Large-scale analysis of interobserver agreement and reliability in cardiotocography interpretation during labor using an online tool.

BACKGROUND: While the effectiveness of cardiotocography in reducing neonatal morbidity is still debated, it remains the primary method for assessing fetal well-being during labor. Evaluating how accurately professionals interpret cardiotocography signals is essential for its effective use. The objective was to evaluate the accuracy of fetal hypoxia prediction by practitioners through the interpretation of cardiotocography signals and clinical variables during labor. MATERIAL AND METHODS: We conducted a cross-sectional online survey, involving 120 obstetric healthcare providers from several countries. One hundred cases, including fifty cases of fetal hypoxia, were randomly assigned to participants who were invited to predict the fetal outcome (binary criterion of pH with a threshold of 7.15) based on the cardiotocography signals and clinical variables. After describing the participants, we calculated (with a 95% confidence interval) the success rate, sensitivity and specificity to predict the fetal outcome for the whole population and according to pH ranges, professional groups and number of years of experience. Interobserver agreement and reliability were evaluated using the proportion of agreement and Cohen's kappa respectively. RESULTS: The overall ability to predict a pH level below 7.15 yielded a success rate of 0.58 (95% CI 0.56-0.60), a sensitivity of 0.58 (95% CI 0.56-0.60) and a specificity of 0.63 (95% CI 0.61-0.65). No significant difference in the success rates was observed with respect to profession and number of years of experience. The success rate was higher for the cases with a pH level below 7.05 (0.69) and above 7.20 (0.66) compared to those falling between 7.05 and 7.20 (0.48). The proportion of agreement between participants was good (0.82), with an overall kappa coefficient indicating substantial reliability (0.63). CONCLUSIONS: The use of an online tool enabled us to collect a large amount of data to analyze how practitioners interpret cardiotocography data during labor. Despite a good level of agreement and reliability among practitioners, the overall accuracy is poor, particularly for cases with a neonatal pH between 7.05 and 7.20. Factors such as profession and experience level do not present notable impact on the accuracy of the annotations. The implementation and use of a computerized cardiotocography analysis software has the potential to enhance the accuracy to detect fetal hypoxia, especially for ambiguous cardiotocography tracings.

Preferences for labor and childbirth, expressed orally or as a written birth plan: Prevalence and determinants from a nationwide population-based study.

BACKGROUND: Shared decision-making is an important component of a patient-centered healthcare system. We assessed the prevalence of parturients with preferences for their labor and childbirth, expressed verbally in the birthing room or as a written birth plan, and studied maternal, obstetric, and organizational factors associated with their expression. METHODS: Data came from the 2016 National Perinatal Survey, a cross-sectional nationwide population-based survey conducted in France. Preferences for labor and childbirth were studied in three categories: expressed verbally, in writing (birth plan), or unexpressed or nonexistent. Analyses used multinomial multilevel logistic regression. RESULTS: The analysis included 11,633 parturients: 3.7% had written a birth plan, 17.3% expressed their preferences verbally, and 79.0% either did not have or did not express any preferences. Compared with the latter group, written or verbal preferences were both significantly associated with prenatal care by independent midwives (respectively, adjusted odds ratio (aOR) 2.19; 95% confidence interval (CI), [1.59-3.03], and aOR 1.43; 95% CI [1.19-1.71]) and with attendance at childbirth education classes (respectively, aOR 4.99; 95% CI [3.49-7.15], and aOR 2.27; 95% CI [1.98-2.62]). As years in traditional schooling increased, so did its association with preferences. Conversely, parturients from African countries were significantly less likely than French mothers to express preferences. A written birth plan was also associated with characteristics of maternity unit organization. CONCLUSION: Only one in five parturients reported having expressed preferences for labor and childbirth to healthcare professionals in the birthing room. This expression of preferences was associated with maternal characteristics and the organization of care.

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population-based study.

INTRODUCTION: Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery. MATERIAL AND METHODS: We performed a national cross-sectional population-based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance. RESULTS: A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively). CONCLUSIONS: Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices.

Implementation of glucose 5% supplementation protocol to reduce the duration of labor among women with cervical ripening by prostaglandins: The GLUCOSHORT before-and-after study.

INTRODUCTION: Previous publications have shown that glucose supplementation could reduce labor duration in women with induction of labor with a favorable cervix but none have shown it for women with an unfavorable cervix.  The purpose of our study was to assess the impact on labor duration of a protocol of glucose supplementation used for induction of labor in women with an unfavorable cervix. MATERIAL AND METHODS: The protocol implemented in November 2017 added glucose supplementation by 5% dextrose at 125 mL/h to Ringer lactate for women with an unfavorable cervix with labor induced with dinoprostone gel. The study included women who underwent this protocol with a singleton, term, cephalic fetus from June 2017 through April 2018. The primary outcome was the labor duration. The secondary outcomes were mode of delivery, postpartum hemorrhage rate, neonatal outcomes, and durations other stage of labor. These outcomes were compared between the pre-intervention (from June 1 to October 31, 2017) and post-intervention (from December 1, 2017 to April 30, 2018) periods. RESULTS: The pre-intervention period included 116 women, and the post-intervention period 123. The characteristics of women and the induction of labor were similar in the two periods. The median duration from induction to delivery was not significantly different between the two periods (13.2 h, IQR 9.1-18.6 versus 13.6 h IQR 9.3-18.3, P=.67). The secondary outcomes did not differ significantly between the two groups. DISCUSSION: Glucose supplementation administered to women with an unfavorable cervix undergoing induction does not appear to reduce the induction-delivery duration.

No pain management for labour: individual and organisational determinants: A secondary analysis of the 2016 French National Perinatal Survey.

BACKGROUND: Disparities in access to pain management have been identified in several care settings, such as emergency departments and intensive care units, but with regard to labour analgesia, it remains poorly explored. OBJECTIVES: To determine the proportion of women without pain management during labour and its individual and organisational determinants. DESIGN: Secondary analysis of a nationwide cross-sectional population-based study, the 2016 French National Perinatal Survey. SETTINGS: All maternity units in France. PARTICIPANTS: Ten thousand and eleven women who attempted vaginal delivery with a labour duration at least 15 min. MAIN OUTCOME MEASURE: Absence of pain management, defined as absence of any pharmacological or nonpharmacological analgesic method during labour. RESULTS: Among the 10 011 women included, 542 (5.4%) had no labour pain management: 318 (3.7%) of the 8526 women who initially preferred to use neuraxial analgesia and 222 (15.8%) of the 1402 who did not. Using generalised estimating equations stratified according to the maternal antenatal preference for neuraxial analgesia, the common determinants of no labour pain management in both groups were no attendance at childbirth education classes and admission to a delivery unit during the night. Among women who initially preferred to use neuraxial analgesia, those who delivered in units with <1500 annual deliveries compared with units with 2000 to 3499 annual deliveries, were more likely to do without pain management [adjusted odds ratio (OR) = 1.96; 95% confidence interval (CI), 1.39 to 2.78]; among those who did not prefer to use it, women born abroad were more likely to do without labour pain management (adjusted OR = 1.64; 95% CI, 1.12 to 2.40). CONCLUSION: In France, 1 : 20 women had no labour pain management, and this proportion was three times higher among women who preferred not to use neuraxial analgesia. Enhancing maternal information on labour pain and its management, especially nonpharmacological methods, and rethinking care organisation, could improve access to analgesia of any kind.

Is duration of passive second stage associated with a risk of hysterotomy extension during cesarean?

OBJECTIVE: To assess obstetric factors associated with hysterotomy extension among women undergoing a second-stage cesarean. STUDY DESIGN: This 5-year retrospective cohort study (2013-2017) included all women with second-stage cesarean deliveries of live-born singleton fetuses in cephalic presentation at term. It took place at a tertiary center that practices delayed pushing. We performed univariable and multivariable logistic regression to assess the maternal, obstetric, and neonatal factors associated with hysterotomy extension mentioned in the surgical report. Operative time, postpartum hemorrhage, and maternal complications were also studied. RESULTS: Of the 3350 intrapartum cesareans, 2637 were performed at term for singleton fetuses in cephalic presentation: 747 (28.3%) during the second stage of labor, 83 (11.1%) of which were complicated by a hysterotomy extension. The median duration of the passive phase of the second stage did not differ between women with and without an extension (164 min versus 160 min, P = 0.85). No other second-stage obstetric characteristics, i.e., duration of the active phase, fetal head station, or fetal malposition, were associated with the risk of extension. Factors significantly associated with extension were the surgeon's experience and forceps use during the cesarean. Women with an extension, compared to women without one, had a longer median operative time (49 min versus 32 min, P<0.001) and higher rates of postpartum hemorrhage and blood transfusion (respectively, 30.1% versus 15.1%, p = 0.002 and 7.2% versus 2.4%, P = 0.03). CONCLUSION: The risk of a hysterotomy extension does not appear to be associated with second-stage obstetric characteristics, including the duration of the passive phase of this stage. In our center, which practices delayed pushing, prolonging this passive phase beyond 2 hours does not increase the risk of hysterotomy extension in second-stage cesareans.

Predictors of incomplete maternal satisfaction with neuraxial labor analgesia: A nationwide study.

PURPOSE: Neuraxial analgesia is effective and widely used during labour, but little is known about maternal satisfaction with its use. Our objectives were to assess the frequency of incomplete maternal satisfaction with neuraxial labour analgesia and its predictors. METHODS: We extracted data from the 2016 National Perinatal Survey, a cross-sectional population-based study including all births during one week in all French maternity units. This analysis included all women who attempted vaginal delivery with neuraxial analgesia. Maternal satisfaction with analgesia was assessed by a 4-point Likert scale during a postpartum interview. Incomplete satisfaction grouped together women who were fairly, not sufficiently and not at all satisfied. We performed generalised estimating equations analyses adjusted for sociodemographic, obstetric, anaesthetic, and organisational characteristics to compare women with incomplete satisfaction to those completely satisfied. RESULTS: Among the 8538 women included, 35.2% were incompletely satisfied with their neuraxial analgesia. The odds of incomplete satisfaction were higher among women who reported a prenatal preference not to use neuraxial analgesia but subsequently did (adjusted odds ratio 1.21; 95% confidence interval 1.05-1.39) and among those who did not use patient-controlled neuraxial analgesia (1.20; 1.07-1.34); the odds were lower among women who used combined spinal epidural analgesia (0.53; 0.28-0.99) than among those with epidural analgesia. CONCLUSION: Incomplete maternal satisfaction with neuraxial analgesia is a frequent concern in France. Increasing the use of patient-controlled neuraxial analgesia and combined spinal-epidural analgesia, as well as consistency between prenatal preference and actual use of neuraxial analgesia may improve maternal satisfaction.

Overuse of antenatal visits and ultrasounds in low-risk women: A national population-based study.

BACKGROUND: A better understanding of the overuse of antenatal care is needed to improve its organisation to deal with limited medical resources and doctor shortages. OBJECTIVES: To assess the proportion of women who overuse antenatal care and the associations of overuse with maternal characteristics and the qualifications of healthcare providers. METHODS: We used the 2016 National Perinatal Survey, a cross-sectional population-based survey, performed in all maternity units in France, including 13,132 women. Based on the French national guidelines, 6-8 antenatal visits were defined as adequate, 9-11 as high use, and ≥12 as overuse, while 3 ultrasounds were considered adequate, 4-5 as high use, and ≥6 as overuse. We performed binary modified Poisson regressions-with adequate care as the reference-including maternal social and medical characteristics and the healthcare professionals' qualifications. RESULTS: After women with inadequate care were excluded, 19.2% of low-risk women had at least 12 visits and 30.5% at least 6 ultrasounds. Overuse of visits was associated with primiparity, average to high income, less than good psychological well-being, and care by an obstetrician. The risks of overuse of ultrasounds were higher among primiparous, women with average to high income and those receiving care from a public-sector obstetrician (adjusted relative risk 1.17, 95% CI, 1.13, 1.21) or private obstetrician (adjusted relative risk 1.12, 95% CI, 1.07, 1.16), compared with a public-sector midwife. CONCLUSIONS: Antenatal care overuse is very common in France and associated with some maternal characteristics and also the qualification of care provider. Antenatal care should be customised according to women's needs, in particular for primiparae and those with poor well-being, and available medical resources.

Impact of national guidelines on the cesarean delivery rate in France: A 2010-2016 comparison using the Robson classification.

OBJECTIVE: French national guidelines on indications of pre-labor cesarean delivery and management of women with a previous cesarean delivery (CD) were published in 2012. Our aim was to assess if these guidelines have impacted the global CD rate in France and the CD rate in specific groups according to the Robson classification, using the national perinatal population-based surveys of 2010 and 2016. METHODS: Women included in the French National Perinatal Surveys in 2010 and 2016 were classified using maternal characteristics and obstetrical history in 12 groups according to Robson's classification (N = 14176 in 2010 and N = 13057 in 2016). We estimated relative size, CD rate and contribution of each group to the global CD rate in 2010 and 2016. Then, we compared the 2 survey years. We analyzed the population characteristics, timing and indications of CD in the groups with significant changes between the two survey years. RESULTS: The global CD rate was 20.5 % in 2010 and 19.5 % in 2016 (p = 0.027), with a lower pre-labor CD rate (10.9 % versus 9.2 %, p < 0.001). Despite an increasing of maternal age in 2016, we observed a decrease of the relative size of group 2b (nulliparous, singleton, cephalic, term, pre-labor CD): 1.1 % in 2010 versus 0.8 % in 2016 (p = 0.008). Group 5 (previous CD, singleton, cephalic, ≥37 weeks) was the higher contributor to the global CD rate in both 2010 and 2016 (contribution: 5.8 % of the 20.5 % CD rate and 5.4 % of the 19.5 % CD rate, respectively). Despite an increase of BMI in this group, its CD rate significantly decreased between the two years (61.2 % in 2010 versus 55.1 % in 2016, p = 0.001). CONCLUSION: In France, CD rates have decreased between 2010 and 2016, among women having a pre-labor CD and women with a previous CD, in accordance with national guidelines. National guidelines can help mode of delivery decision-making of physicians and impact the national CD rates.

Determinants of the use of nonpharmacological analgesia for labor pain management: a national population-based study.

Besides neuraxial analgesia, nonpharmacological methods are also proposed to help women coping with pain during labor. We aimed to identify the individual and organizational factors associated with the use of nonpharmacological analgesia for labor pain management. Women who attempted vaginal delivery with labor analgesia were selected among participants included in the 2016 National Perinatal Survey, a population-based cross-sectional study. Labor analgesia was studied as neuraxial analgesia alone, nonpharmacological analgesia alone, and neuraxial and nonpharmacological analgesia combined. The associations were studied using multilevel multinomial logistic regression. Among the 9231 women included, 62.4% had neuraxial analgesia alone, 6.4% had nonpharmacological analgesia alone, and 31.2% had both. Nonpharmacological analgesia alone or combined with neuraxial analgesia were both associated with high educational level (adjusted odds ratio 1.55; 95% confidence interval [CI], 1.08-2.23 and 1.39; 95% CI, 1.18-1.63), antenatal preference to deliver without neuraxial analgesia, and public maternity unit status. Nonpharmacological analgesia alone was more frequent among multiparous women, and in maternity units with an anesthesiologist not dedicated to delivery unit (1.57; 95% CI, 1.16-2.12) and with the lowest midwife workload (2.15; 95% CI, 1.43-3.22). Neuraxial and nonpharmacological analgesia combined was negatively associated with inadequate prenatal care (0.70; 95% CI, 0.53-0.94). In France, most women who had nonpharmacological analgesia during labor used it as a complementary method to neuraxial analgesia. The use of nonpharmacological analgesia combined with neuraxial analgesia mainly depends on the woman's preference, but also on socioeconomic factors, quality of prenatal care, and care organization.