Manœuvres systématiques dans l’accouchement eutocique du siège par voie basse en France et en Belgique

Abstract : Vaginal delivery of breech presentation (VBD) was always a subject for debate among obstetricians worldwide but is possible in France providing that safety criteria are filled (the PREMODA study by Goffinet et al 2008). Maneuvers during VBD are hardly ever used, firstly because of the rare occurrence of breech presentation, and secondly because there are no guidelines clearly defining their indications. The objective of our study was to identify factors associated to systematic maneuvers in eutocic VBD and a potential effect of these maneuvers on neonatal and maternal outcomes.
Material and Methods
Data were extracted from the PREMODA database (Goffinet et al, 2008). Patients presenting a VBD were included into two groups: 626 women in the group without manoeuvers (WM) and 537 in the group with systematic maneuvers (SM). Women who had maneuvers for dystocic obstetrical situation, like head retention and/or arm extension, were excluded. Maternal, institutional, fetal and neonatal characteristics were compared to identify factors associated to systematic maneuvers and neonatal outcomes.
Results
Concerning maternal and neonatal outcomes, no difference between groups were noted except for umbilical cord arterial pH measurement, which was lower in the SM group (7.25±0.1 Vs. 7.27±0.1, p=0.01), and 1st and 2nd maternal perineal tears, which were more often observed in SM group (85.7% Vs. 78.2%, p=0.002) (Table 1). Factors associated with systematic maneuvers were: first vaginal delivery (OR=1.65, CI95%[1.30,2.09], p<0.001), non-Caucasian ethnic origin (OR=2.07, CI95%[1.41,3.05], p<0.001), secondary and post-secondary educational school level (OR=1.51, CI95% [1.06,2.17], p=0.02), delivery at a level 2B or 3 maternal health care hospital (OR=1.74, CI95%[1.16,2.62], p=0.008 and OR=1.87, CI95%[1.22,2.85], p=0.004, respectively), the presence of a junior or senior obstetrician at the moment of delivery (OR=5.12, CI95%[1.69,15.5], p=0.004 and OR=4.57, CI95%[2.33,8.97], p<0.001, respectively), and a passive phase of 2nd stage of labor lasting more than 40 minutes (OR= 1.39, CI95%[1.01,1.89], p=0.04).
Discussion
Our results show that the vast majority of systematic maneuvers are performed by senior obstetricians in large general hospitals or university hospitals. However, when a VBD occurs in a 3rd level maternity care structure, ie. university hospitals, systematic maneuvers are used in only 40.6% of cases. In addition, they seem to be performed more easily in primiparous women, in whom a dystocic situation can be expected. On the other hand, it seems difficult to find an obvious link between maternal ethnic origin, educational level and the use of systematic maneuvers. Regarding neonatal and maternal outcomes, our study lacks power to detect major complications, but there is no evidence that systematic maneuvers in eutocic VBD increase neonatal or maternal morbidity.
Conclusion
Systematic maneuvers for eutocic VBD are mostly performed in primiparous women, by a senior obstetrician, and in level 3 maternity care structures, but their use is far from being the rule. Larger studies are required to detect their impact on severe adverse neonatal outcomes
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Master Thesis
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Cécile Hennebert. Manœuvres systématiques dans l’accouchement eutocique du siège par voie basse en France et en Belgique. Médecine humaine et pathologie. 2019. ⟨dumas-02073848⟩

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