[Report of the French Comité national technique de l'échographie de dépistage prénatal (CNTEDP)--Recommendations for second line prenatal ultrasound]. / Rapport du Comité national technique de l'échographie de dépistage prénatal (CNTEDP): recommandations pour l'échographie de diagnostic.

OBJECTIVES: The committee has among its functions, to promote a quality assurance policy for obstetrics and foetal ultrasound scans by participating in the development of an information strategy for the professionals and the public on the interest and limits of these techniques, and in the development of rules for good practice. Thus, the committee produced in 2005 a good practice's recommendations report concerning the screening ultrasound scans. It pursued its work with a similar report concerning this time the "diagnostic" prenatal ultrasound or second line prenatal ultrasound. The present report has set its objective to define as precisely as possible the content of a "diagnostic" ultrasound scan and what should be expected from it. MATERIALS AND METHODS: A group of experts from the committee members has functioned as a task team that met on a regular basis. First, in the context of a professional consensus and a review of the literature, it determined the clinical goals in regard to the indication of the "diagnostic" ultrasound scan. After discussing different formats of the scan test procedure, some intuitive hypotheses on the content of the test were developed. Each criteria was validated by the group of experts with a statistics' definition and a diagnosis' capacity. The hypotheses were finally validated or discarded after confrontation with the data of the literature. Finally, the content of the report was discussed during the plenary sessions of the CNTEDP, the National Committee on the Technical aspect for PreNatal Ultrasound Screening. All the items validated in format document have been the subject of a consensus with a right to veto. The preliminary report was reviewed by a group of six readers not members of the CNTEPD. RESULTS: The "diagnostic" ultrasound scan test is organized in two parts: one common part made of the content of the screening test, to which is added the study of the anatomic structures and taking some additional pictures. The sonologist must then do a specific scan study for the organ suspected or diagnosed with an anomaly. Subsequently, a series of ten format documents per anomaly is proposed to guide the examiner (i.e., abdomen, chest, heart, genitourinary, cerebrospinal, skeletal and limbs, IUGR, polyhydramnios, infection, twin pregnancy). These documents suggest a check-list of items to study during the scan, specific pictures to take, and, give some comments on the management plan. DISCUSSION AND CONCLUSION: The CPDPN, the Multidisciplinary Committee for PreNatal Diagnosis, since it was established in 1994, has contributed to structure most of the activity of the prenatal diagnosis, but did not answer the question of the quality of the second line prenatal ultrasound. Screening ultrasound, and focused ultrasound scan are not "levels" in the scan procedure, but different and supplementary studies contributing to the quality of the mother and her foetus follow-up. This report of the CNTEDP, in defining the content of this scan test, clarifies the objectives of the diagnostic test compared to the screening test, and subsequently gives the public a better understanding of what is expected or due in regard to our prenatal screening strategy. A reliable second level scan, affordable and consistent, is a label of good quality for our prenatal strategy. The recommendations of the committee should be understood in a large perspective of quality assurance, that includes an initial and a continuous medical education, a quality control system for the echograph, and a procedure to inform the public.

[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.

[Audipog perinatal network. Part 1: principal perinatal health indicators, 2004-2005]. / Réseau sentinelle Audipog 2004-2005. Partie 1 : résultats des principaux indicateurs périnatals.

OBJECTIVE: To present the principal perinatal indicators for 2004-2005, based on data from the Audipog sentinel network. PATIENTS AND METHODS: The database for 2004 and 2005 covers 71,406 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: The number of women working during pregnancy increased between 2004 and 2005 (62.3% versus 66.3%) (p=0.0008) as did the percentage with a postsecondary education (35.1% versus 41.9%) (p<0.0001). The percentage of amniocenteses declined (10.4% versus 7.9%) (p<0.0001). Use of prenatal care improved: more women had prenatal visits before week 14 (30.5% versus 33.9%) (p=0.0002), and fewer women had no prenatal care at all (1.1% versus 0.4%) (p=0.0003). The percentage of preterm deliveries was 6.4% in 2004 and 7% in 2005 (p=0.14) and the percentage of induced preterm deliveries was 37% in 2004 and 41.2% in 2005 (p=0.18). The cesarean rate was essentially stable (19 and 19.2%) and the rate of instrumental intervention in vaginal deliveries fell from 13.1% in 2004 to 11.2% in 2005 (p=0.0015). DISCUSSION AND CONCLUSION: The rates of cesarean and of preterm deliveries remained stable between 2004 and 2005, but the rate of induced preterm deliveries rose. These indicators are consistent with trends that began earlier.

[Length of pushing efforts: pushing is not playing. Reply to the article of C. Le Ray and F. Audibert]. / Durée des efforts expulsifs : pousser n'est pas jouer. Réponse à l'article de C. Le Ray et F. Audibert.

The aim of this work is to answer constructively to C. Le Ray and F. Audibert who were surprised that the French guidelines recommended an assisted delivery after 30 min pushing, even if the fetal heart rate is reassuring. We first resumed the definition of "second stage of labor", this word including the first phase with no pushing efforts and the second phase with active pushing of the mother. With that definition, the length of the second stage is around 60 min for the primipara and 20 min for the multipara, this length being modified by the use of peridural. We then specified the physiological mechanisms influencing the acidobasic equilibrium during the pushing time. Those mechanisms are difficult to consider because foetal heart rate monitoring is often "lost" during that phase. Altogether, these factors bring incertitude about progressive foetal acidosis and incapacity to diagnose it. Finally, the literature analysis teaches us that increasing the second stage of labor (inactive plus active phases) during the normal pregnancy seems to be at low risk for the foetus within the primiparas, but display a risk for the mother and so might be limited. Comparing the delayed pushing with the immediate pushing only lead us to conclude that delayed pushing is dangerous, as is prolonged second stage. In conclusion, we think that prolonging the second stage of labor is possible but must be by increasing the inactive first phase of the second stage, especially as long as we will not get a noninvasive and reliable method allowing assessing the well-being of the foetus.

[Protocol of cervical maturation by acupuncture]. / Protocole de maturation cervicale par acupuncture.

Protocol was carried out on 98 patients who were divided into three groups selected as (one control group, two "placebo" group, and three treated with acupuncture). This protocol showed that it was possible to improve cervical maturation if acupuncture sessions were carried out at the beginning of the 9th month. The Bishop scores in the three groups after 10 days interval show that there was a significant progression of 2.61 points in the group treated with acupuncture as against only 0.89 and 1.08 in the placebo and control groups.