[Vaginal delivery in case of breech presentation: Impact of a service's incentive]. / Accouchement par voie basse des fœtus en présentation du siège : impact d'une politique incitative de service.

OBJECTIVES: The mode of delivery in podalic presentation was controvertible since the 2000s, which led to a high rate of caesarean section. In our center, the delivery mode was physician-dependent before 2012. Since 2012, the management of podalic presentations was supervised by a protocol allowing a collegiate management to promote vaginal delivery. The objective of this study was to evaluate the impact of this policy on neonatal outcomes and obstetric practices. METHODS: A retrospective study was carried out with comparison of 135 patients who gave birth in 2008 with 110 patients who gave birth in 2014, before and after the implementation of the protocol in a type III university maternity hospital. Two hundred and forty-five singleton pregnancies with podalic presentation and a gestational age more than 32 weeks of gestation were included in this study. The rate of vaginal delivery trial, the evolution of clinical practices and neonatal outcomes were respectively compared. RESULTS: One hundred and twenty-six patients who gave birth in 2008 were compared to the 105 one of 2014. The rate of successful vaginal birth trial increased from 32.7% (n=16/49) to 63.8% (n=37/58) (P>0.05) between the two periods, this induced a decrease of 16.3% of planned caesarean sections rate [(77/126) versus (47/105) (P<0.02)] and of 6.2% of emergency caesarean sections rate [(33/126) versus (21/105) (P<0.001)]. No significant difference was observed regarding neonatal outcomes. CONCLUSIONS: This work shows that it is possible to limit the rate of planned and emergency caesarean sections because of an incentive policy of service without impact on neonatal morbidity and mortality.

Intraaortic balloon pumping in the treatment of low cardiac output following open heart surgery--immediate results and long-term prognosis.

From 1979 through 1986, 90 patients required intraaortic balloon pumping (IABP) due to low cardiac output complicating open heart surgery. Preoperatively, functional class III or IV was present in 92%; in patients with coronary artery disease (n = 54), three-vessel or left main disease was found in 72%; patients with valvular disease (n = 37) generally had multiple surgical procedures or valve re-replacement performed. Intra-IABP mortality was 49% (n = 44) and 30-day mortality 61% (n = 55). The latter figure decreased from 75% in 1979-81 to 53% in 1985-86. Cumulative 5-year survival was 22%. Logistic regression analysis identified as independent predictors of 30 day mortality the necessity for adjuvant treatment with the more powerful "pressure drugs" isoprenaline/noradrenaline, number of DC-defibrillations, functional classes III-IV, and chronic left ventricular failure. Different combinations of these risk factors identified different patient groups with 30-day mortalities ranging from 100% to 0%. The risk factors reflected both acute cardiac failure probably due to severe ischemia and chronic failure due to advanced primary disease. Taking the high-risk composition of the material into account, a 5-year survival of 22% cannot be regarded as discouraging. Continued employment of IABP treatment in open heart surgery, using an aggressive approach coupled with individualized inotropic support, seems justified.