Carlo BellieniSiena

 Francome (1986) identifies misreading of foetal monitors as a significant factor in explaining why the UK’s caesarean section rate is twice as high as is medically necessary. Sharpe and Faden (believe 

that only the practice of defensive medicine can explain why foetal monitoring, a commonly used diagnostic procedure, has done so little to improve the outcome of ‘high risk’ deliveries, but is strongly 

associated with increased operative delivery rates. Barrett et al. (1990) suggests that as many as a third of all caesarean sections carried out on the grounds of foetal distress may be unnecessary.

Davis-Floyd (1987) describes contemporary western ‘birth culture’ :it both underestimates and undervalues vital psychosocial changes occurring within the woman as she undergoes this important transition in her social status, i.e. from woman to mother. Findings from Oakley’s (1980) study indicate that the routine use of ‘high-

tech’ interventions such as epidural anaesthesia, forceps and caesarean section are closely associated with the incidence of postnatal mood disturbance. She argues that many disturbances in mood are iatrogenic in nature and recommends an end to all unnecessary interventions in childbirth.

Planned home birth in the United States appears to be associated with a two- to threefold increase in neonatal mortality or an absolute risk increase

of approximately 1 neonatal death per 1000 nonanomalous live births. Infants born at home in the United States have an increased incidence of

low Apgar scores and neonatal seizures.

Registered midwives in British Columbia are mandated tooffer women the choice to deliver in a hospital or at home if they meet the

eligibility criteria for home birth defined by the College of Midwifery of British Columbia (Table 1).

As recommended by the AAP and the American Heart Association, there should be at least 1 person present at every delivery whose primary responsibility is the care of the newborn infant. Situations in which both the mother 

and the newborn infant simultaneously require urgent attention are infrequent but will nonetheless occur. Thus, each delivery should be attended by 2 individuals, at least 

1 of whom has the appropriate training, skills, and equipment to perform a full resuscitation of the infant in 

accordance of the principles of the Neonatal Resuscitation Program.

The operational integrity of the telephone or other communication system should be tested before the delivery (as should every other piece of medical equipment), and the weather should be monitored. In addition, a previous arrangement with a medical facility needs to be in place to ensure a safe and timely transport in the event of an emergency.

Subsequent newborn care should adhere to the AAP standards as describedin Guidelines for Perinatal Care as well as to the AAP statement

regarding care of the well newborn infant.

• Transitional care (first 4–8 hours)• Monitoring for group B streptococcal disease• Glucose screening• Eye prophilaxis• Vitamin k• Hepatitis B• Assessment of feeding• Screening for hyperbilirubinemia• Universal newborn screening• Hearing screening• Provision of follow-up care

Travel time from home to the hospital was estimated using the time needed to travel by road between the postal code of the woman’s residence and the postal cod of the Hospital

• Birthing pools were integrated into mainstream maternity care in the United Kingdom in 1992 after a recommendation that all maternity services provide women with the option to labor or deliver in water [1], and their use is supported by national practice guidelines. 

• By 2007, 95 percent of maternity services in the United Kingdom had a birthing pool [5]. 

• In response to professional and maternal concerns about the routine overuse of labor interventions and a decline in the spontaneous birth rate from 76.7 percent in 1990/1991 to 67.7 percent in 2009/2010, a national drive to normalize birth has occurred [6]. Birthing pools are promoted as a care option that increase a spontaneous birth with fewer interventions [7], and are chosen by women primarily as a means of nonpharmacologic pain relief and to facilitate normal birth.s the likelihood that a woman will achieve

• Randomized controlled trials on birthing pool use during the first stage of labor have shown a significant reduction in the use of epidural analgesia, and no adverse maternal or neonatal effects [8]. 

• Observational studies have also shown that women who used a birthing pool were significantly less likely to require labor augmentation or epidural analgesia, or to sustain a perineal tear, and more likely to have a spontaneous birth.

• There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  

• Evidence was mainly limited to single trials. • These interventions relieved pain and improved 

satisfaction with pain relief (immersion, relaxation, acupuncture, local anaesthetic nerve blocks, non-opioids) and childbirth experience (immersion, relaxation, non-opioids) when compared with placebo or standard care.

• This review includes 12 trials (3243 women). Water immersion during the first stage of labour significantly reduced epidural/spinal analgesia requirements, without adversely affecting labour duration, operative delivery rates, or neonatal wellbeing. 

• One trial showed that immersion in water during the second stage of labour increased women’s reported satisfaction with their birth experience. 

• Further research is needed to assess the effect of immersion in water on neonatal and maternal morbidity.

• No trials could be located that assessed the immersion of women in water during the third stage of labour, or evaluating different types of pool/bath.

• There is only 1 report of a randomized, controlled trial (RCT) of underwater birth, but it has not been published in a peer-reviewed journal. This study showed no difference in the number of neonates admitted to a NICU; however, it was not sufficiently powered to evaluate important morbidities (n 120). 

• There have been 6 published RCTs of water immersion during labor. A Cochrane systematic review of 3 of theses trials, involving 988 mothers, found no benefits for pain relief, the course of labor, or perineal trauma for the mother and no differences in neonatal outcomes. The authors concluded that there were insufficient data to evaluate water immersion for labor. 

• Individual case reports of respiratory difficulties, umbilical cord snap, and infections for babies born into water have been published [14-19]. 

• An RCT of water immersion for labor of 274 Australian women also found no benefit for pain relief, the length of labor, perineal trauma, or mode of delivery. However, more neonates born to mothers who labored underwater required oxygen or positive-pressure ventilation in the delivery room compared with the control group (49% vs 35%; relative risk: 1.41). Birth. 2001 Jun;28(2):84-93

• Moreover, critics of water birth have expressed concerns about birthing pool use, namely that it may slow labor progress, mask pain for women who had a previous cesarean section, or increase perineal tears, postpartum hemorrhage, and maternal infection [20-22]. 

Immersion in Water During Labour and Birth (RCOG/Royal College of Midwives Joint Statement No. 1)

Issued April 2006 and valid until April 2009 unless otherwise indicated

• Both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives support labouring in water for healthy women with uncomplicated pregnancies. 

• The evidence to support underwater birth is less clear but complications are seemingly rare. If good practice guidelines are followed in relation to infection control, management of cord rupture and strict adherence to eligibility criteria, these complications should be further reduced.

• The safety and efficacy of underwater birth for the newborn has not been established. 

• There is no convincing evidence of benefit to the neonate but some concern for serious harm.

• Therefore, underwater birth should be considered an experimental procedure that should not be performed except within the context of an appropriately designed RCT after informed parental consent.

• In an effort to support normal labour and birth for healthy childbearing women, a variety of institutional maternity care settings have been constructed. Some are ’home-like’ bedrooms within hospital labour wards. Others are ’home-like’ birthing units adjacent to the labour wards. Others are freestanding birth centres. More recently, ’ambient’ and Snoezelen rooms have been constructed within labour wards; these rooms are not home-like but contain a variety of sensory stimuli and furnishings designed to promote feelings of calmness, control, and freedom of movement.

• Ten trials involving 11,795 women. When compared to conventional institutional settings, alternative settings were associated with reduced likelihood of medical alternative settings were associated with reduced likelihood of medical interventions, increased likelihood of spontaneous vaginal birth, increased interventions, increased likelihood of spontaneous vaginal birth, increased maternal satisfaction, and greater likelihood of continued breastfeeding at one to maternal satisfaction, and greater likelihood of continued breastfeeding at one to two months postpartum, with no apparent risks to mother or baby. two months postpartum, with no apparent risks to mother or baby.

• We conclude that women and policy makers should be informed about the benefits of institutional settings which focus on supporting normal labour and birth.

CONCLUSIONE

Quando usare alternative alla SP?Non c’è un vantaggio provatoC’è un vantaggio provato

Non ci sono rischi**Ci sono rischi

Serve ulteriore sperimentazione

OK all’uso

Scelta della paziente

↓Rischi se selez popolazionee garanzie*

Rischi fissi

*N. basso rischio, personale, logistica (CASA)Prima fase del parto (ACQUA)

**CASA-PARTO