J Gynecol Obst Bio R
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J Gynecol Obst Bio R · Jun 2004
Review[Evaluation of cesarean rate: a necessary progress in modern obstetrics].
During the last 10 Years, the cesarean section (CS) rate was increased despite of the recommendations of the World Health Organization to keep it below 10-15%. The purpose of this review of the literature was to demonstrate how the concept of CS rate limitation has become obsolete. The increase in the CS rate is mainly justified by the decrease in maternal mortality and morbidity following elective CS: surgery-related risks have decreased and the confusion that was made between the risks of vaginal delivery and those of trial of labor has to be clarified to show that maternal mortality and morbidity are not increased by elective CS. ⋯ The rising duty to provide information to patients in high risk obstetrical situations such as a history of CS also contributes to the overall increase in CS rate mainly through the elective CS rate. Indeed, when faced with the alternative choices of potentially severe complications either for themselves or their child, women are likely to choose what appears to be the safest mode of delivery for their child and thus to opt for a CS. Finally, widespread delivery of information to the patients about trial of labor itself and the risks of vaginal delivery is the first step towards a "principle of preference", which consists in giving an important place to the patient's choice in the decision-making process, and thus to recognize her right to ask for an elective CS.
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Labor pain is of major concern since most parturients experience significant pain of extremely severe intensity for many. The purpose of this review was to provide an overview of the mechanisms and pathways of labor pain (including new insights on integration of the nociceptive signal) and to emphasize the need of effective labor pain relief. ⋯ Despite its complex pathophysiology, labor pain can be efficiently managed. Thanks to multidisciplinary care, obstetric analgesia (mainly epidural analgesia) prevents deleterious effects of labor pain on the mother and fetus.
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J Gynecol Obst Bio R · Feb 2004
Review[Cancer and pregnancy: risks of exposure to cancer chemotherapy during pregnancy].
Animal studies reveal that almost all antineoplastic agents are teratogenic. But extrapolation to human beings is not simple because of species differences. ⋯ Adverse effects observed in adult and children are helpful if data during fetal life are lacking. Long-term studies are needed to evaluate the transplacental effects of chemotherapy during pregnancy; these studies should assess the child's mental and physical development, infertility and the occurrence of second malignancies.
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J Gynecol Obst Bio R · Feb 2004
Review[Extremely preterm infants: resuscitation criteria in the delivery room and dialogue with parents before birth].
The resuscitation of extremely preterm infants presents complex medical, social and ethical issues for the families and the health professionals. The principle of a systematic resuscitation "temporary intensive care" does not prohibit the question of a limit in terms of gestational age and birth weight. In France, a do not resuscitate order (comfort care alone) is appropriate for newborns weighing less than 500g and/or with a gestational age of less than 24 weeks' since the mortality is nearly 100%. ⋯ The physician should follow the parents' desires whenever the parents' decision would not obviously violate the infants' best interests. However, they must be informed that decisions about neonatal management made before the delivery can have to be changed in the delivery room, depending on the condition of the neonate at birth. At 25 weeks of gestational age, the prognosis is better and the resuscitation should be more intensive.
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Early administration of analgesics, generally before awakening from general anesthesia is useful to improve the patient's comfort in the post-anesthesia care unit (PACU). Multimodal analgesia includes administration of several analgesics from different pharmacological classes but in almost every combination, morphine or one of its derivatives is included. In the PACU, morphine is titrated using the intravenous route to obtain adequate and rapid pain relief. ⋯ Morphine is often applied using a patient-controlled analgesia device (PCA). After major surgery (especially after radical surgery for malignant disease), intrathecal or epidural analgesia, using a local anesthetic and an opioid is extremely efficient and is combined with other analgesics. Finally, because the affective dimension is extremely important after gynecologic surgery (especially in mutilating interventions), psychologic preparation, patient information and communication are essential components of care.