Nascere nell’acqua : revisione della letteratura in merito al travaglio e parto in acqua e realizzazione di un Percorso Diagnostico Terapeutico Aziendale (PDTA)

Waterbirth. The use of water as a therapeutic instrument is not new. Its origins are still unknown, however we know that water immersion was already used to treat physical and psychological illness in ancient Chinese, Egiptian, Japanese and Assyrian populations, as well as in ancient Rome and Greece (Reid Campion 1990; Reind Campion 1997). Water has always been considered as the eternal source of life. At the same time, immersions in hot water during labour and birth as an instrument for relaxation and reduction of pain have their origins in the past. This type of birth was promoted for the first time by the Russian doctor Igor Tjarkowskij in 1970, then it was consolidated and sustained by a second doctor, Michel Odent, in 1980. Even though they were considered an ephemeral trend by some, labour and birth in water began to attract both women and couples, mainly those who were looking for an experience that put the woman in the middle, had limited medical interventions and was as physiological as possible. In the UK in 1993, water became a recognized and sustained method of pain control during the first and second stage of labour: the tub would become an available option for all British clinics. In 1994, “The Royal College of Midwives”, “The United Kingdom Central Council for Nursing, Midwifery” and “Health Visiting” showed their official position about waterbirth, explaining that they were in favour of it and defining it as field of midwifery competence. In 1995, there was the first international conference about waterbirth in London. (1) Since then, many studies and many researches have been conducted upon the matter, showing the relative risks and benefits. The majority of the reviews inspected (1, 2, 3, 4, 5, 6, 7), one of which was a study conducted in Sweden on 306 waterbirths and 306 not in water (8), registered a lower number of first and second-degree tears, a shorter labour, less medical interventions and less cases of dystocia. All of this could be a consequence of vasodilatation due to heat, or it may be a result of the type of midwifery assistance offered during waterbirths, “wait and see” instead of “directive”, or perhaps it could be because of the buoyancy effect caused by water which would reduce the pressure of the foetus on the perineal tissues. It has been demonstrated that the effect of water can reduce the weight on the pelvis and the force of gravity that acts on it; this would determine a relaxation and stretching of the pelvis muscle-beam-connective components, it would increase the perineal elasticity by reducing tears and limiting the need for episiotomies. This aspect, together with the lower request for analgesia, lower oxytocin administration and amniotomy executions, have been highlighted from this study, but also from others that were executed in Italy or by “The American College of Obstetricians and Gynecologists”. The buoyancy and the tissues and sustaining structures relaxation allow for a better perfusion and oxygenation of the uterine muscle and the foetus, they favour the maternal movement and the release of endorphins and natural oxytocin, making the contractions less painful. Moreover, the increased possibility of movement would be able to improve the adaptation of the foetus to the maternal pelvis and stimulate the flexion of the presented part. An interesting aspect has been considered by a comparative study conducted in Sweden (8) and by a review proposed by the Cochraine Library (1) which underline how waterbirth increases the maternal level of satisfaction, probably thanks to the higher degree of relaxation, understanding of the situation and self-control that it determines. Another review conducted by Groves Alison in 2019 (3), underlines how, besides the augmented satisfaction of the parents, waterbirth leads to a higher satisfaction of the midwives, which is probably a consequence of the continuous assistance that this kind of birth needs, meaning that it allows for the creation of more wide/intimate/warm bonds with the couples. Regarding the neonatal outcomes, studies have declared that there are no significant additional risks linked to this type of birth; there is no evidence of waterbirth leading to bad outcomes for the mother or the child. Having the second stage of labour in water does not increase the probability of admission to NICU or receiving a bad Apgar score in the 5th minute of life. The aspects that deserve more attention are the actual risk of umbilical cord avulsion, the risk of maternal and foetus infections, which means that the correct hygienical and preventive norms must always be observed, the risk of breathing problems and water ingestion, which are very rare thanks to the presence of active laryngeal chemoreceptors also in the newborn, and finally the risk of developing thermoregulation problems. The last risks reported in the literature concern the possibility of slipping while entering or exiting the tub and the worst risk of uterine extra extension in post-partum due to the warm water effect. (1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14) Since waterbirth is associated to a very physiological assistance during first and second stage of labour and is against some medical practices (i.e. continuous monitoring of foetal heart rate, amniotomy, oxytocin administration) it is necessary for the women who choose this type of labour and/or birth to be inside specific categories of access, which must be accurately defined by the hospital guidelines. In general, waterbirth is possible for all low-risk pregnancies with a gestational age between 37 and 42 weeks, no foetal or maternal pathologies and no epidural analgesia. Once the eligibility of the woman for waterbirth is established, this must be managed with maximum respect for the physiology and the natural timing, while at the same time granting an accurate monitoring of the woman and her child. It is necessary to regulate in a precise way the water temperature, different from first and second stage of labour, monitoring and register at regular intervals the parameters of the woman and auscultate intermittently (if possible) the foetus heart rate. In these occasions, it is good practice to advise the woman to empty the bladder and walk to change her position and interrupt temporarily the effects that warm water can have on the skin, circulation and body temperature. It is important to favour the spontaneous hydration to contrast the loss of liquids consequent to the water immersion and a light diet to prevent fasting. The second stage of labour begins once the dilatation is complete and the urge is sustained: the presence of two midwives, one of whom should be an expert of waterbirth, is highly recommended at this stage. This stage of labour is conducted in the woman’s preferred position, who is invited to spontaneously push following her sensations. The midwife limits her assistance to labour to the observation of the progression of the foetus with a mirror: when the expulsion of the foetus is complete, the midwife slowly accompanies the newborn to the surface without exercising any traction on the umbilical cord. If the chord is too short to allow for the rise of the newborn, it is necessary to prematurely cut it or to make the woman stand up. It is fundamental not to douse the child again after his head has emerged: this could interfere with breathing and the immersion reflexion. (11) In physiological conditions, one must proceed with the third stage inside water, securing an adequate skin-to-skin contact with the newborn, who must remain immersed until the shoulders.If the hematic loss is too abundant and/or an active assistance for the third stage has been chosen, it is important to carry the woman out of water. (2, 11, 12, 16). It can be stated that in order to reduce to the minimum the risks and difficulties related to the waterbirth, it is necessary to establish adequate process for the selection of low risk pregnancies, grant maximum efficacy and cleanness in the pools and the tubes connected to them, create control procedures for possible infections, monitor the parameters and vital conditions of the woman and the foetus at intervals, grant to women the possibility to exit the water and being assisted in the shortest time possible in the case of complications. (The American College of Obstetricians and Gynecologists). Moreover, the possibility of waterbirth should already be discussed with women during pregnancy, correctly notifying them about the benefits and risks related to this decision, allowing them to make an informed choice. Starting from these instructions suggested by “The American College of Obstetricians and Gynecologist”, the aim of this elaborate is to write a process to regulate the management of waterbirth