis including significant variable in univariate analysis and relevant factors known to be associated both with OASIS and/or OVD. RESULTS: Over the study period, 1709 (17.1%) women had an OVD, among them 40 (2.3%) had OASIS. In the 1342 (78.5%) nulliparous women, OASIS rate were 2% and 5.1% with and without episiotomy (p < 0.01). In multivariate analysis a lower incidence of OASIS with the use of episiotomy (OR 0.267 IC 0.132-0.541) were observed. The persistent occiput posterior position was associated with an increase risk of OASIS (OR 6.742 IC 2.376-19.124). Spatula/forceps, as compared to vacuum operative vaginal delivery increased the risk OASIS (OR 2.847 IC 1.311-7.168). Area under the curve of the model was 0.745. CONCLUSION: Episiotomy is a modifiable risk factors which can contribute to reduce the risk of OASIS in nulliparous women with operative vaginal delivery. This intervention should be included in a global management of the second stage of labor.

[Deep infiltrating endometriosis surgical management and pelvic nerves injury]. / Identification des sites anatomiques à risque de lésion nerveuse lors de chirurgie pour endométriose pelvienne profonde.

OBJECTIVES: Deep pelvic endometriosis surgery may need substantial excisions, which in turn expose to risks of injury to the pelvic nerves. To limit functional complications, nerve-sparing surgical techniques have been developed but should be adapted to the specific multifocal character of endometriotic lesions. The objective was to identify the anatomical areas where the pelvic nerves are most at risk of injury during endometriotic excisions. METHODS: The Medline and Embase databases have been searched for available literature using the keywords "hypogastric nerve or hypogastric plexus [Mesh] or autonomic pathway [Mesh], anatomy, endometriosis, surgery [Mesh]". All relevant French and English publications, selected based on their available abstracts, have been reviewed. Five female adult fresh cadavers have been dissected to localize the key anatomical areas where the pelvic nerves are most at risk of injury. RESULTS: Six anatomical areas of high risk for pelvic nerves have been identified, analysed and described. Pelvic nerves can be damaged during the dissection of retrorectal space and the anterolateral rectal excision. Furthermore, before an uterosacral ligament excision, a parametrial excision, a colpectomy or a dissection of the vesico-uterine ligament, the hypogastric nerves, splanchnic nerves, inferior hypogastric plexus and its efferent pathways must be mapped out to avoid injury. The distance between the deep uterin vein and the pelvic splanchnic nerves were measured on four cadavers and varied from 2.5cm to 4cm. CONCLUSION: Six key anatomical pitfalls must be known in order to limit the functional complications of the endometriotic surgical excision. Applying nerve-sparing surgical techniques for endometriosis would lead to less urinary functional complications and a better short-term postoperative satisfaction.

[Urinary incontinence in nulliparous women: prevalence and evaluation of self-perineal reeducation]. / Incontinence urinaire chez la femme nullipare: prévalence et évaluation de l'auto-rééducation périnéale.

AIMS: To assess the prevalence of urinary incontinence (UI) in a population of young nulliparous women and the effectiveness of self-perineal exercises in symptomatic women. MATERIAL: Three hundred and fifteen nulliparous students from French secondary establishments answered through a secure website, created for the study, an anonymous questionnaire about UI. The questionnaire included validated symptom scores (International Consultation on Incontinence Questionnaire-Short Form, ICIQ-UI SF) and quality of life (Contilife). Women who reported UI were asked to perform a self-perineal rehabilitation program for 8 weeks. A second questionnaire was completed after reeducation to assess the evolution of their UI. RESULTS: Among the 315 respondents, 92 women (29.2%) reported UI. The mean age was 23.0 (± 4.4) years in the continent group and 22.9 (± 3.6) years in the incontinent group. Only 24 of the 92 women with UI (26.1%) completed the reeducation program with a significant improvement in UI and quality of life (QoL). CONCLUSION: UI is a common disorder in young nulliparous women. Perineal self-exercises without the intervention of a professional could help to improve the disorders. LEVEL OF EVIDENCE: 5.