Research procedure acceptability through women during pregnancy and postpartum: A pilot study.

OBJECTIVE: To assess the feasibility and relevancy of a systematic data collection process in characterizing factors influencing research acceptability through women during pregnancy and early postpartum. METHODS: A pilot prospective observational crossover unicentric study was conducted in Est France. All the women (except language barrier and intensive care transfer) were called upon to complete a survey (33 questions). The primary endpoints were the participation rate and the completeness of the information. The secondary endpoint was the participants' sociodemographic background and preferences regarding research (bivariate analysis, P value <0.20). RESULTS: Within the research period (February 23-March 8, 114 childbirths), 105 women fitting the criteria were called upon for the survey. The participation rate and completeness were high. The participation rate was 93% with six lost to follow-up, and one refusal. The global filling rate was 95%. We highlighted two plausible variables of interests for research participation: women age older (P value 0.119) and level of education (P value 0.176). A sufficient cooling-off period, the commitment of women's health providers, and the possibility to accede research results might favor women's involvement. Acceptability would appear to be decreasing when the protocol implied fetal or neonatal data collection (compared to maternal data), unless research led to a better therapeutic option. CONCLUSION: The data collection process is highly feasible and provide consistent data. Larger-scale output obtention should enhance the conception and rollout of projects, first by calculating sample size based on potentials for recruitments adjusted to populations, characteristics and second by fitting the experimental design to women's expectations.

Change in Hemoglobin Was Not a Reliable Diagnostic Screening Test for Postpartum Hemorrhage: A French Prospective Multicenter Cohort Study (HERA Study).

Changes between pre- and postpartum hemoglobin might be useful for optimizing the postpartum diagnosis of postpartum hemorrhage (PPH), defined as a blood loss exceeding 500 mL. This study's principal objective was to estimate the mean change in hemoglobin (between pre/post-delivery hemoglobin) among women with vaginal deliveries and PPH. The secondary objectives were to analyze: hemoglobin changes according to blood volume loss, the appropriateness of standard thresholds for assessing hemoglobin loss, and the intrinsic and extrinsic performances of these threshold values for identifying PPH. French maternity units (n = 182) participated in the prospective HERA cohort study. Women with a vaginal delivery at or after a gestation of 22 weeks with a PPH (n = 2964) were eligible. The principal outcome was hemoglobin loss in g/L. The mean hemoglobin change was 30 ± 14 g/L among women with a PPH. Overall, hemoglobin decreased by at least 10% in 90.4% of women with PPH. Decreases ≥ 20 g/L and ≥40 g/L were found, respectively, in 73.9% and 23.7% of cases. Sensitivity and specificity values for identifying PPH were always <65%, the positive predictive values were between 35% and 94%, and the negative predictive values were between 14% and 84%. Hemoglobin decrease from before to after delivery should not be used as a PPH diagnostic screening test for PPH diagnosis for all vaginal deliveries.

Does the type of pushing at delivery influence pelvic floor function at 2 months postpartum? A pragmatic randomized trial-The EOLE study.

INTRODUCTION: Maternal pushing techniques during the second stage of labor may affect women's pelvic floor function. Our main objective was to assess the impact of the type of pushing used at delivery on the mother's medium-term pelvic floor function. MATERIAL AND METHODS: This is a secondary analysis of a randomized clinical trial (clinicaltrials.gov: NCT02474745) that took place in four French hospitals from 2015 through 2017 (n = 250). Women in labor with a singleton fetus in cephalic presentation at term who had undergone standardized training in both of these types of pushing were randomized after cervical dilation ≥7 cm. The exclusion criteria were a previous cesarean, a cesarean delivery in this pregnancy or a fetal heart rate anomaly. In the intervention group, open-glottis (OG) pushing was defined as a prolonged exhalation contracting the abdominal muscles to help move the fetus down the birth canal. Closed-glottis (CG) pushing was defined as Valsalva pushing. The principal outcome was the stage of pelvic organ prolapse (POP) assessed by the Pelvic Organ Prolapse-Quantification 2 months after delivery. A secondary outcome was incidence of urinary incontinence (UI). The results of our multivariable, modified intention-to-treat analysis are reported as crude relative risks (RRs) with their 95% confidence intervals. RESULTS: Our analysis included 207 women. Mode of birth was similar in both groups. The two groups did not differ for stage II POP: 10 of 104 (9.4%) in the OG group compared with 7 of 98 (7.1%) in the CG group, for a RR 1.32, 95% confidence interval [CI] 0.52-3.33, and an adjusted RR of 1.22, 95% CI 0.42-3.6. Similarly, the incidence of UI did not differ: 26.7% in the OG group and 28.6% in the CG group (aRR 0.81, 95% CI 0.42-1.53). Subgroup analysis suggests that for secundiparous and multiparous women, OG pushing could have a protective effect on the occurrence of UI (RR 0.33, 95% CI 0.13-0.80). CONCLUSIONS: The type of directed pushing used at delivery did not impact the occurrence of pelvic organ prolapse 2 months after delivery. OG pushing may have a protective effect against UI among secundiparous and multiparous women.

Intervention during the Perinatal Period: Synthesis of the Clinical Practice Guidelines from the French National College of Midwives.

These clinical practice guidelines from the French National College of Midwives (CNSF) are intended to define the messages and the preventive interventions to be provided to women and co-parents by the different professionals providing care to women or their children during the perinatal period. These guidelines are divided into 10 sections, corresponding to 4 themes: 1/ the adaptation of maternal behaviors (physical activity, psychoactive agents); 2/ dietary behaviors; 3/ household exposure to toxic substances (household uses, cosmetics); 4/ promotion of child health (breastfeeding, attachment and bonding, screen use, sudden unexplained infant death, and shaken baby syndrome). We suggest a ranking to prioritize the different preventive messages for each period, to take into account professionals' time constraints.

Initiating and Supporting Breastfeeding: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives.

Exclusive breastfeeding is recommended for children for the first 4 to 6 months of life, with complementary foods added thereafter. It is the most ecological way of protecting the child's and mother's health. Training of health professionals is required to avoid transmitting inconsistent information in 3 areas: 1) implementing these 3 predictors: safe skin-to-skin, first breastfeed, and rooming-in 24/7; 2) teaching and monitoring: i) early signs of waking and feeding rhythms, ii) positioning and latching, and iii) signs of effective transfer; and 3) referring women to specialized support services if difficulties arise (eg, inadequate milk production, pain, cracked nipples, engorgement). Breastfeeding should continue during mastitis or an abscess. Ultrasound-guided needle aspiration is beneficial in treating an abscess. Précis: Information is provided to enable health professionals to better support breastfeeding and help women with the most common difficulties, thus promoting breastfeeding initiation and duration.

Pregnancy, Mental Well-Being and Lockdown: A Nationwide Online Survey in France.

The objective of this study was to compare the mental well-being of French women who were and were not pregnant during the first COVID-19 pandemic lockdown. We performed a nationwide online quantitative survey including all women between 18 and 45 years of age during the second and third weeks of global lockdown (25 March-7 April 2020). The main outcome measure was mental well-being measured by the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS). This study analysed 275 responses from pregnant women and compared them with those from a propensity score-matched sample of 825 non-pregnant women. In this French sample, the median WEMWBS score was 49.0 and did not differ by pregnancy status. Women living in urban areas reported better well-being, while those with sleep disorders or who spent more than an hour a day watching the news reported poorer well-being. During the first lockdown in France, women had relatively low mental well-being scores, with no significant difference between pregnant and non-pregnant women. More than ever, health-care workers need to find a way to maintain their support for women's well-being. Minor daily annoyances of pregnancy, such as insomnia, should not be trivialised because they are a potential sign of poor well-being.

Workplace Lactation Support: A Cross-Sectional Study in a University Hospital and a Perinatal Network.

Return to work negatively affects the initiation and duration of breastfeeding. Our study's objective was to assess the percentage of departments in Auvergne with an appropriate space for pumping milk at work. Our cross-sectional survey investigated the arrangements for facilitating the continuation of breastfeeding on return to work at all departments at the Clermont-Ferrand University Hospital Center and perinatal (obstetric and pediatric) departments in this region. Our principal endpoint was the percentage of departments reporting that they had a lactation room­a room where nursing mothers can express milk­and whether it met the criteria defined by the French Labor Code. Among 98 respondents, 44 departments (44.9%) did not offer lactation rooms; of the remaining 54 departments, only 11 rooms met the legal requirements. All perinatal departments offered lactation rooms. The availability of a lactation room was associated with other breastfeeding support, such as a break period for expressing milk (p < 0.0001) and the availability of a refrigerator to store it (p = 0.01). Almost half the responding departments did not offer a lactation room where mothers could breastfeed or pump their milk. Measures must be envisioned to facilitate the pumping of breast milk by French women returning to work.

Does the Quality of Postpartum Hemorrhage Local Protocols Improve the Identification and Management of Blood Loss after Vaginal Deliveries? A Multicenter Cohort Study.

Substandard care, which can result from a delayed recognition of the severity of blood loss, can increase maternal morbidity. Our objectives were to assess the incidence of postpartum hemorrhage (PPH) and of second-line procedures in maternity units according to the quality of their PPH protocol. We used a mixed design, a prospective cohort (3442 women with PPH after vaginal delivery; February−July 2011), and an audit of the written protocols (177 French maternity units; September 2010−June 2011). A quality score was calculated for the protocol of each unit. Maternity units were classified into three categories according to this score: category 1 (total score: 0−8), category 2 (9−12.5), and category 3 (>12.5). The PPH incidence (>500 mL) was 3.2%, 3.3% and 4.6% among maternity units in categories 1, 2 and 3, respectively (p < 0.0001). The incidence of severe maternal morbidity (surgery and/or artery embolization and/or blood transfusion) was higher among maternity units in category 1 (54.8%; 95% CI: 51.9, 57.7) than in either category 2 (50.1%; 95% CI: 47.8, 52.5) or 3 (38.0%; 95% CI: 33.8, 42.4]) (p < 0.0001). The risks of severe maternal morbidity were lower for category 3 than category 1 and 2 (respectively, adjusted RR 0.68, 95% CI 0.60−0.86 and 0.77, 95% CI 0.68−0.87). Finally, maternity units with higher scores identified PPH better and used fewer curative second-line procedures.

Measuring the readiness to screen and manage intimate partner violence: Cross-cultural adaptation and psychometric evaluation of the PREMIS tool for perinatal care providers.

INTRODUCTION: Pregnancy and perinatal periods are significant risk factors of intimate partner violence (IPV), a major public health problem that could begin or intensify during these periods. Perinatal care providers have a major role in the identification and the management of IPV. This study aimed to cross-culturally adapt into French the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS) tool, a reliable instrument to assess the knowledge, attitudes and preparedness to address IPV, and to evaluate its psychometric properties. METHODS: The PREMIS was cross-culturally adapted by conducting forward and backward translations, following international guidelines. An online cross-sectional study was conducted to assess the psychometric properties of the PREMIS-French in perinatal care providers: data completeness, factor analysis, score distribution, floor and ceiling effects, internal consistency, item-total correlations, inter-subscale correlations and test-retest reliability. RESULTS: The PREMIS was successfully translated and cross-culturally adapted to the context of metropolitan France. The results obtained from 360 perinatal care providers showed good acceptability. Exploratory factor analysis of the "Opinions" items resulted in a six-factor solution with six of the eight subscales of the original structure identified. Good internal consistency (Cronbach's alpha ranging from 0.54 to 0.97) and good test-retest reliability (intraclass correlation coefficients ranging from 0.46 to 0.92) for the "Background" and "Opinions" subscales were found. DISCUSSION: This study provides evidence of the good psychometric properties of the PREMIS-French. This valid instrument will help to understand perinatal care providers' barriers to IPV screening and management and will help to focus on specific lacks of knowledge for developing IPV education programs.

Breastfeeding after Returning to Work: A Systematic Review and Meta-Analysis.

BACKGROUND: The benefits of breastfeeding are widely known; however, continuation after returning to work (RTW) is not. We aimed to conduct a systematic review and meta-analysis to assess the prevalence of breastfeeding after RTW. The secondary objectives were to compare the economic statuses between continents. METHOD: PubMed, Cochrane Library, Base, and Embase were searched until 1 September 2020, and two independent reviewers selected the studies and collated the data. To be included, articles needed to describe our primary outcome, i.e., prevalence of breastfeeding after RTW. RESULTS: We included 14 studies, analyzing 42,820 women. The overall prevalence of breastfeeding after RTW was 25% (95% CI, 21% to 29%), with an important heterogeneity (I2 = 98.6%)-prevalence ranging from 2% to 61%. Stratification by continents and by GDP per capita also showed huge heterogeneity. The Middle East had the weakest total prevalence with 10% (6% to 14%), and Oceania the strongest with 35% (21% to 50%). Despite the prevalence of breastfeeding in general increasing with GDP per capita (US$50,000 42%), the prevalence of non-exclusive breastfeeding follows more of a U-curve with the lowest and highest GDP per capita having the highest percentages of breastfeeding (US$50,000: 50%, versus <28% for all other categories). CONCLUSION: Breastfeeding after RTW is widely heterogeneous across the world. Despite economic status playing a role in breastfeeding after RTW, cultural aspects seem influential. The lack of data regarding breastfeeding after RTW in most countries demonstrates the strong need of data to inform effective preventive strategies.

A French audit of maternity unit protocols for immediate postpartum hemorrhage: A cross-sectional study (HERA).

OBJECTIVES: The principal objective of this work was to assess how well the written protocols of maternity units used for the prevention and management of postpartum hemorrhage (PPH) corresponded to the 2004 French guidelines on this topic. The second objective was to assess whether or not this correspondence with the national guidelines varied according to hospital level (basic, specialized, and subspecialized) and status (teaching, public, and private). METHODS: This observational multicenter cross-sectional study took place in September 2010 and included French perinatal networks that volunteered to participate. We asked 300 French maternity units belonging to these networks to participate by emailing a copy of their department's protocol for PPH to the study team. This team designed and performed a clinical audit of these protocols, defining 16 criteria that incorporated the 2004 French guidelines for prevention and management of PPH. The main outcome measure was the percentage of units reporting protocols meeting these criteria. RESULTS: Of the 244 maternity units responding, 97.1 % had a written protocol but only 67.0 % had a local protocol. Protocol correspondence with the 2004 French guidelines was good for the criteria involving quantitative assessment of the quantity of blood loss (83.5 %) and secondary management of PPH (>80 %). Correspondence with the guidelines was poor in terms of defining PPH in the protocol (25.3 %) and of requiring the recording of the time of PPH diagnosis (53.2 %) and of the volume of blood loss (55.7 %). These results differed only slightly according to maternity unit status or level. CONCLUSION: In all, 67.0 % (159/237) of maternity units had a local protocol for PPH. The contents of these protocols should be improved to be closer to the national guidelines.

Is directed open-glottis pushing more effective than directed closed-glottis pushing during the second stage of labor? A pragmatic randomized trial - the EOLE study.

OBJECTIVE: To compare the effectiveness of directed open-glottis and directed closed-glottis pushing. DESIGN: Pragmatic, randomised, controlled, non-blinded superiority study. SETTINGS: Four French hospitals between July 2015 and June 2017 (2 academic hospitals and 2 general hospitals). PARTICIPANTS: 250 women in labour who had undergone standardised training in the two types of pushing with a singleton fetus in cephalic presentation at term (≥37 weeks) were included by midwives and randomised; 125 were allocated to each group. The exclusion criteria were previous caesarean birth or fetal heart rate anomaly. Participants were randomised during labour, after a cervical dilation ≥ 7 cm. INTERVENTIONS: In the intervention group, open-glottis pushing was defined as a prolonged exhalation contracting the abdominal muscles (pulling the stomach in) to help move the fetus down the birth canal. Closed-glottis pushing was defined as Valsalva pushing. MEASUREMENTS: The principal outcome was "effectiveness of pushing" defined as a spontaneous birth without any episiotomy, second-, third-, or fourth-degree perineal lesion. The results in our intention-to-treat analysis are reported as crude relative risks (RR) with their 95% confidence intervals. A multivariable analysis was used to take the relevant prognostic and confounding factors into account and obtain an adjusted relative risk (aRR). FINDINGS: In our intention-to-treat analysis, most characteristics were similar across groups including epidural analgesia (>95% in each group). The mean duration of the expulsion phase was longer among the open-glottis group (24.4 min ± 17.4 vs. 18.0 min ± 15.0, p=0.002). The two groups did not appear to differ in the effectiveness of their pushing (48.0% in the open-glottis group versus 55.2% in the closed-glottis group, for an adjusted relative risk (aRR) of 0.92, 95% confidence interval (CI) 0.74-1.14) or in their risk of instrumental birth (aRR 0.97, 95%CI 0.85-1.10). KEY CONCLUSIONS: In maternity units with a high rate of epidural analgesia, the effectiveness of the type of directed pushing does not appear to differ between the open- and closed-glottis groups. IMPLICATIONS FOR PRACTICE: If directed pushing is necessary, women should be able to choose the type of directed pushing they prefer to use during birth. Professionals must therefore be trained in both types so that they can adequately support women as they give birth.

Follow-up for pregnant women during the COVID-19 pandemic: French national authority for health recommendations.

INTRODUCTION: In the context of the stage 3 SARS-Cov-2 epidemic situation, it is necessary to put forward a method of rapid response for an HAS position statement in order to answer to the requests from the French Ministry of Solidarity and Health, healthcare professionals and/or health system users' associations concerning follow-up of pregnant women during the COVID-19 outbreak. METHODS: A simplified 7-step process that favours HAS collaboration with experts (healthcare professionals, health system users' associations, scientific societies etc.), the restrictive selection of available evidence and the use of digital means of communication. A short and specific dissemination format, which can be quickly updated in view of the changes in available data has been chosen.

Post-natal follow-up for women and neonates during the COVID-19 pandemic: French National Authority for Health recommendations.

INTRODUCTION: In the context of the stage 3 SARS-Cov-2 epidemic situation, it is necessary to put forward a method of rapid response for an HAS position statement in order to answer to the requests from the French Ministry of Solidarity and Health, healthcare professionals and/or health system users' associations, concerning post-natal follow-up for women and neonates during the COVID-19 pandemic. METHODS: A simplified 7-step process that favours HAS collaboration with experts (healthcare professionals, health system users' associations, scientific societies etc.), the restrictive selection of available evidence and the use of digital means of communication. A short and specific dissemination format, which can be quickly updated in view of the changes in available data has been chosen.

Practices during the active second stage of labor: A survey of French midwives.

OBJECTIVE: the principal objective of our study was to describe the practices reported by French midwives during the active second stage of labor (expulsion phase). DESIGN: this cross-sectional Internet survey questioned French midwives who attended at least one childbirth in 2013. SETTING: this open survey was posted on a website from June 15 through December 1, 2014. PARTICIPANTS: 1496 midwives from 377 maternity units participated in the study. MEASUREMENTS AND FINDINGS: the midwives most often reported suggesting horizontal positions during the active second stage (supine with footholds, lithotomy, lithotomy with knees turned in, or lateral positions). Non-horizontal positions were more often proposed by midwives in level I units (p<0.0001). Almost half the midwives responding (46.4%), especially those working in level III units (51.1%, p = 0.006), advised Valsalva pushing. The mean maximum pushing time was 35.3 minutes±12.8 minutes. Nearly all the midwives favored the 'hands on' technique at childbirth (91.4%), and 24% reported using warm compresses on the perineum at childbirth. KEY CONCLUSION: most midwives advised horizontal positions for childbirth. The practices of French midwives differed as a function of where they worked. The midwives, especially those in level III facilities, reported that they cannot always ensure 'physiological childbirth'. IMPLICATIONS FOR PRACTICE: the practices of French midwives must become more evidence-based. The development of professional guidelines for midwives in France appears essential. This study also helps to prioritise national training for midwives.

Positions during the first stage and the passive second stage of labor: A survey of French midwives.

OBJECTIVE: the objective of our study was to describe the practices reported by French midwives during labor (first stage and passive phase of the second stage). DESIGN: this cross-sectional internet questionnaire surveyed French midwives who attended at least one delivery in 2013. SETTING: this open survey was posted on a website from June 15 through December 1, 2014. PARTICIPANTS: 1496 midwives from 377 maternity units participated in the study. Nearly 93% of the midwives worked in an obstetric unit, 5.9% had a mixed practice, and 1.3% worked in private practice. MEASUREMENTS AND FINDINGS: during the first stage of labor, midwives reported suggesting that women without epidural analgesia use a birthing ball (98.1%) and that they walk around (97.4%). For women with epidural analgesia, most suggested motion in horizontal positions. Epidural analgesia was proposed more often by midwives from level II (75.7%) and level III (73.5%) maternity wards than by those at level 1 units (57.7%) (p<0.0001). The midwives preferred a lateral position during the first stage for women with epidural analgesia and during the second stage for women both with and without it. Midwives in practice for 5 years or less suggested a kneeling position for women with epidural analgesia more often than more experienced midwives. KEY CONCLUSION: the practices of French midwives vary with their place of practice and their experience. IMPLICATIONS FOR PRACTICE: to promote normal labor, French midwives must reappropriate vertical positions and analgesic alternatives to epidurals.

Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial-the EOLE study protocol.

INTRODUCTION: The scientific data currently available do not allow any definitive conclusion to be reached about what type of pushing should be recommended to women during the second stage of labour. The objective of this trial is to assess and compare the effectiveness of directed open-glottis pushing versus directed closed-glottis pushing. Secondary objectives are to assess, according to the type of pushing: immediate maternal and neonatal morbidity, intermediate-term maternal pelvic floor morbidity, uncomplicated birth, and women's satisfaction at 4 weeks post partum. METHODS AND ANALYSIS: This multicentre randomised clinical trial compares directed closed-glottis pushing (Valsalva) versus directed open-glottis pushing during the second stage of labour in 4 hospitals of France. The study population includes pregnant women who received instruction in both types of pushing, have no previous caesarean delivery, are at term and have a vaginal delivery planned. Randomisation takes place during labour once cervical dilation ≥7 cm. The principal end point is assessed by a composite criterion: spontaneous delivery without perineal lesion (no episiotomy or spontaneous second-degree, third-degree or fourth-degree lacerations). We will need to recruit 125 women per group. The primary analysis will be by intention-to-treat analysis, with the principal results reported as crude relative risks (RRs) with their 95% CIs. A multivariate analysis will be performed to take prognostic and confounding factors into account to obtain adjusted RRs. ETHICS AND DISSEMINATION: This study was approved by a French Institutional Review Board (Comité de Protection des Personnes Sud Est 6:N°AU1168). Results will be reported in peer-reviewed journals and at scientific meetings. This study will make it possible to assess the effectiveness of 2 types of directed pushing used in French practice and to assess their potential maternal, fetal and neonatal effects. Findings from the study will be useful for counselling pregnant women before and during labour. TRIAL REGISTRATION NUMBER: Agence national de sécurité du médicament et des produits de santé (ANSM): 150099B-22 and IDRCB: 2014-A01920-47. ClinicalTrials.gov: NCT02474745. Pre-result stage.

Incidence of immediate postpartum hemorrhages in French maternity units: a prospective observational study (HERA study).

BACKGROUND: Most estimates of postpartum hemorrhage (PPH) are calculated from studies that use administrative or medical birth databases, and only a few from prospective observational studies. Our principal objective was to estimate the incidence of PPH according to their severity (mild or severe) in vaginal deliveries (>500 mL, ≥1000 mL) and cesareans (>1000 mL and ≥1500 mL). The secondary objectives were to describe the incidence of PPH according to maternity unit characteristics, causes, and types of PPH management. METHODS: This prospective observational study took place in French maternity wards. Women who gave birth at a term ≥ 22 weeks were eligible for the study. 182 maternity units participated in a study with prospective data collection from 1 February, 2011, to 31 July, 2011. The main outcome measure was PPH incidence. RESULTS: PPH incidence after vaginal delivery was 3.36 % [95 % CI: 3.25-3.47 %] and after cesareans 2.83 % [95 % CI: 2.63-3.04 %]. The incidence of severe PPH after vaginal delivery was 1.11 % [95 % CI: 1.05-1.18 %] and after cesareans 1.00 % [95 % CI: 0.88-1.13 %]. This incidence rate varied according to maternity unit characteristics. The principal cause of PPH for both modes of delivery was uterine atony (57.7 % for vaginal births and 66.3 % for cesareans). Vascular embolization was more frequent among women with cesareans (10.0 vs. 2.9 %), who also required transfusions more often (44.4 vs 12.7 %). CONCLUSIONS: The incidence of PPH was lower than the rate expected from the literature. Effective treatment of uterine atony and optimizing the identification of blood loss remain important priorities.

Policies for management of postpartum haemorrhage: the HERA cross-sectional study in France.

OBJECTIVE: The principal objective of this study was to describe the policies reported by French maternity units for the prevention and early management of postpartum haemorrhage (PPH). The second objective was to assess their variation according to hospital level and status. STUDY DESIGN: Cross-sectional observational study of French maternity units, from January 2010 to April 2011. The medical supervisor (obstetrician or midwife) of participating maternity wards completed a questionnaire designed to ascertain the unit's protocol for preventing and managing PPH after both vaginal and caesarean deliveries at a gestational age >22 weeks (or a birth weight >500g). The main outcome measure was the percentage of units reporting protocols adhering to the principal criteria for adequate management defined by the 2004 French guidelines for PPH. RESULTS: 252 maternity units participated in the survey. Almost all units had a written protocol for PPH (97.2%). For vaginal deliveries, 82.5% of units had a definition of PPH (>500ml) and 92.8% had a policy of preventive oxytocin use. For caesareans, only 23.8% defined PPH (as >1000ml), 68.8% used manual delivery of the placenta, and 76.9% recommended oxytocin injection immediately after the birth. The first-line medication for PPH was oxytocin (96.3%) and the second-line treatment a prostaglandin (97.5%). Level III maternity units had a definition of haemorrhage for vaginal deliveries more often than did other levels of care (P=0.04). Manual removal of the placenta after caesareans was significantly more frequent in level I than level III units (P=0.008) and in private than other types of maternity units. Medical management of haemorrhage did not differ according to level of care or maternity status. CONCLUSIONS: The responses by maternity unit supervisors showed significant improvement in the management of PPH accordingly to the 2004 French guidelines, especially for the third stage of labour. This improvement did not differ between hospitals by levels of care or legal status.

Does maternal race influence the short-term variation of the fetal heart rate? An historical cohort study.

OBJECTIVES: The main aim of this article was to analyze short-term variation (STV) of the fetal heart rate according to maternal race. The secondary aim was to study the baseline fetal heart rate according to this factor. STUDY DESIGN: This single-center historical cohort study covered the period from November 2008 through December 2011 (n=182). The inclusion criteria were: black women from sub-Saharan Africa or white European women, with a singleton pregnancy ≥34 weeks and fetal heart rate recorded by computerized analysis (Oxford Sonicaid System 8002) at a prenatal visit. The exclusion criteria were: medication likely to modify fetal heart rate, abnormal fetal heart rate tracing, and being in labor. A multiple linear regression analysis was used to study the association between maternal race and STV. RESULTS: STV was lower by 2.6ms in fetuses of black women (n=55) compared to those of white women (n=127) (8.9±2.1ms vs. 11.4±3.4ms) (p<0.001). The basal fetal heart rate was higher (p=0.001), and the recording criteria were met less often for the black women (p=0.04). After adjustment for maternal age, body mass index at the beginning of pregnancy, maternal cigarette smoking, parity, gestational diabetes, gestational age at the time of the fetal heart rate recording, and the time between the last meal and the recording, mean STV was lower by 3.1±0.6ms in fetuses of black compared with white women (p<0.001). CONCLUSION: STV is lower in fetuses of black women compared to those of white women in a low-risk population. A study of black and white women with high-risk pregnancies is necessary to assess the impact of medical practices on perinatal outcome after STV analysis.