Out-of-maternity deliveries in France: A nationwide population-based study

International audienceINTRODUCTION:In France, many maternity hospitals have been closed as a result of hospital restructuring in an effort to reduce costs through economies of scale. These closures have naturally increased the distance between home and the closest maternity ward for women throughout the country. However, studies have shown a positive correlation between this increase in distance and the incidence of unplanned out-of-maternity deliveries (OMD). This study was conducted to estimate the frequency of OMD in France, to identify the main risk factors and to assess their impact on maternal mortality and neonatal morbidity and mortality.MATERIALS AND METHODS:We conducted a population-based observational retrospective study using data from 2012 to 2014 obtained from the French hospital discharge database. We included 2,256,797 deliveries and 1,999,453 singleton newborns in mainland France, among which, 6,733 (3.0‰) were OMD. The adverse outcomes were maternal mortality in hospital or during transport, stillbirth, neonatal mortality, neonatal hospitalizations, and newborn hypothermia and polycythemia. The socio-residential environment was also included in the regression analysis. Maternal and newborn adverse outcomes associated with OMD were analyzed with Generalized Estimating Equations regressions.RESULTS:The distance to the nearest maternity unit was the main factor for OMD. OMD were associated with maternal death (aRR 6.5 [1.6-26.3]) and all of the neonatal adverse outcomes: stillbirth (3.3 [2.8-3.8]), neonatal death (1.9 [1.2-3.1]), neonatal hospitalization (1.2 [1.1-1.3]), newborn hypothermia (5.9 [5.2-6.6]) and newborn polycythemia (4.8 [3.5-6.4]).DISCUSSION:In France, OMD increased over the study period. OMD were associated with all the adverse outcomes studied for mothers and newborns. Caregivers, including emergency teams, need to be better prepared for the management these at-risk cases. Furthermore, the increase in adverse outcomes, and the additional generated costs, should be considered carefully by the relevant authorities before any decisions are made to close or merge existing maternity units

Correction: Passive hypothermia (≥35 - <36°C) during transport of newborns with hypoxic-ischaemic encephalopathy.

[This corrects the article DOI: 10.1371/journal.pone.0170100.]

Risk factors for not delivering in a level III unit before 32 weeks of gestation: results from a population-based study in Paris and surrounding districts in 2003

ACL (facteur d'impact)International audienceDelivery of very preterm babies in maternity units with on-site neonatal intensive care (level III units) is associated with lower mortality and morbidity. This analysis explores risk factors for not delivering in a level III unit, using data from a population-based study of very preterm births in Paris and surrounding districts in 2003. The sample for analysis included resident women with a fetus alive at the onset of labour between 24 and 31 weeks of gestation (n = 641). Characteristics of women delivering in and those not in level III units were compared using logistic regression. Further analysis was carried out for the subgroup of women not already scheduled to deliver in a level III unit. Twenty-nine per cent of women did not deliver in level III units; in the subgroup scheduled to deliver in level I or II units, 43% were not transferred. Women were less likely to deliver in a level III unit if they had a singleton pregnancy, a gestation of <26 weeks or at 31 weeks, experienced antenatal haemorrhaging, lived in socially deprived neighbourhoods or at a greater distance from the nearest level III. Women scheduled to deliver in a maternity unit with a special care nursery were also less likely to deliver in a level III unit. In contrast, preterm rupture of membranes and fetal growth restriction increased the likelihood of a level III delivery. These results underline the importance of controlling for clinical characteristics when analysing perinatal outcome by place of delivery and show how socioe-conomic factors, known to impact on the risk of having a preterm birth, can also affect access to appropriate care

Risk factors for delivery out of a level III unit before 32 weeks of gestation: results from a population based study in Paris and surrounding districts in 2003

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Outcomes of Preterm Neonates Transferred Between Tertiary Perinatal Centers.

International audienceTo verify if preterm neonates transferred between tertiary referral centers have worse outcomes than matched untransferred infants.Cohort study with a historically matched control group.Two tertiary-level neonatal ICUs.Seventy-five neonates per group.Transfer between tertiary-level neonatal ICUs carried out by a fully equipped transportation team.We measured in-hospital mortality, frequency of intraventricular hemorrhage greater than 2nd grade, periventricular leukomalacia, necrotizing enterocolitis greater than or equal to grade 2, bronchopulmonary dysplasia, composite outcomes (in-hospital mortality/bronchopulmonary dysplasia, in-hospital mortality/intraventricular hemorrhage > 2nd grade, and bronchopulmonary dysplasia/periventricular leukomalacia/intraventricular hemorrhage > 2nd grade), length of neonatal ICU stay, weight at discharge, and time spent on ventilatory support. Seventy-five similar (except for antenatal steroids administration) neonates were enrolled in each cohort. Cohorts did not differ in mortality, bronchopulmonary dysplasia, intraventricular hemorrhage greater than 2nd grade, periventricular leukomalacia, necrotizing enterocolitis greater than or equal to grade 2, any composite outcomes, neonatal ICU stay, weight at discharge, and duration of respiratory support. Results were unchanged adjusting for antenatal steroids.Neonatal transfer between tertiary-level centers does not impact on clinical outcomes, if performed under optimal conditions

Premedication practices for tracheal intubation in neonates transported by French medical transport teams: a prospective observational study

International audienceObjectives: Premedication practices for neonatal tracheal intubations have not yet been described for neonatal transport teams. Our objective is to describe the use of sedation/analgesia (SA) for tracheal intubations and to assess its tolerance in neonates transported by medical transport teams in France.Setting: This prospective observational study was part of the EPIPPAIN 2 project and collected around-the-clock data on SA practices in neonates intubated by all five paediatric medical transport teams of the Paris region during a 2-month period. Intubations were classified as emergent, semiemergent and non-emergent. Sedation level and conditions of intubation were assessed with the Tonus, Reactivity, Awareness and Conditions of intubation to Help in Endotracheal intubation Assessment (TRACHEA score). The scores range from 0 to 10 representing an increasing ladder from adequate to inadequate sedation, and from excellent to very poor conditions of intubation.Participants: 40 neonates intubated in 28 different centres.Results: The mean (SD) age was 34.9 (3.9) weeks, and 62.5% were intubated in the delivery room. 30/40 (75%) of intubations were performed with the use of SA. In 18/30 (60.0%) intubations performed with SA, the drug regimen was the association of sufentanil and midazolam. Atropine was given in 19/40 intubations. From the 16, 21 and 3 intubations classified as emergent, semiemergent and non-emergent, respectively, 8 (50%), 19 (90.5%) and 3 (100%) were performed with SA premedication. 79.3% of intubations performed with SA had TRACHEA scores of 3 or less. 22/40 (55%) infants had at least one of the following adverse events: muscle rigidity, bradycardia below 100/min, desaturation below 80% and nose or pharynx-larynx bleeding. 7/24 (29.2%) of those who had only one attempt presented at least one of these adverse events compared with 15/16 (93.8%) of those who needed two or more attempts (p<0.001).Conclusion: SA premedication is largely feasible for tracheal intubations performed in neonates transported by medical transport teams including intubations judged as emergent or semiemergent

Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN)

International audienceContext Laryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates. Methods A group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology. Results Among the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1−), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1−). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided. Conclusion This statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices

Table1_Premedication before laryngoscopy in neonates: Evidence-based statement from the French society of neonatology (SFN).docx

ContextLaryngoscopy is frequently required in neonatal intensive care. Awake laryngoscopy has deleterious effects but practice remains heterogeneous regarding premedication use. The goal of this statement was to provide evidence-based good practice guidance for clinicians regarding premedication before tracheal intubation, less invasive surfactant administration (LISA) and laryngeal mask insertion in neonates.MethodsA group of experts brought together by the French Society of Neonatology (SFN) addressed 4 fields related to premedication before upper airway access in neonates: (1) tracheal intubation; (2) less invasive surfactant administration; (3) laryngeal mask insertion; (4) use of atropine for the 3 previous procedures. Evidence was gathered and assessed on predefined questions related to these fields. Consensual statements were issued using the GRADE methodology.ResultsAmong the 15 formalized good practice statements, 2 were strong recommendations to do (Grade 1+) or not to do (Grade 1−), and 4 were discretionary recommendations to do (Grade 2+). For 9 good practice statements, the GRADE method could not be applied, resulting in an expert opinion. For tracheal intubation premedication was considered mandatory except for life-threatening situations (Grade 1+). Recommended premedications were a combination of opioid + muscle blocker (Grade 2+) or propofol in the absence of hemodynamic compromise or hypotension (Grade 2+) while the use of a sole opioid was discouraged (Grade 1−). Statements regarding other molecules before tracheal intubation were expert opinions. For LISA premedication was recommended (Grade 2+) with the use of propofol (Grade 2+). Statements regarding other molecules before LISA were expert opinions. For laryngeal mask insertion and atropine use, no specific data was found and expert opinions were provided.ConclusionThis statement should help clinical decision regarding premedication before neonatal upper airway access and favor standardization of practices.</p