[Fetal monitoring: Current limitations and new approaches based on analysis of the fetal autonomic nervous system]. / Surveillance fœtale : limites actuelles et nouvelles pistes basées sur l'analyse du système nerveux autonome fœtal.

OBJECTIVE: Currently, fetal monitoring during labor is based on visual analysis of the fetal heart rate (FHR). This test is imperfect, with high intra- and inter-observer variability and a moderate to poor prediction of the occurrence of neonatal acidosis or anoxic-ischaemic encephalopathy. In situations where there is an intermediate risk of acidosis, it is possible to use second-line tests such as blood scalp sampling (with pH or lactate measurement) or ST segment analysis of the fetal ECG. However, these invasive tests have many limitations and their place is debated. Some authors suggest a more physiological approach to FHR assessment. The main actor in maintaining fetal homeostasis is the autonomic nervous system (ANS). Its activity can be assessed by analysing heart rate variability (HRV). The aim is to assess whether HRV can be used to identify situations at risk of acidosis. MATERIALS AND METHODS: Our team has developed an index, the Fetal Stress Index, to measure HRV. To test it in a situation of acidosis, we used a pregnant ewe model. We also developed in parallel a human fetal ECG recording system. RESULTS: In our experimental model, we have shown that this index reflects variations in the parasympathetic system and correlates with the onset of acidosis. As its use in clinical practice requires the acquisition of a beat-to-beat FHR signal, we have also developed an abdominal patch that allows highly accurate analysis of the fetal ECG. CONCLUSION: The future is therefore to validate the FSI as a marker of acidosis in a prospective cohort using the signal obtained from our patch. This could be a new tool for fetal monitoring during labor.

[Comparison of antepartum management of breech versus cephalic presentation]. / Comparaison de la prise en charge per-partum des présentations podaliques par rapport aux présentations céphaliques.

OBJECTIVES: Delivery mode of term breech presentation is still being discussed. The aim of this study was to compare the labor management of a breech presentation to a vertex presentation during a vaginal delivery attempt. METHODS: It was a single-center, comparative, descriptive retrospective study from 2014 to 2017. We studied fetal heart rate (FHR) during labor and expulsion, duration of the different stage of labor, mode of delivery and neonatal outcomes for breech and vertex presentations. RESULTS: Two hundred and thirty-nine patients were included whom 106 (44%) breech presentation. The use of oxytocin was more common in breech group (63,2% versus 48,1%, P=0.020). Average dilatation rate was slower for breech presentation than for vertex presentation (1.9cm/h vs. 2.8cm/h; P=0.005). There was more FHR with high risk of acidosis in the breech presentations (37.2% vs 19.1%, P=0.001) and Melchior's FHR classification were comparable in both groups. CONCLUSIONS: The per-partum management of a fetus in breech presentation differs from a fetus in cephalic presentation. It must be known and anticipated for an optimal management in the delivery room.

[Effects of a policy for reasonable use of oxytocin during spontaneous labor at term]. / Impact d'une politique d'utilisation raisonnée de l'oxytocine de synthèse lors du travail spontané à terme.

OBJECTIVE: To assess the effect of a modified definition of dystocia and of a different timing of interventions during spontaneous labor on the rate of oxytocin use and on its consequences on labor outcome. METHODS: We compared oxytocin use and labor outcome before and after the introduction of a new protocol for the management of spontaneous labor. By protocol, oxytocin use and/or artificial rupture of the membranes was restricted to cases without progress in cervical dilatation for≥1h and/or no progress of fetal descent for≥1h at full dilatation. The main outcome measure was the rate of oxytocin use. Secondary outcome criteria were the consequences on labor (duration of labor, tachysystole and uterine hyperstimulation, abnormal fetal heart rate, cesarean delivery rate) and neonatal outcome. RESULTS: Oxytocin use was strongly reduced from 2015 (69.2%) to 2016 (39.8%; P<0.01) and 2017 (31.9%; P<0.01). Abnormal FHR rates decreased simultaneously (respectively 52%, 37% et 29%, P<0.05), as well as uterine hyperstimulation (respectively 33.6%, 21.3% et 23.0%; P<0.05). The cesarean delivery rate did not vary significantly from 2015 (11.5%) to 2016 (8.4%; NS) but it decreased from 2015 to 2017 (11.5% to 2.6%, respectively; P<0.05). No difference was found in postpartum hemorrhage rates or in neonatal outcome. The duration of labor was significantly longer for women who delivered in 2017, compared with 2015 (372 minutes versus 306 minutes, respectively; P<0.05). After multivariate analysis, FHR abnormalities were reduced (aOR 0.65 IC 95% [0.49-0.86]) as well as cesarean deliveries during labor (aOR 0.5 IC 95% [0.26-0.97]) in 2017 only, compared with the reference year 2015. CONCLUSION: A simple and easy-to-use definition of dystocia and of interventions required during labor allowed a strong reduction of oxytocin use during labor with subsequent benefits such as reduced rates of FHR abnormalities, uterine hyperstimulations and cesarean deliveries, at the cost of a limited prolongation of labor, mainly in nulliparous women.

[Does rupture of membranes have an impact on the fetal heart rate during spontaneous labor?] / Quel est l'impact de la rupture des membranes amniotiques sur le rythme cardiaque fœtal au cours du travail spontané ?

OBJECTIVES: Evaluate the influence of rupture of membranes (spontaneous or artificial) on fetal heart rate. Secondary objectives were to compare spontaneous and artificial ruptures and to investigate the risk factors associated with the occurrence of abnormalities of fetal heart rate (FHR). METHODS: This is a monocentric retrospective study (Lille, France) from January to March 2018. All low-risk pregnancies with cephalic presentation, spontaneous labor, gestational age more than 37 weeks of amenorrhea, singleton pregnancy, absence of maternal or fetal pathology were included. The elements sought were the occurrence of bradycardia, tachycardia, decelerations (early, late, typical variable, atypical variable, prolonged) and abnormal variability. FHR was analyzed one hour before and one hour after rupture. The groups with and without abnormalities of FHR were compared according to the type of rupture. RESULTS: Two hundred and thirty-three patients were included. A total of 44.54% (n=129, P<0.001) showed abnormalities of FHR after rupture of membranes. In the fetal heart rate time study after the rupture event, prolonged decelerations were more frequent in the first quarter hour compared to the second quarter hour. There was significantly more risk of abnormalities of fetal heart rate if the fetal heart rate before the rupture of membranes was already pathological, as well as if the time between rupture and delivery was short. The type of rupture, artificial or spontaneous, was not a risk factor. CONCLUSION: The rupture of membranes increased the occurrence of abnormalities of FHR. However, there is no more deleterious impact of one type of rupture than the other.

[Stained amniotic fluid and meconium amniotic fluid: Should they change our obstetric management ?] / Liquide amniotique teinté ou méconial : doivent-ils modifier notre prise en charge obstétricale ?

OBJECTIVES: To assess if a stained or meconial amniotic fluid during labor is correlated with a greater risk of neonatal metabolic acidosis. METHODS: In a retrospective case-control study carried out in a level 3 maternity from 1st of January to 31st of December 2014, all patients who delivered a singleton eutrophic fetus in cephalic presentation after 37WG and with a stained or meconial amniotic fluid during labor were included. Obstetrical and neonatal outcomes were compared according to the amniotic fluid's color. RESULTS: At all, 302 patients in the group « Abnormal amniotic fluid¼ (198 patients with stained amniotic fluid, 104 with meconial amniotic fluid) vs. 302 in the group « clear amniotic fluid¼ were included. No significant difference on the rate of neonatal severe acidosis between the two groups were found. Fetal heart rhythm abnormalities were more frequent in case of meconial amniotic fluid (11,3% vs. 31,7%, P<0,0001). The composite endpoint, defined by the association of umbilical arterial pH <7,0±base excess ≥12mmol/L±Apgar score at 5min <7, was more frequent in case of meconial amniotic fluid (4,0% vs. 12,5%, P=0,0018). CONCLUSION: The occurrence of severe neonatal metabolic acidosis was not more frequent in case of stained or meconial amniotic fluid, but with an increase in the use of fetal scalp pH and cesaerian deliveries when the fluid was meconial.

[Indications of primary cesarean deliveries in a regional teaching hospital and reasonable strategies for reducing them]. / Indications des premières césariennes dans un centre hospitalo-universitaire régional et stratégies raisonnables pour les diminuer.

OBJECTIVES: To characterize the indications of primary cesarean sections and discuss the various possibilities to reduce them. MATERIALS AND METHODS: Retrospective study, carried out over a period of 1 year in a university hospital having a level 3 perinatal activity, including the 499 primary cesarean sections of 2013. Two groups were defined by parity: nulliparous patients (group 1) and multiparous patients who had never previously been delivered by cesarean section (group 2). We have assessed the indication of every primary cesarean section and health status of newborns in each group. RESULTS: Groups 1 and 2 respectively included 369 and 130 patients. The cesarean section rate in 2013 was 24.7% with a primary cesarean section rate of 17%. Seventy-four percent of the primary caesarean deliveries were performed on nulliparous women and 26% on multiparous (P<0.001). Sixty-three percent of the primary caesarean deliveries were performed on nulliparous women with a singleton fetus in cephalic presentation. The most common indications for primary cesarean delivery were non-reassuring fetal heart rate tracing (47.1%), failure to progress (24.8%) for which nulliparous women were more involved (29% vs. 13%, P<0.001) and fetal malpresentation (9.6%). CONCLUSION: Further analysis of fetal heart rate during labor, a larger use of second line means to evaluate the fetal status during labor, using 6cm as the cut off for active labor, and encouraging vaginal operative delivery constitute the best way to decrease the primary cesarean section rate.

[Evaluation of the CNGOF foetal heart rate classification]. / Évaluation de la forme simplifiée de la classification du rythme cardiaque fœtal proposée dans le cadre des recommandations pour la pratique clinique « surveillance du travail ¼.

INTRODUCTION: The 2007 CNGOF guidelines for good practice on "Methods of foetal surveillance during labour" proposed a consensual definition of intra-partum foetal heart rate (FHR) patterns. In order to facilitate its application, Carbon et al. published in 2013 a simplified table of the classification with 5 types of tracing. OBJECTIVES: To evaluate the diagnosis value of this FHR classification to determine the risk of foetal acidosis. METHODS: Retrospective single-centre study including 252 single pregnancies beyond 34 weeks of gestation with a record of at least 60minutes before delivery. The primary endpoint was a pH at birth < 7.20. RESULTS: When pH was < 7.20, type 3 tracing was significantly more frequent during the first stage of labour while types 4 and 5 were more frequently found during active second stage. A pH<7.20 was significantly associated with more instrumental extractions, emergency caesarean section, Apgar score < 7 and neonatal respiratory distress. The areas under the curve were 0.63 for the analysis during the first stage of labour, 0.69 for second stage, and 0.68 when the two stages were combined. CONCLUSION: Our study found that the CNGOF classification improved the FHR interpretation but its diagnosis value to predict acidosis remained limited.

[Can caesarean delivery prevent cerebral palsy? Medico-legal implications of a French ecological study]. / La césarienne peut-elle prévenir la paralysie cérébrale ? Implications médico-légales d'une étude écologique française.

OBJECTIVE: For a long time, the benefit of a caesarean delivery in the prevention of cerebral palsy (CP) has been put forward, which was based on the assumption that CP is due to asphyxia in more than 50 % of the cases. However, from register-based data, this rate has been estimated less than 4 %. The aim of this study was to evaluate whether the rate of caesarean sections for fetal indication was correlated with the prevalence rate of CP in a French county. PATIENTS AND METHODS: This was an ecological study of register-based prevalence estimates of children with CP (postnatal cases excluded) born between 1997 and 2003 in a French county compared with the rates of caesarean section for fetal distress obtained from the maternal and infant protection service of the county. RESULTS: Whilst the rate of caesarean section for fetal indication increased by 44% during the period studied, the prevalence of CP remained nearly stable around 1.5 per 1000 live births. There was no correlation between caesarean section and CP prevalence (r'=-0.36, P=0.43). DISCUSSION AND CONCLUSION: The present study was in accordance with the results of a recent meta-analysis which concluded that emergency and prophylactic caesarean deliveries were not efficient in the prevention of CP. Indication of caesarean delivery for foetal heart rhythm anomaly, which is the most relevant cause for the growing rate of caesarean sections, should be justified by additional examinations in ambivalent cases, in order not to consider it as defensive medicine, which is ethically and therefore juridically blameworthy.

[Fetal heart rate patterns of breech presentations during expulsion. A comparative study with cephalic presentations]. / L'analyse du rythme cardiaque fœtal au cours de l'expulsion des présentations podaliques. Analyse comparative dans une maternité de niveau III.

INTRODUCTION: Expulsion upon vaginal delivery is a period at risk for the foetus, especially in case of breech presentation. In fact, monitoring the fetal well-being is complex in this phase. The correct interpretation of fetal heart rate (FHR) during expulsion, using Melchior's classification, is important because it helps screen for fetal acidosis. The aim of this study was to determine if it was possible to tolerate an abnormal FHR during expulsion of breech presentations. MATERIAL AND METHODS: A retrospective study was conducted to compare FHR during expulsion and neonatal results between breech and cephalic presentations at Besançon's university hospital. RESULTS: We collected data from 118 breech presentations and 236 cephalic presentations. Melchior's FHR classification types were significantly different between breech and cephalic presentations with a majority of type 1. Neonatal results were significantly less favorable for breech presentations, but without any increase in mortality and in severe morbidity. DISCUSSION AND CONCLUSION: Melchior's expulsion FHR classification seems to be applicable for breech presentations with a different distribution of FHR types compared to cephalic presentations. Following the results of this study, it seems to be possible to tolerate an abnormal FHR during expulsion of breech presentation, so far as is reasonable.

[Correlation between fetal scalp samples and umbilical cord samples]. / Corrélation entre prélèvements au scalp fœtal et prélèvements artériels au cordon.

OBJECTIVE: The objective was to evaluate the correlation between fetal scalp base excess (BE) and umbilical cord BE. Respective value of fetal scalp pH, BE and lactate for the prediction of neonatal metabolic acidosis were also evaluated. METHODS: A retrospective monocentric study was conducted in a French tertiary care academic maternity. All the patients who had a fetal scalp sampling during labor in 2010, less than 90 minutes before delivery were included. Fetal heart rate abnormalities (FHRA) were classified by degree of severity, according to the French guidelines. The differences between fetal scalp samples and umbilical cord samples over time and in relation with the type of FHRA were analyzed for pH and BE. The differences between fetal scalp pH and cord pH over time and in relation with scalp BE were analyzed. The correlation between fetal scalp samples and cord samples for pH, BE and lactate was estimated. Receiver operating characteristics (ROC) curves for fetal scalp pH, lactate and BE to predict umbilical cord pH under 7.20 were calculated. RESULTS: Seventy-one cases were included. The difference between fetal scalp sample and cord sample was lower when the sample was made closest to delivery both for pH and BE. The gravity of FHRA was not predictive of a faster decrease of pH or BE over time. The correlation was significant for pH (r=0.23, p=0.03) between scalp samples and cord samples, as for BE (r=0.49, p=0.001) and lactate (r=0.52, p=0.001). The ROC curves for pH, BE and lactate displayed a similar pattern. CONCLUSION: Fetal scalp and umbilical cord samples, for pH, BE and lactate were significantly correlated but their respective predictive value for cord pH less or equal to 7.20 was poor.

[Prenatal management of isolated IUGR]. / Surveillance anténatale, prise en charge et indications de naissance en cas de RCIU vasculaire isolé.

OBJECTIVE: To evaluate the performance of different antenatal tools for the monitoring of fetuses with isolated intrauterine growth restriction (IUGR). To define the prenatal management of IUGR and indications for delivery before and after 32 weeks of gestation. METHOD: PubMed, Embase and the Cochrane databases were searched using the keywords "IUGR", "fetal growth restriction", "cardiotocography", "amniotic fluid", "ultrasound assessment", "biophysical profile", "Doppler ultrasonography", "randomized trial", "meta-analysis". These terms were also combined together. RESULTS: Fetal monitoring of isolated IUGR should be based on the combined use of fetal heart rate (FHR) and ultrasound Doppler. The use of computerized FHR, with short-term variability (STV) measurement allows longitudinal monitoring and provides objective values upon which to decide very premature delivery (LE3). The use of umbilical Doppler is associated with a decrease in perinatal morbidity, especially in IUGR (LE1). It should be the first-line mean for the monitoring of SGA and IUGR fetuses (LE1). The additional use of cerebral Doppler is associated with a better predictive value for a poor perinatal outcome than the umbilical Doppler alone (LE3). Therefore, cerebral Doppler should be used in fetuses with IUGR, whether the umbilical Doppler is normal or not. As morbidity and mortality is increased in IUGR with pathological ductus venosus, the use of this Doppler should be considered in the monitoring of IUGR at before 32 weeks (professional consensus). Routine hospitalization is not mandatory for the monitoring of fetuses with IUGR/SGA. However, tertiary referral is advisable in cases of severe IUGR at between 26 to 32 weeks (professional consensus). The decision for delivery cannot be standardized and should be based on the combined analysis of gestational age, fetal heart rate analysis and Doppler study (professional consensus). CONCLUSION: Monitoring of fetuses with IUGR and decision for delivery should be based on the combined analysis of gestational age, fetal heart rate analysis and Doppler study before 32 weeks, this should ideally be performed by the association of computerized FHR and arterial and venous Doppler.

[Analysis of fetal heart rate abnormalities occurring within one hour after laying of epidural analgesia]. / Analyse des anomalies du rythme cardiaque fœtal survenant dans l'heure suivant la pose d'une analgésie péridurale.

OBJECTIVES: The objective of this study is to classify abnormalities of fetal heart rate (FHR) occurring in the first hour after performing the epidural analgesia, and to assess the impact of these abnormalities on delivery and on after-birth neonatal state. PATIENTS AND METHODS: Retrospective study of 6676 patients continuously from 1 January 2007 to 31 December 2010 who benefited, during the labor, of epidural analgesia. Seven hundred and sixty (14,1%) presented anomalies of FHR in the hour following the laying of epidural (group 1), and 5916 showed no abnormalities of the RCF (group 2). RESULTS: Among the 760 anomalies of the FHR in the hour following the laying of epidural, 319 (42%) showed prolonged decelerations, 169 (22.2%) variable decelerations, 122 (16.1%) early decelerations, 110 (14.5%) late decelerations and 40 bradycardia (5.3%). In the group 1, incidence of caesarean delivery was 21.4% (163 patients); in group 2, it was 9.63% (P<0.002). In group 1, the umbilical artery pH was less than 7.20 in 13,6% of patients, whereas in group 2, the prevalence was only 6,5% (P<0.002). There is no statistically significant differences on Apgar score between the two groups. CONCLUSION: This study helped to characterize anomalies in the FHR following epidural. There is an increase of obstetric interventions. There is no impact on neonatal clinical state. The administration of systematic ephedrine shall be investigated to reduce these interventions.