077 Results of an evaluation of clinical practice concerning the management of heart rate anomalies during labour

Peripartum foetal asphyxia may lead to cerebral motor infirmity due to hypoxic and ischaemic encephalopathy. This cerebral motor infirmity has severe social, familial and medicolegal consequences, as it is one of the two leading reasons for filing a legal complaint, and is a burden on public health expenditure (costs of managing affected children). The aetiology of this encephalopathy is difficult to determine and is, in most cases, antenatal. Prevention is possible, through improvements in the management of patients during labour based on the analysis of foetal heart rate. One of the essential criteria for attributing neonatal encephalopathy to peripartum asphyxia is a pH in the umbilical artery below 7.0. Midwives attended a theoretical training course on peripartum heart rate at the maternity unit. This led to a significant decrease in the number of cases in which an umbilical artery pH below 7.0 was recorded. To confirm these findings, we set up a procedure for evaluating professional practices based on a retrospective analysis of obstetric files for cases in which an umbilical artery pH below 7.0 was recorded. Every month, the files concerned are analysed by the doctors and senior staff of the department. For each file, we complete a computerised data form covering 14 analytical criteria based on: Peripartum foetal heart rate (continuous recording, anomalies identified and characterised). The study of uterine contractions (interpretable recordings, anomalies identified, possibility of analysing foetal heart rate as a function of contractions). Determination of pH in utero in accordance with the recommendations of the CNGOF (indication, decision after noting the results). Why the doctor was called (as a function of heart rate or pH when carried out). Time between the decision to operate being taken and extraction, in cases of Caesarean section. At the end of the year, four indicators are calculated: The percentage of heart rate anomalies for which continuous recordings were made. The percentage of anomalies characterised. The percentage of anomalies justifying pH measurement for which this indication was retained. The number of cases of Caesarean section for which the interval between the decision to operate being taken and extraction exceeded 20 min. An analysis of these indicators in 2008 identified several improvements that could be made. Colour codes according to the urgency of the Caesarean section were introduced, and a new training session on foetal heart rate for midwives was programmed for 2009 (in one quarter of cases, the heart rate anomalies were not characterised, contraction anomalies were not identified and pH tests were not carried out). The indicators for 2009 will be calculated at the end of December. This institutional approach has led to a decrease in the number of cases in which an umbilical artery blood pH below 7.0 is recorded (from 0.71% in 2006, to 0.54% in 2007 and 0.57% in 2008). Despite the low frequency with which a pH below 7.0 in the umbilical artery is recorded, the particular gravity of the consequences of this phenomenon and the margin for possible improvement justify the implementation, in maternity units, of a procedure for evaluating professional practices or a review of morbidity and mortality. L9asphyxie fœtale per-partum a pour consequences potentielles possibles une infirmite motrice cerebrale par encephalopathie hypoxique et ischemique. Cette infirmite motrice cerebrale est lourde de consequences sociales et familiales, medicolegales puisqu9elle constitue l9une des deux premieres causes de plainte, et en terme de sante publique (cout de prise en charge des enfants). L’etiologie de cette encephalopathie est difficile a preciser et est dans la majorite des cas antenatale. Une prevention est possible par une amelioration de la prise en charge des patientes pendant le travail, basee sur l9analyse du rythme cardiaque fœtal. L9un des criteres essentiels permettant d9attribuer une encephalopathie neonatale a une asphyxie perpartum est un pH arteriel realise sur l9artere ombilicale inferieur a 7.0. Apres une formation theorique des sages-femmes du centre la naissance sur la rythmologie per-partum, une diminution significative des pH arteriels inferieurs a 7.0 l9annee suivante a ete enregistree. Afin de conforter ce resultat, nous avons mis en place une procedure d’evaluation des pratiques professionnelles basee sur l9analyse retrospective des dossiers obstetricaux pour lesquels les enfants presentaient un pH sur l9artere ombilicale inferieur 7.0. Tous les mois, une analyse des dossiers concernes est realisee par les medecins et les cadres du service. Pour chaque dossier est etablie une fiche de recueil informatisee comprenant 14 criteres d9analyse bases sur: Le rythme cardiaque fœtal per-partum (enregistrement continu, anomalies signalees et caracterisees). L’etude des contractions uterines (enregistrement interpretable, anomalies identifiees, rythme cardiaque fœtal analysable en regard des contractions). La realisation d9un pH in utero conformement aux recommandations du C.N.G.O.F (indication posee, decision apres resultats notee). L9appel du medecin (en fonction du rythme ou du pH s9il est realisable). Le delai decision-extraction en cas de cesarienne. En fin d9annee est etabli un tableau de bord base sur 4 indicateurs: Pourcentage d9enregistrements continus sur le total des anomalies de rythme. Pourcentage d9anomalies caracterisees sur le total des anomalies. Pourcentage d9indications de pH posees sur le total des anomalies le justifiant. Nombre de cas de cesariennes avec delai decision-extraction superieur a 20 minutes. L9analyse du tableau de bord en 2008 a permis de mettre en evidence des axes d9amelioration. Des codes couleur en fonction du degre d9urgence de la cesarienne ont ete mis en place et une nouvelle cession de formation des sages-femmes sur l9analyse du rythme cardiaque fœtal a ete programmee en 2009 (dans un quart des cas les anomalies du rythme n’etaient pas caracterisees, les anomalies de contractions non identifiees et les pH non faits). L9analyse du tableau de bord de 2009 sera cloturee fin decembre. Cette demarche institutionnelle a permis une diminution du nombre de pH inferieurs a 7.0 (de 0.71% en 2006 a 0.54 puis 0.57% en 2007 et 2008). Malgre la faible frequence des pH inferieurs a 7.0, la particuliere gravite des consequences et les marges d9amelioration possibles rendent legitime la mise en place dans les centres de naissance d9une procedure d’evaluation des pratiques professionnelles ou d9une revue de morbi-mortalite.