Impact of implementation of a breech clinic in a tertiary hospital.

BACKGROUND: The incidence of breech presentation in single pregnancies at term is between three to 5 %. In order to support eligible women in their choice of mode of delivery, a dedicated breech clinic with a care pathway was developed in December 2015 in a tertiary referral centre in Brussels. The primary objective of this study was to evaluate the vaginal birth rate before and after the introduction of a dedicated breech clinic. The secondary objective was to compare the early neonatal outcomes before and after the breech clinic was introduced. METHODS: This was a single centre retrospective and prospective study. The inclusion criteria were term (from 37 weeks), singleton fetus and breech presentation at delivery. The exclusion criteria were suspected intrauterine growth restriction, severe fetal malformations and intrauterine fetal demise. We used a composite outcome as an indicator of neonatal morbidity and mortality. RESULTS: After the introduction of the breech clinic, we observed a significant increase in planned vaginal delivery from 7.4% (12/162) to 53.0% (61/115) (OR: 13.5; 95% CI: 6.7-27.0). The effective vaginal breech delivery rate (planned and unexpected) significantly increased from 4.3% (7/162) pre-implementation of breech clinic to 43.5% (50/115) post-implementation (OR: 17.0; 95% CI: 7.3-39.6). Neonatal outcomes were not statistically different between the before and after periods. CONCLUSION: The introduction of a dedicated breech clinic has led to an increase in vaginal deliveries for breech babies without adversely affecting neonatal outcomes.

[Home births]. / L'accouchement à domicile.

In Belgium, very few women give birth outside the delivery room. In the United Kingdom and in the Netherlands, they are more numerous. Several studies evaluated obstetric and neonatal outcomes of home births compared with hospital births. We selected seven recent and large studies (with cohorts of more than 5.000 women) using PubMed, Science Direct and Cochrane Database of Systematic Reviews. Several questions were examined. Is there any difference in maternal and neonatal outcomes depending on the intended place of birth? Does parity affect outcomes ? What are the characteristics of women who choose to deliver at home ? We conclude that giving birth at home improves obstetric outcomes but is riskier for the baby, especially for the first one. The women delivering at home are mainly white Europeans, between 25 and 35 years old, in a relationship, multiparous and wealthier. In order to avoid this increased risk for the baby while preserving the obstetric advantages, alongside birth centers offer an intermediate solution. They combine the reassuring home-like atmosphere with the safety of the hospital. In Belgium, the first alongside birth center " Le Cocon " (a low technicity unit distinct from the delivery room) offers now this type of alternative place of birth for women in Hôpital Erasme in Brussels.

En Belgique, peu de femmes choisissent d'accoucher en dehors d'une salle d'accouchement. En Grande-Bretagne ou aux Pays-Bas, celles-ci sont plus nombreuses. Plusieurs études dans ces pays se sont penchées sur les issues obstétricales et néonatales des accouchements à domicile par rapport aux accouchements à l'hôpital. Nous avons effectué une revue de cette littérature. La méthodologie utilisée a consisté en l'inclusion d'études récentes et larges comparant les issues maternelles et néonatales des accouchements à domicile et des accouchements à l'hôpital. Nous nous sommes intéressés aux accouchements à domicile avec les questions suivantes : Y a-t-il une différence dans les issues maternelles et néonatales selon le lieu de naissance prévu ? La parité joue-t-elle un rôle ? Quel est le profil des femmes désireuses d'accoucher à domicile ? Nous concluons que les accouchements à domicile ont de meilleures issues maternelles car il y a moins d'interventions. En revanche, les risques sont augmentés pour les bébés en particulier ceux des primipares. Les patientes choisissant d'accoucher à domicile sont majoritairement caucasiennes, âgées de 25 à 35 ans, en couple, multipares et plus nanties que celles qui accouchent à l'hôpital. Dans le but d'éviter ce surrisque pour le bébé tout en conservant les avantages obstétricaux, les maisons de naissance adossées à une salle d'accouchement traditionnelle offrent une solution intermédiaire en combinant un cadre familial rassurant et la sécurité pour le couple mère-enfant. Cette réflexion a mené à la création du premier gîte de naissance intra-hospitalier " Le Cocon " au sein de l'hôpital Erasme à Bruxelles.

[Prenatal screening: the example of Down's syndrome screening]. / Le dépistage prénatal : 1'exemple de la trisomie 21.

Prenatal screening for Down's syndrome initially targeted high-risk pregnant women (> 35 years old). However, the vast majority of babies with Down's syndrome are born to younger women (as the majority of babies are born in this age category). It was first discovered that some serum analytes were altered in pregnancies affected with Down's syndrome (triple test). In the nineties, the association between an increased nuchal translucency measurement and trisomy 21 was noted. The use of this measurement in combination with serum markers has enabled an increased detection rate but still at the cost of a false positive rate of around five percent (combined test). Recently, major advances in sequencing technologies have allowed reasearchers to make use of the cell free fetal DNA in maternal blood. This new test (named non invasive prenatal test) made it into clinical use as early as 2011 in some countries. Its sensitivity is above 99 % for trisomy 21 and the false positive rate is very low. It is risk-free and much more accurate than previous approaches. It is largely favored over an invasive test by high risk women (advanced maternal age or high-risk combined test). Its use is still restricted by a high cost which is for the moment still entirely beared by the patient. The availability of NIPT in our routine practice and the increased complexity of screening options have highlighted the need for a more dedicated counselling consultation before Down's syndrome screening is performed.