THe more recent achievements and warnings about giving birth outside the hospital (with a recommendation: the safest way is the hospital).

1. Carlo Bellieni
Siena

4. misreading of foetal monitors
Francome (1986) identifies
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
foetal monitoring
that only the practice of defensive medicine can explain why
, a commonly used
diagnostic procedure, has done so little to improve the outcome of ‘high risk’ deliveries, but is strongly
a third
of all caesarean sections carried out on the grounds of foetal
distress may be unnecessary.
associated with increased operative delivery rates. Barrett et al. (1990) suggests that as many as
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 ‘hightech’ 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.

10. 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 to
offer 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).

11. 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.

12. Subsequent newborn care should adhere to the AAP standards as described
in 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

13. 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

16. •
•
•
•
•
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.

17. • 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, nonopioids) and childbirth experience (immersion,
relaxation, non-opioids) when compared with placebo
or standard care.

18. • 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.

19. •
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.

21. • 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].

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.

23. • 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.

25. 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 interventions,
increased likelihood of spontaneous vaginal birth, increased maternal satisfaction,
and greater likelihood of continued breastfeeding at one to 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.

26. CONCLUSIONE

27. Quando usare alternative alla SP?
Non c’è un vantaggio provato
C’è un vantaggio provato
Non ci sono rischi**
Ci sono rischi
OK all’uso
↓Rischi se selez popolazione
e garanzie*
Scelta della paziente
*N. basso rischio, personale, logistica (CASA)
Prima fase del parto (ACQUA)
**CASA-PARTO
Rischi fissi
Serve ulteriore
sperimentazione