Le mode d'entrée aux urgences peut-il être utilisé comme indice de gravité ?

Objectif : établir le lien entre le mode d arrivée au service d accueil des urgences (SAU) et le devenir à court terme des patients. Méthodes : Nous avons étudié le devenir en terme d hospitalisation de 3553 patients admis au SAU de l hôpital Conception, (Marseille, France) en fonction de leur mode d arrivée : propres moyens, ambulance privée, Véhicule de Secours et d Aide au Victimes (VSAV), transport médicalisé (Service d aide médicale urgente/SAMU),sur une période d un mois. Résultats : Le taux d hospitalisation est significativement plus important pour les patients arrivés au SAU avec une aide au transport (p<0.001). Le risque relatif d être hospitalisé en cas d aide transport par rapport à un patient arrivé par ses propres moyens et de 23.5 pour le SAMU (p<0.001), de 10.3 pour les ambulances privées (p<0.001) et de seulement 3.4 pour les VSAV (p<0.001). Conclusion : Le mode d arrivée au SAU peu être considéré comme prédictif de l évolution précoce, surtout pour les patients arrivés avec le SAMU et en ambulance privée. Dans le cas des patients arrivés en VSAV, le risque relatif d être hospitalisé ne justifie pas de prise en charge privilégiée par rapport aux patients arrivés par leurs propres moyens.AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Be prepared for unexpected events: A case of vaginal rupture during breech delivery [Letter]

International audienc

Does a physiology-based interpretation of cardiotocography allow to dispense with second-line methods? A cross-sectional online survey

Context: Second line methods are used to help obstetricians to identify abnormalities that reflect foetal acidosis. Since the use of a new technique of cardiotocography (CTG) interpretation based on the pathophysiology of the foetal period, the use of second-line tests has been questioned.Objective: To evaluate the impact of specific training in CTG physiology-based interpretation on professional attitudes towards the use of second-line methods.Methods: This cross-sectional study included 57 French obstetricians divided into two groups: the trained group (obstetricians who had already participated in a training course in physiology-based interpretation of CTG) and the control group. Ten medical records of patients who had abnormal CTG tracings and underwent foetal blood sampling pH measurement during labour were presented to the participants. They were given three choices: use a second-line method, continue labour without using second-line method, or perform a caesarean section. The main outcome measures was the median number of decisions to use second-line method.Results: Forty participants were included in the trained group and 17 in the control group. The median number of recourses to second-line method was significantly inferior for the trained group (4/10 s-line methods) than for the control group (6/10, p = 0.040). Regarding the 4 records for which a caesarean section was the real outcome, the median number of decisions of continuing labour was significantly superior in the trained group than in the control group (p = 0.032).Conclusions: Participation in a training course in physiology-based interpretation of CTG could be associated with a less frequent use of second-line method at the cost of more frequently continuing labour with the risk compromising foetal and maternal well-being. Additional studies are required to determine whether this change in attitude is safe for the foetal well-being

Intra- and interobserver agreement among obstetric experts in court regarding the review of abnormal fetal heart rate tracings and obstetrical management

International audienceOBJECTIVE: The objective of the study was to evaluate the intra-and interobserver agreement among obstetric experts in court regarding the retrospective review of abnormal fetal heart rate tracings and obstetrical management of patients with abnormal fetal heart rate during labor. STUDY DESIGN: A total of 22 French obstetric experts in court reviewed 30 cases of term deliveries of singleton pregnancies diagnosed with at least 1 hour of abnormal fetal heart rate, including 10 cases with adverse neonatal outcome. The experts reviewed all cases twice within a 3-month interval, with the first review being blinded to neonatal outcome. For each case reviewed, the experts were provided with the obstetric data and copies of the complete fetal heart rate recording and the partogram. The experts were asked to classify the abnormal fetal heart rate tracing and to express whether they agreed with the obstetrical management performed. When they disagreed, the experts were asked whether they concluded that an error had been made and whether they considered the obstetrical management as the cause of cerebral palsy in children if any. RESULTS: Compared with blinded review, the experts were significantly more likely to agree with the obstetric management performed (P \textless .001) and with the mode of delivery (P \textless .001) when informed about the neonatal outcome and were less likely to conclude that an error had been made (P \textless .001) or to establish a link with potential cerebral palsy (P = .003). The experts' intraobserver agreement for the review of abnormal fetal heart rate tracing and obstetrical management were both mediocre (kappa = 0.46-0.51 and kappa = 0.48-0.53, respectively). The interobserver agreement for the review of abnormal fetal heart rate tracing was low and was not improved by knowledge of the neonatal outcome (kappa = 0.11-0.18). The interobserver agreement for the interpretation of obstetrical management was also low (kappa = 0.08-0.19) but appeared to be improved by knowledge of the neonatal outcome (kappa = 0.15-0.32). CONCLUSION: The intra-and interobserver agreement among obstetric experts in court for the review of abnormal fetal heart rate tracing and the appropriateness of obstetrical care is poor, suggesting a lack of objectivity of obstetrical expertise as currently performed in court

Women and health professionals’ perspectives on a conditional cash transfer programme to improve pregnancy follow-up: a qualitative analysis of the NAITRE randomised controlled study

Objectives Women of low socioeconomic status have been described as having suboptimal prenatal care, which in turn has been associated with poor pregnancy outcomes. Many types of conditional cash transfer (CCT) programmes have been developed, including programmes to improve prenatal care or smoking cessation during pregnancy, and their effects demonstrated. However, ethical critiques have included paternalism and lack of informed choice. Our objective was to determine if women and healthcare professionals (HPs) shared these concerns.Design Prospective qualitative research.Setting We included economically disadvantaged women, as defined by health insurance data, who participated in the French NAITRE randomised trial assessing a CCT programme during prenatal follow-up to improve pregnancy outcomes. The HP worked in some maternities participating in this trial.Participants 26 women, 14 who received CCT and 12 who did not, mostly unemployed (20/26), and - 7 HPs.Interventions We conducted a multicentre cross-sectional qualitative study among women and HPs who participated in the NAITRE Study to assess their views on CCT. The women were interviewed after childbirth.Results Women did not perceive CCT negatively. They did not mention feeling stigmatised. They described CCT as a significant source of aid for women with limited financial resources. HP described the CCT in less positive terms, for example, expressing concern about discussing cash transfer at their first medical consultation with women. Though they emphasised ethical concerns about the basis of the trial, they recognised the importance of evaluating CCT.Conclusions In France, a high-income country where prenatal follow-up is free, HPs were concerned that the CCT programme would change their relationship with patients and wondered if it was the best use of funding. However, women who received a cash incentive said they did not feel stigmatised and indicated that these payments helped them prepare for their baby’s birth.Trial registration number NCT0240285