Les pratiques obstétricales utilisées lors des accouchements sont nombreuses et certaines peuvent avoir un impact sur son déroulement ainsi que sur les issues maternelles et foetales. Durant le travail, ces pratiques reposent sur l’utilisation de différentes positions ou de techniques antalgiques pharmacologiques (analgésie péridurale, protoxyde d’azote) ou non (déambulation, utilisation de la baignoire, de la douche, du ballon etc.). Au moment de l’accouchement, il existe également différentes techniques de poussée, de maintien de la tête foetale, de soutien périnéal ou encore différentes positions d’accouchement. Cependant, à ce jour, ces pratiques ne sont pas ou très peu étudiées en France et ne répondent à aucune recommandation pour la pratique clinique. Dans le premier volet de cette thèse (n=1496), nous avons réalisé un état des lieux des pratiques déclarées par les sages-femmes et étudié si les pratiques différaient en fonction du lieu d’exercice et de l’ancienneté. Les sages-femmes françaises proposaient largement le recours à l’analgésie péridurale, surtout celles exerçant en maternité de type II ou III. Le décubitus latéral était la position préférée des sages-femmes durant le 1er stade avec analgésie péridurale et durant la phase de descente du 2ème stade. Pour l’accouchement, la plupart des sages-femmes conseillaient des positions en décubitus. La poussée en bloquant était celle la plus conseillée par les sages-femmes et majoritairement par celles ayant ≤ 5 ans d’ancienneté. Ces données ont montré que les pratiques des sages-femmes françaises étaient hétérogènes et variaient selon le niveau des maternités et l’ancienneté des sages-femmes. Notre deuxième volet repose sur un essai randomisé multicentrique (n=250) dont l’objectif principal était d’évaluer l’efficacité de la poussée dirigée à glotte ouverte vs celle à glotte fermée. Le critère de jugement principal était un critère de jugement composite : accouchement spontané, sans lésion du périnée (épisiotomie ou lésion spontanée des 2ème, 3ème ou 4ème degrés). Les femmes éligibles étaient celles ayant suivi intégralement la séance de formation aux types de poussées, avec une grossesse monofoetale en présentation céphalique, un accouchement par voie basse acceptée, admises en maternité entre 37 et 42 semaines d’aménorrhée pour un travail spontané ou induit, à partir d’une dilatation cervicale utérine ≥ 7 cm. Les critères d’exclusion étaient une pathologie contre-indiquant des efforts expulsifs ou un antécédent d’utérus cicatriciel, ou une anomalie du rythme cardiaque foetal avant la randomisation. Nous n’avons pas retrouvé de risques absolus ou bruts statistiquement différents en terme d’efficacité de la poussée, ni sur la morbidité maternelle (déchirures périnéales sévères ou hémorragies du post-partum) et néonatale immédiate (pH défavorable). Après prise en compte des facteurs de confusion et des facteurs pronostiques cliniquement pertinents, l’efficacité de la poussée n’était pas, non plus, statistiquement différente entre les deux types de poussées (RR ajusté : 0,92 [IC95% : 0,74-1,14]). En conclusion, les pratiques maïeutiques différent durant l’accouchement en France et il n’y a pas lieu de conseiller un type de poussée plutôt qu’un autre. Les femmes doivent, toutefois, être informées des différentes positions et des types de poussées lors des préparations à l’accouchement et doivent pouvoir choisir la position et la poussée qui leur conviennent, voir en changer, au cours du travail (Fédération Internationale de Gynécologie Obstétrique, 2012). / Many different obstetric practices are used during delivery, and some of them can affect the course of labor and delivery as well as maternal and fetal outcomes. During labor, these practices mainly concern the use of different positions and of analgesic techniques, both pharmacological (epidural analgesia, nitrous oxide) or not (walking, water immersion in a pool, large tub, or shower, birthing balls, etc.). At delivery, there are also different techniques of pushing, of fetal head management, perineal support, and birthing positions. Nonetheless, until now, the use of these practices in France has been studied little if at all, and there are no Clinical Practice Guidelines to help midwives choose their practices based on scientific evidence.The first component of this dissertation describes our inventory of practices reported by midwives (n=1496) and examines whether these practices differ as a function of either place of practice or experience. French midwives very frequently offer women epidural analgesia, especially those practicing in level II or III maternity units. Lateral decubitus was the position midwives preferred during the first stage for women with epidural analgesia and during the descent phase of the second stage. For delivery, most midwives advised decubitus positions. Pushing with Valsalva breathing was advised most often, mostly by midwives with ≤ 5 years of experience. These data show that French midwives use heterogeneous practices that vary according to the maternity unit level and the midwife's experience.The second component of this dissertation is based on a multicenter randomized trial (n=250) to assess the effectiveness of directed pushing when used with open glottis or closed glottis (Valsalva) breathing. The principal endpoint was a composite criterion: spontaneous delivery without perineal lesion (episiotomy, or spontaneous 2nd, 3rd, or 4th degree lacerations). Women were eligible if they have taken an antenatal class that includes a specific training in the types of pushing, and had a singleton pregnancy in cephalic presentation, planned vaginal delivery, and were admitted to the maternity ward between 37 and 42 weeks of gestation in spontaneous or induced labor when cervical dilation was ≥ 7 cm. The exclusion criteria were a disorder contraindicating expulsive efforts, previous cesarean or other uterine scar, or a fetal heart rate anomaly before randomization. The unadjusted analysis show no difference between the groups in the effectiveness of pushing, in maternal morbidity (severe perineal lacerations or postpartum hemorrhage), or immediate neonatal morbidity (unfavorable pH). After adjustment for confounding factors and clinically relevant prognostic factors, there was still no statistically significant difference in the effectiveness of the type of pushing (RR adjusted: 0.92, 95% CI 0.74-1.14).In conclusion, midwifery practices during delivery in France differ, and there is no evidence to recommend one type of pushing over another. Women must nonetheless be informed about the different positions and types of pushing during their preparation for delivery and must be able to choose the position and type of pushing they prefer, and be able to change it, during labor (International Federation of Gynecology and Obstetrics, 2012).

Made available in DSpace on 2016-06-02T19:46:32Z (GMT). No. of bitstreams: 1 592.pdf: 666034 bytes, checksum: a7eb721ac07da78d431e418a8eeadcfc (MD5) Previous issue date: 2005-02-28 / Financiadora de Estudos e Projetos / The repertoire of social skills of blind and sighted children can be different from each other, inasmuch as the absence of the sense of sight prevents the blind children from using the same resources as those commonly used by the sighted ones, for example the visual imitation in the process of learning social skills and behaviors. The area of Social Skills Training (SST) was the theoretical and practical reference for this study, whose general aim was to describe and characterize the social performances of two identical twins aged ten years old: Célia, who is blind; and Virna, who is sighted. In addition, the beliefs and educational practices of their mother, who is their main caregiver, were identified. The data were obtained by conducting an interview with the mother as well as by filming the children during free situations. A transcript was made of the mother s answers to the questions from the interview script, and then the content was analyzed by theme. According to a protocol for observing the free situations, the films were assessed so that the children s performances enabled to infer the categories of social skills. The results showed that the mother considers that Virna is more independent to perform certain activities, while Célia requires more care and attention, besides being more subject to restrictions. The results also showed that the sighted child presented a wider and more refined repertoire of social skills in relation to her sister. From the data, it is possible to conclude that blind and sighted children have distinct social skills repertories, and the existing differences can be related to the blind variable as well as to the differences in the way the caretaker stimulates the children. Therefore, it is considered important to plan programs aiming to maximize the social development of visually impaired children, including social skills training and advices for the caregivers. / O repertório de habilidades sociais de crianças cegas e videntes pode ser diferente, uma vez que a ausência do sentido da visão impede que as crianças cegas utilizem recursos comumente utilizados pelas crianças videntes, como, por exemplo, a imitação visual durante o processo de aprendizagem de habilidades e comportamentos sociais. A área do Treinamento de Habilidades Sociais (THS) foi a referência teórica e prática do presente estudo, cujo objetivo geral foi o de descrever e caracterizar o desempenho social de duas crianças, gêmeas idênticas, com dez anos de idade: Célia, que é cega; e Virna, que é vidente. Além disso, foram identificadas as crenças e práticas educativas da mãe, principal cuidadora dessas crianças. Os dados foram obtidos por meio da realização de uma entrevista com a mãe, bem como por meio de filmagens das crianças em situações livres. As respostas da mãe referentes às questões do roteiro de entrevista foram transcritas, procedendo-se, então, uma análise de conteúdo por tema. A filmagem foi avaliada de acordo com um protocolo de observação das situações livres, de modo que os desempenhos das crianças possibilitaram inferir as classes de habilidades sociais. Os resultados mostraram que a mãe considera que Virna é mais independente ao desempenhar determinadas atividades, enquanto que Célia requer maior número de cuidados, além estar sujeita a um número maior de restrições. Os resultados mostraram, ainda, que a criança vidente apresentou repertório de habilidades sociais mais amplo e refinado do que o de sua irmã. Com base nos dados, é possível concluir que crianças cegas e videntes possuem repertórios de habilidades sociais distintos, sendo que as diferenças existentes podem estar relacionadas tanto à variável cegueira quanto às diferenças na maneira como a cuidadora estimula as crianças. Dessa forma, considera-se indicado o planejamento de programas que visem maximizar o desenvolvimento social de crianças deficientes visuais, incluindo os de treinamento das habilidades sociais e de orientação para pais.

Introduction : Le cadre de la gouvernance clinique a été développé afin d’atteindre de hauts standards de qualité de soins et de services, en conjuguant les notions d’amélioration continue de la qualité, d’excellence clinique et d’imputabilité corporative. La présente démarche doctorale avait pour objectif de comprendre le processus d’institutionnalisation de la gouvernance clinique dans un centre de réadaptation. Méthodologie : Une synthèse méta-narrative de 65 documents répertoriés dans 4 bases de données bibliographiques sur la conceptualisation et la mise en œuvre de la gouvernance clinique a été menée. Une étude qualitative de cas unique a été menée dans un centre de réadaptation en déficience intellectuelle et en troubles du spectre de l’autisme, au Québec (Canada). En mobilisant les cinq construits du cadre conceptuel basé sur théorie du processus de normalisation (cohérence, participation cognitive, action collective, suivi réflexif et contexte organisationnel), une analyse thématique des entrevues individuelles auprès de 22 participants (5 administrateurs, 11 gestionnaires et 6 cliniciens) et de 3 groupes de discussion auprès de 8 cliniciens et de 4 proches d’usagers a été menée. Enfin, une analyse d’une centaine de documents administratifs du Centre a été effectuée. Résultats : L’analyse de la littérature a permis de constater que le cadre de la gouvernance clinique est un concept en évolution et encore perçu comme une avenue intéressante pour l’amélioration de la qualité des soins. Toutefois, la confusion autour de sa définition et de sa conceptualisation ainsi que les difficultés de sa mise en œuvre demeurent des enjeux pour les organisations. Par la mobilisation du cadre de gouvernance clinique, la haute direction du centre de réadaptation à l’étude a souhaité systématiser le processus d’amélioration continue de la qualité des services offerts aux usagers et à leurs proches par l’adoption des bonnes pratiques de gouvernance. Ce virage a été bien reçu par les administrateurs et les gestionnaires, résultant sur une participation active et un fort engagement aux activités de leur part. La complexité du cadre et l’absence d’implication des cliniciens dans le processus de mise en œuvre ont créé chez ces derniers une appréhension quant à l’apport de la gouvernance clinique pour la pratique clinique et le bien-être des usagers. Les cliniciens ont dénoncé l’absence d’arrimage entre la théorie et les réalités de la pratique clinique ; la grande vitesse d’implantation et une approche décisionnelle de type top-down comme des enjeux de l’institutionnalisation de la gouvernance clinique. Pour les gestionnaires, les défis ont été la mise en place des moyens de communication efficaces ; l’arrimage des mécanismes de gestion et la disponibilité des ressources humaines. Pour les administrateurs, l’enjeu principal a été l’instabilité des contextes organisationnels interne et externe qui a ralenti la mise en œuvre et freiné l’élaboration d’un processus évaluatif. Conclusion : L’institutionnalisation de la gouvernance clinique dans les établissements non hospitaliers offrant des services sociaux passe par la valorisation de ce concept comme un projet commun au bénéfice de l’usager en vue de renforcer la participation et l’engagement de tous et l’adoption d’une approche de partenariat entre les usagers, leurs proches et les autres acteurs de l’organisation. / Introduction: Clinical governance framework was developed in order to achieve high standards of quality of care and services, by combining the concepts of continuous quality improvement, clinical excellence and corporate accountability. The aim of this doctoral thesis was to understand the implementation process of clinical governance in a rehabilitation center. Methods: A meta-narrative synthesis on the conceptualization and implementation of clinical governance was conducted. 65 tittles screened in 4 international databases were analysing. A qualitative single case study was conducted in a rehabilitation center for intellectual disabilities and autism spectrum disorders, in Quebec (Canada). By mobilizing the five constructs of the conceptual framework based on normalization process theory (coherence, cognitive participation, collective action, reflexive monitoring and organizational context), a thematic analysis of individual interviews with 22 participants (5 administrators, 11 managers and 6 clinicians) and tree focus groups with 8 clinicians and 4 relatives of users were conducted. Finally, an analysis of around hundred administrative documents from the Center was conducted. Results: The literature revealed that the clinical governance framework is an evolving concept and still seen as an interesting avenue for improving the quality of care. However, confusion over its definition and conceptualization, and the difficulties of its implementation remain challenges for organizations. By mobilizing the clinical governance framework, the senior management of the rehabilitation center under study wished to systematize the process of continuous improvement of quality of services offered to users and their families, by adopting good governance practices. This shift was well received by administrators and managers, resulting in active participation and a strong commitment to activities. The complexity of the framework and the absence of involvement of clinicians in the implementation process have created in them an apprehension regarding the contribution of clinical governance to clinical practice and the well-being of users. Clinicians have criticized the lack of alignment between theory and the realities of clinical practice; the high speed of implementation and a top-down decision-making approach as issues of the implementation of clinical governance. For managers, the challenges have been the establishment of effective communications; the alignment of management mechanisms and the availability of human resources. For administrators, the main issue was the instability of the internal and external organizational contexts which slowed down the implementation and the development of an evaluation plan. Conclusion: The implementation of clinical governance in non-hospital facility requires the promotion of this concept as a joint project for the benefit of the user with a view to strengthening the participation and commitment of all and the adoption of a partnership approach between users, caregivers and other actors in the organization.