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Objective: To assess whether outpatient cervical ripening at 41 0/7 weeks of gestation with the nitric oxide donor isosorbide mononitrate reduces cesarean delivery rates in nulliparous women with an unfavorable cervix., Methods: We recruited nulliparous pregnant women with a Bishop score less than 6 in a randomized, multicenter, double-blind, placebo-controlled trial. Women received 40 mg vaginal isosorbide mononitrate or a placebo at 41 0/7, 41 2/7, and 41 4/7 weeks of gestation. They returned home between visits. At 41 5/7 weeks of gestation, for women who had not yet given birth, labor was induced with oxytocin or prostaglandins, depending on cervical status. We needed 685 women per group to detect a 25% reduction in the cesarean delivery rate, the primary outcome measure, from 25% in the placebo group to 18.75% in the isosorbide mononitrate group (1-β=0.8, α=0.05, two-sided)., Results: The NOCETER (NO donors for reduction of CEsareans at TERm) trial was a negative study. The cesarean delivery rate was 27.3% (185/678) in the isosorbide mononitrate group and 27.2% (186/684) in the placebo group (relative risk 1.00, 95% confidence interval [CI] 0.84-1.19). None of the maternal secondary efficacy outcomes differed between groups. Side effects were more common among women receiving isosorbide mononitrate than in the placebo group (78.8% [534/678] compared with 27.9% [191/684], relative risk 2.82, 95% CI 2.49-3.20). Composite perinatal morbidity did not differ between groups., Conclusion: Outpatient cervical ripening with vaginal isosorbide mononitrate for prolonged pregnancy in nulliparous women does not reduce cesarean delivery rate., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00930618.

Background: The poisoning of carbon monoxide (CO) is the leading cause of death by poisoning in France. Its consequences are potentially serious to the fetus. Literature is ancient and little known., Purpose and Method: Make an inventory of knowledge about carbon monoxide poisoning during pregnancy., Result: The CO causes maternal then fetal tissue hypoxia primarily by binding to hemoglobin with which it has a high affinity. Its transplacental passage may cause fetal harm, predominantly in the brain. Severity seems correlated with maternal symptoms during exposure. In the absence of maternal symptoms, however, the available data are reassuring. Hyperbaric oxygen therapy may reduce the risk to the fetus., Discussion: Oxygen therapy should be offered in all cases of CO poisoning, especially if there are maternal symptoms during exposure. In addition, a fetal echography directed on the cephalic pole - even a fetal magnetic resonance imaging three weeks after exposure - should also be proposed., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objectives: To evaluate the educational interest of a workshop on diagnosis and repair of obstetric anal sphincter injuries (OASIS). To evaluate the theoretical and anatomical knowledge of OASIS repair by French residents in obstetrics and gynecology., Materials and Methods: The workshop was composed of slides, video of repair and training using cadaveric sow's anal sphincters. All subjects were tested with a questionnaire before and after the course., Results: Thirty residents participated. Classification of OASIS was known by 13.3% of the residents before the training versus 93.3% after the workshop (P<0.001). Initially, only 6.7% correctly classified operative procedures of OASIS versus 86.7% after the workshop (P<0.001). Per pre-test, 90% of residents did not know how to identify the internal anal sphincter (IAS) versus 3% at post-test (P<0.001). Seventy percent of trainees correctly identified the external anal sphincter (EAS) at the beginning of training. Before the course, no resident knew the repair of the IAS and only one third knew the technical repair of the EAS. After the workshop, the theoretical knowledge of EAS and IAS repair were acquired by all (P<0.001)., Conclusion: Structured hands-on training improves significantly the knowledge of OASIS diagnosis and repair., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Background: Recently, a Belgo-French study led by PREMODA group showed that there was no significant difference between caesarean and vaginal delivery for neonatal outcome., Objective: To study protocols and rate of vaginal delivery of single breech in 2006 in the 30 French teaching hospitals that participated to the PREMODA study., Method: Postal survey., Results: Nineteen university hospitals answered (63%). Eighteen used a written protocol and three of them underwent systematic prophylactic caesarean section for breech presentation. Among 15 others, the decision criteria for the way of delivery included pelvimetry, absence of primary cephalic deflexion and foetal measurements. Some centres required additional restrictions. The rates of vaginal delivery varied from 1.7 to 49.7% depending on the centre with very different policies concerning decisional elements. Protocols with restrictions less than three were associated with higher percentages of vaginal delivery (28.9% vs. 21.6%, p<0.001)., Conclusion: Most of teaching centres use a written protocol for breech delivery. Huge variations exist between vaginal delivery rates which seems partially linked to the number of restrictions of the protocol. However, criteria used to accept vaginal delivery in breech presentation are variable between centres and do not lie on objective findings.

Objective: To compare the effectiveness of two single-use vacuum devices, the Kiwi Omnicup and the Mitysoft Bell., Material and Methods: This retrospective study was conducted during two different periods: from January 15th to March 14th to assess the Kiwi Omnicup and from March 15th to June 15th for the Mitysoft Bell. The primary outcome was the successful completion of delivery with the allocated instrument. Secondary outcomes were fetal scalp trauma and maternal perineal lesions. All deliveries were performed by similar teams., Results: Thirty-nine patients were included in the Kiwi Omnicup group and 48 in the Mitysoft Bell group. Compared to the Kiwi Omnicup, the Mitysoft Bell was associated with a greater number of cup detachments (41.7% vs. 10.3%; p<0.01) and a significantly higher rate of failure (31.3% vs. 12.8%). Rates of substantial scalp trauma and maternal trauma were similar in both groups., Conclusion: The Mitysoft Bell is not as successful at achieving a vaginal delivery as the Kiwi Omnicup. This could be explained by the shape of the cup.

Intrapartum asphyxia is increased in several situations such as intrauterine growth retardation, preterm labor, postdate pregnancy or maternal diabetes. In all these cases, fetal heart rate monitoring should be preferred to intermittent auscultation. Fetal scalp blood pH or lactates can be used to identify fetuses at risk of intrapartum asphyxia. However, fetal scalp blood sampling should not delay delivery in case of severe abnormal fetal heart rate as fetal asphyxia could occur rapidly in theses high-risk pregnancies. Data is insufficient to recommend fetal pulse oximetry or ECG analysis. Research should be undertaken to evaluate their performance in these situations.

The 1-3 piezocomposite transducers used in specific medical applications--as lithotripsy--must be excited by intense electrical impulses. By inference, the composite material is subjected to high-stress levels. To explain possible failure, a numerical tool for analyzing singular two- and three-dimensional stress fields in piezocomposite structures is proposed. Following a finite-element iterative method, singularity parameters values and intensity factors for the mechanical stresses and the electrical field are computed in several bimaterial configurations. The finite-element analysis uses commercial software.

Objective: To estimate the performance of the foetal fibronectin test as a predictor of preterm delivery., Patients and Methods: This prospective study concern 61 patients who had a singleton pregnancy between 24 and 36 weeks of gestation and were hospitalized because of a threatened preterm labor without premature rupture of the membranes. For each patient the presence of foetal fibronectin in cervicovaginal secretions was determined with a rapid swab-test., Results: Prematurity rate was 38% (23 patients). In case of positive result, delivery became before 37 weeks in 75% (12/16) against 24% in case of negative result (11/45). The prolongation of pregnancy after the test was on average 21 days in the positive group and 44 days in the negative group. About the prediction of preterm delivery, the results showed a sensibility of 52%, a specificity of 89%, a positive predictive value of 75%, a negative predictive value of 76%. To predict a delivery within the two weeks after the test, the sensibility was 88%, the specificity 83%, and the negative predictive value 98%., Conclusion: The presence of foetal fibronectin in cervicovaginal secretions represent an increased risk of preterm delivery, whereas its excellent negative predictive value allow to be reassuring, especially within a period of 15 days.