> Giving birth in myths and reality on childbirth: the midwife and the epidural

Birth and the epidural. About some common places reported in the newspapers, in forums, in a recent hearing of experts in the Parliament, ‘ to be Born safe.” The midwife and epidural

“The birth is physiological only in retrospect…”

The fact that pregnancy and labor it is appropriate for the woman to undergo repeated checks of health, contrary to what we normally do in our everyday life if we are good, indirectly makes us say that pregnancy and childbirth are not only an expression of well-being, but can also be a source of adverse events that are suddenly emerging.

But in developed Countries the share of labors in which is really this disease is low (it is difficult to quantizzarne the prevalence perché depends on the definition itself of the disease) and the proportion of trials in which a disease manifests itself suddenly in an unpredictable manner is exceptional (e.g. In an analysis of all births occurred at the hospital of Monza from 1-1-1995 to 31-12-1999 divided by risk è found 1 case/6932 travails classified a priori at low risk and managed by midwives on the basis of precise guidelines, which has required intensive care neonatal unexpectedly).

è, therefore, justified the alarmism that invests equally all births and that leads to subject every woman to a quantity; and qualityà of controls are useful only in cases that are pathological or at risk. We must not forget that a procedure that you è proved to be useful in the pathology of può be iatrogenic in physiology.

A model of care that differentiates the women for risk factors, and who do not undergo diagnostic or therapeutic procedures women without specific risk factors, improves outcomes for maternal and neonatal strengthens the perception of well-being of the woman, saves the companyà, it contrasts the current culture in which, compared to a net improvement in health indicators, there is a subjective perception always più spread of the disease.

“The support midwife in the hospital always provides the best outcomes in maternal and neonatal…”

In the face of the awareness of how some of the interventions that have definitely improved the health of the woman and the infant in pathological conditions (the use of the active treatment drug in the 3° stage, the use of the surfactant in the premature, quick access to laboratory tests and the use of blood products, to the theatre,..) often there is the same consciousness as the excess of medicalization in the sufferings physiological can be a iatrogenic one.

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3 examples:

  • the routine use of theoxytocin in the period of expulsion for bringing back the times of the second stage within the limits arbitrarily laid down, even in the presence of a fetal well-being, increases the incidence of abnormalities of the CTG, which result in an increased appeal to the birth operative vaginal or caesarean section;

  • liberal use/routine use of episiotomy in order to reduce trauma to the perineal area and promote the well-being of newborn at birth is supported by evidence from the literature, recommending instead use restrictive of the same. The use of restrictive (conducting only in the presence of the alterations in pathological CTG or signs of severe tearing) increases the chanceà to have the perineum intact (30% vs 10%), increases the chanceà to have only a laceration of 1° degree ( 39% vs. 13%), reduces blood loss post-partum, promotes a more speedy and satisfactory resumption of sexual relations;

  • the routine use of an active assistance on the part of the midwife to facilitate the disengagement of the shoulders, immediately after that è was the expulsion of the head, without waiting for the return, and the rotation of the spontaneous of the shoulders, and increases the chanceà to determine a fracture of the clavicle in the newborn (2% vs 0.3%) and favors the appearance of dystocia of the shoulders (3% vs 0.2%). The return rotation of the the spontaneous happens in the majority of cases (80%) after the first contraction, and at an average distance of 90 seconds.

” The support midwife in the hospital è più safe with respect to the domicile or to the houses of maternityà…”

Although in Italy the request of childbirth at home is a required niche and the Houses of Maternityà are not a reality; organizational assistance in the expansion, there is considerable suspicion on the part of all operators of hospitals on the safety of these choices for the health of the woman and of the newborn, and a deterrent active with regard to women-oriented this choice.

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the current state of knowledge, there are no studies that are valid conclusive on the subject, but the long Dutch experience (where, even today, 25% of women deliver at home) and più observational clinical studies have highlighted as the mother and the fetus are carefully selected for a birth at home or in Unità obstetric physiology out of the hospital, assisted by experienced midwives, have a probability; lower, compared to a woman equally low-risk birth in hospital, to be the subject of obstetric interventions, without disadvantages for the health of the newborn and of the mother.

Più recently, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives, the United Kingdom, in a joint document (April 2007) conclude that there are reasons for it to not offer the possibilityà of the births at home to women at low risk of complications, having regard to the favourable ratio of benefits/risks of this intervention.

The document currency that the evidence available to demonstrate the safety of the option home to many of the selected women not only in terms of physical safety, but also for those elements that affect the well-being emotional and psychological.

In Italy, the prejudice against the birth of extra-hospital, the not habit to distinguish the risk groups and the belief that caesarean section is a modeà birth safe is sì that there is the same mistrust and deterrence vis-à-vis women, likely to healthy and at term of pregnancy, who choose to give birth in small reality; hospital, public and private & lt; 400 parts.

The national data from the time reveal how in this reality the rate of caesarean sections is significantly higher than that of hospitals with a number of parts to > 2500, which probably focuses the pathology and maternal mortality (60% vs 30%).

“analgesia epidural is good for the fetus…”

analgesia, epidural has beneficial effects on maternal health, in some conditions, the midwives, such as the presence of hypertension/pre-eclampsia, dyskinesia/tachisistolia uterine, needà of the early use of oxytocin (for induction, or acceleration of labor).

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In these conditions, even the fetus has the benefits of the procedure analgesic for the improvement of the circulation in the placental by vasodilation, reduction of secretion of catecholamines resulting in the improvement of foetal oxygenation and reduction of metabolic acidosis at birth.

But, sinceé each medical act, if effective, also have side effects, the fact that the procedure the best outcome neonatal conditions obstetric pathological does not correspond to a state that is beneficial even in normal situations.

Would be equivalent to say that, becauseè the electronic monitoring, continuous travail, it is proved to be useful in the same conditions as midwives above, is useful also in the throes physiological.

This statement is widely disproved by clinical studies controlled trials performed on the theme, that reported instead an increase is unwarranted parts operative vaginal and caesarean section in the group of labors physiological subjected to electronic monitoring to be continuous, with no benefit for the infant.

the current state of knowledge, we cannot quantify the effect on infants of the use ofanalgesia, epidural in a suffering and physiological, in which the indication for analgesia is “the demand for maternal”, becauseé there are no controlled clinical trials about it, but you can notò say tout court that he will do well in all the infants.

by Anita Regalia (October 2011)

For the bibliography on the following please consult the web sites www.saperidoc.it, www.snlg-iss.it , www.nice.org.uk  www.icsi.org, www.rcog.org.uk

Donati S. et al. Maternal mortality in Italy: a record-linkage study. BJOG 2011; DOI:10.1111/j.1471-0528.2011.02916.x.

For the parliamentary debate see the website  http://www.senato.it/japp/bgt/showdoc/frame.jsp?tipodoc=SommComm&leg=16&id=616185

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