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HISTORY OF WATER BIRTH
The first modern document was found in a village in France in 1805 and complete the collection of medical journals in France, where there has been a significant reduction in maternal birth with dystocia (which does not progress in the delivery process) will become more progressive by using a water birth delivery method,where the baby will be bor more easily. Russian reasercher Igor Charkovsky that examines the safety and possible benefit or water birth in the soviet union during the 1960s. In the late 1960s, french obstetrician frederick leboter develop new techniques soaking in warm water to easy the transition a baby from the birth canal to the outside world, and can reduce the effects of trauma that may accour. Inthe early 70s Dr.Michel odent, head of the hospital surgicak installation phitiviers, france, was first introduce the benefits of labour and birth in water. He noted that many women want to use a water birth during labor to get the "labor became easier, more comfortable, less painful, and more efficient."
During the years 1980-1990, water birth grow rapidly in the UK, Europe, and Kanada.11 In 1985, The Family Birthing in Upland, Southern California led by Dr. Michael Rosenthal advised women to give birth and water birth. After five years of accumulated experience of water birth, in 1993 there have been 1000 birth, Odent's Birthing Center at Pithiviers without complication or infection in the mother or baby. In 1989, Project Water Birth International, Barbara Harper developed the "Topic Of Gentle Alternatives In Childbirth". In 1991, Monadnock Community Hospital in Peterborough, New Hampshire became the first hospital that makes the protocol a water birth. In 1990, The Scientific Advisory Committee made a statement about a water birth with an emphasis on the importance of scientific research. The statement in the 1994 revision of the importance of security of water labor and birth, and the need for precise information about the benefits and risks of water birth. On 1-2 April 1995 at the Wembley Conference Centre in London, England, held the first conference to explore a water birth problems that develop, attended by 39 countries with data 19 000 deliveries in the water. The conference continued in 1996, 2004, and in September 2007. In 2005, there were more than 300 hospitals in the United States has adopted a water birth protocol. More than ¾ of all hospitals in England has provided a water birth.

In Indonesia, a water birth was new and became popular when Liz Adianti Harlizon birth with this method, four Tuesdays in October 2006 at 6:05 pm in SanMarie Family Healthcare, Jakarta handled by dr. T. Otamar Samsudin, SpOG and dr. Keumala Pringgadini, SpA.

In Bali has existed since 2003, Robin Lim of the clinic Yayasan Bumi Sehat Nyuh Kuning Village, Ubud, Bali has handled more than 400 cases per year including water birth Oppie Andal (July 20, 2007). While the General Hospital in Bali for the first time provide a water birth facilities are Harapan Bunda Hospital ~ Maternity Hospital, Jl. Tukad Unda No. 1, Renon, Denpasar, Bali. Water Birth seven have been implemented since October 2007. and delivery is handled by dr. I Nyoman Sanjaya Hariyasa, SPOG.

Water birth is one alternative method of vaginal deliveries, where pregnant women without complications of childbirth by soaking in warm water with the aim of reducing the pain of contraction and gives the sensation of feeling comfortable.

One of the most important thing in the development of modern obstetrics is the humanization of labor and birth. This is an approach that focuses on family, patient autonomy, and pain management. This effort is an essential thing for the safety of the fetus and neonate. Pain in childbirth due to the significant tissue damage, which can be categorized as acute pain. Labor pain is divided into four phases: Phase I (opening) is caused by contractions of the uterus and cervix stretching. Phase II (Pelahiran) pain caused by stretching of the pelvic floor and not infrequently as a result of cutting (episiotomy) if necessary. Phase III (Disposal of Placenta) give the sensation of pain is very minimal. Finally phase IV, is more of a pain that arises from the perineal wound suturing due to tears with or without episiotomy. One way that is considered to relieve pain in non-pharmacological (without drugs) is a method of water birth, where pregnant women give birth in warm water immersion.

Benefits for Mom
A. Reduce Labor Pain And Comfort Pain Giving
Mother's labor pain is reduced due to soaking in warm water is relaxing and comfortable so that pain and stress will be reduced. Reducing pain is a primary objective, while technically give birth in water is basically the same as a normal delivery, process and procedure is the same, just a different place. In a water birth mother gave birth to her baby in a pool with free position and, most felt uncomfortable by the mother. The pool can be made of fiber glass or other materials.

The existence of the myth that says that water birth can reduce the overall pain in childbirth, but the cause elongation phases of labor. In fact, water birth is a natural childbirth and not completely reduce the pain of contractions, however many women feel the pain when there is a reduction in the water, soaking in warm water and floats. Research also shows the actual labor of water to shorten the first stage of labor and blood pressure becomes lower than conventional delivery. Harper reports that water birth effectively to deal with labor pain. A randomized controlled trial (RCT), pregnant women are soaking in warm water at birth with complications (dystocia) compared with standard of augmentation showed that the rate of use of epidural analgesia and obstetric interventions is lower. Retrospectively reported less pain and increased satisfaction.

Water Birth is a form of hydrotherapy, this method is effective and useful in the treatment of pain in conditions such as lower back pain (which is generally a complaint mother during childbirth). Evaluation of more than 17 randomized controlled trial (RCT), two-Controlled Studies, 12 Cohort Studies, and two case reports, concludes that there are advantages hydrotherapy in pain management, beneficial, effective and has the effect of mobility, strength, and balance, particularly in people with arthritis and chronic lower back pain. Hydrotherapy is also a relatively safe alternative compared with conventional labor pain management (anesthesia and drug use). Soaking in water will be able to reduce labor pain 75percent or at labor and birth in water, buoyancy will help mothers to relax, the movement of water during labor is more liberal causes birth mother comfortable and relaxed, while the warm water will help reduce nyeri.8, 11 , 23 A Cochrane systemic reviews also support the notion that soak in water during first stage labor will be able to reduce the use of analgesics and pain on the mother's birth, without any adverse matter in the duration of labor, operative delivery and infant outcomes.

B. Reducing episiotomy Actions
In the case of trauma to the perineum, support water on the baby's head is crowning slow would reduce the risk of tears, and can reduce the need for episiotomy action. In literature, water birth is not even found the incidence of episiotomy. Besides this, the trauma of the perineum are reflected not heavy, with more events found intact perineum, but some literature to get the same frequency of tears in primiparous deliveries in and out of water. There is still a myth that women giving birth in water is more likely to experience tears because that helps labor difficulties to perform an episiotomy if necessary. But the real mother who gave birth in the warm water of less experienced tears, because warm water can increase blood flow and is able to soften the tissues around the perineum mother. When require episiotomy, rescuers are even more easily reach the mother's perineum to perform massage or other action. Most of episiotomy is not necessary, and if rescuers assume during the birth process there is a state of emergency, rescuers will cancel the implementation of this method.

The Birth Centre Network UK, Nicoll A. et al get the 300 births per year, 150 of which use a water birth with episiotomy rate 2percent.A Comparative Study of the water birth method that compares the Maia-birthing stool, bedbirths (except vacuum extraction), which obtained the data that the incidence of episiotomy at a water birth 12, 8percent, Maia-birthing stool 27.7 percent, 35.4 percent bedbirths, this difference was statistically highly significant.

C. Maternity shortening Phase I
Labor and birth in water can also speed up the delivery process is significantly associated with first stage of labor will be shorter. In this case the mother can better control their feelings, lowering blood pressure, more relaxed, comfortable, energy saving mothers, reducing the use of drugs and other interventions, provide personal protection, reducing perineal trauma, minimize the use of episiotomy, reducing the incidence of cesarean section, facilitate labor.

A comparative study after 555 birth in water. This study showed the medical benefits that are relevant to labor in water, and a significant reduction of the duration of the first stage of labor, episiotomy and meaningless reduction of perineal laceration and analgesic purposes. Neonates security guaranteed by taking into account the existing contraindication.

D. Lowering Blood Pressure
In terms of lowering blood pressure. According Psycology Pre & Perinatal Association of North America Conference, women with hypertension will experience a decrease in blood pressure after soaking in warm water for 10-15 minutes. Anxiety leading to an increase in blood pressure can be reduced by soaking in warm water.

 
E. Benefits for Baby.
Childbirth itself can be a problem, may also interfere, and an experience for the baby. Water Birth advantages especially when the baby's head into the birth canal, where labor will be easier. Warm water with suitable temperature atmosphere resembling intrauterine environment to facilitate the transition from the birth canal into the world of warm outside.Air perineum may also reduce tension and give a sense of comfort for both mother and baby, so baby born less get trauma (due to the effects can flex and tissues stretch the perineum and vulva) than in cold water birth and place of birth in general.

Babies born in the water did not immediately cry, baby seems to be calm. Babies do not drown if born in water, because during pregnancy the baby live in the water (amniotic) until there is a transition from the uterus to the surface delivery air.22 Similarly the problem of umbilical cord coils in the neck, not a problem, as long as there is no baby's heart rate decelerations (indicating fetal distress) as a result of the tight turns of cord around the neck. Shortening the first stage of labor in addition to facilitate childbirth for the mother, is also good for babies that is preventing the risk of injury or trauma to the baby's head, baby skin cleaner, lower the baby's risk of water intoxication fetal membrane.16, 21.32 Therefore this method is known as a childbirth "Easier for Mom ~ Better for Babies ".
 
WATER LOSS Birth
A. Risks and Complications
According to proponents of water birth method does not cause serious risks or complications. This will only happen, if the procedure is not appropriate or bad handling. Delivery protocol is an important matter that must be held to prevent the risks and complications. A comparative study. A prospective study on More Than 2000 waterbirths; water birth and delivery alternatives such as Maia-birthing stool had a lower risk to the mother and baby than bedbirths if in the handling of birth using a good monitoring.
The risks that can arise include:
1. Maternal Risk
A. Infection. 
According to the European Journal of Obstetrics and Reproductive Biology, 2007, Water Birth is a normal delivery Valuable alternative. The study, led by Rosanna Zanetti-Daellenbach found no difference in the incidence of maternal or neonatal infection or laboratory parameters including fetal outcomes in terms of Apgar score, blood pH, and needs intensive care. There is an opinion which states that a water birth because of a risk of infection by soaking in water is not sterile and can remove dirt mother when straining in pools of water. However, research shows that the intestinal tract babies benefit from this exposure. Birth and ourselves are not sterile. Vaginal secretions, blood slim, amniotic fluid, and feces mother when the baby into the pelvic cavity, the whole is not sterile. If the mother is in a state of active stage of labor, water will not enter into the birth canal while Mother is in the pond. Water can get into the vagina, but can not get into the inside of the vagina, the cervix and uterus. Certain infectious diseases, will die immediately when in contact with water. One way that is used to prevent infection is to use a regulator for the water pump still circulates with a filter / filter the water so that if water is swallowed is not at risk of infection. Pool that has been sterilized and then filled with water where the temperature will be around 32-370C adjusted to body temperature.
B. Postpartum hemorrhage.
Risk of bleeding in the mother and baby should also be considered. Although the comparative study in Switzerland showed a positive thing, but other studies in England found no significant difference between water-birth method with other delivery methods. Service providers who are not experienced water birth would be difficult to assess the amount of post partum hemorrhage, while the method has been developed with good handling. This causes a number of service providers prefer to give birth the placenta in the outside pool as at The University of Michigan Hospital.
C. Trauma to the Perineum.
The use of episiotomy at a water birth 8.3 percent did not indicate the degree perineal laceration III and IV and 25.7 percent, on land birth indicates the degree perineal laceration events III and IV with the use of episiotomy rates higher. A Cochrane review by Cluett et all, proving that there is a risk of perineal trauma at birth with a water birth, but there were no significant differences in clinical outcomes in trauma research perineum. In years 1991-1997 Obstetrics and Gynecology of the Cantonal Hospital of Frauenfeld, Switzerland compare the vaginal delivery group three: water birth, Maia-birthing stool, and the incidence of episiotomy bedbirth get 12.8 percent on 27.7 percent water birth at Maia-birthing stool, and 35.4 percent in bedbirth. This is statistically highly significant. Besides the episiotomy rate bedbirth occurred also showed the highest degree perineal laceration III and IV (4.1 percent)
2. Neonatal Risk
There is a clinically important risk to the infant, including respiratory problems, cord rupture accompanied by bleeding, infection and transmission through air.32, 40.41 Reports from a number of cases linking a water birth with respiratory distress, hyponatremia, infection, hypoxic ischemic encephalopathy, cord rupture center, seizures, tachycardia, fever (associated with water temperature), and near drowning in infants or fetuses.
a. Umbilical Cord dissolution.
Mechanism of interruption of the umbilical cord occurs when the baby is born as soon as possible brought to the surface water is not a "gentle", if the short umbilical cord can cause excessive tension on the umbilical cord. A review that identified 16 articles, 63 reported a neonatal complications caused by a water birth, one of them is a matter of breaking the string center.40 An unexpected study results showed that five of 37 infants (14percent) who was born in water and require special care due to interruption of the umbilical cord, one infant requires transfusion. The case of disconnection of cord may be caused by raising baby's surface too quickly, causing rapid pull of the cord that goes beyond the rope length as compared usally.32, 42 No data found the risk of interruption of the umbilical cord at birth averages out of water.

b.Takikardi.
c. Infection.
Risk of infection is rare in a water birth. Respiratory tract infections in infants who are born in a water birth is rare, but risk must still be taken into account. A number of cases that might harm the baby, among others, herpes infection, extensive bleeding, and various other infections. Water-birth method is not recommended in preterm infants. Based on the published case reports, infection with P. aeruginosa was found in swab ear and umbilicus of babies born with water birth. In a randomized controlled trial of effect of water birth in Canada, found no difference in low-risk mothers and signs of infection in the mother with amniotic membrane rupture. Research in 1999 on the bacterial culture at Oregon Health Sciences University Hospital, found no direct bacterial culture ponds in childbirth, while pseudomonas bacteria that commonly exist in tap water was found, but the fetus is infected with the bacteria do not require anti-infective therapy. This confirms to what is found in the British study of more than three years. There should be a strict protocol to maintain the cleanliness of the pool of labor to one another (especially in hospitals), because there is little risk of transfer of bacteria from baby to baby or mother to mother. Also on tap water usually contained the bacteria Pseudomonas. Pediatrics recommends to consider the evidence of pseudomonas infections in infants with birth water birth.
D. Hypoxia.
The umbilical cord will continually provide oxygenated blood, while responding to stimulation of a new baby is the first time filling his lungs with air. Delays clamping and cutting the umbilical cord is very useful in the process of transition the baby to live outside the uterus. This will maximize the function of lung tissue perfusion. Garland (2000) and pengkleman not recommend cutting the umbilical cord until the baby reaches the water surface caused by the increased risk of hypoxia. Hypoxia baby would interfere with the baby's dive reflex, which resulted in suppression response will cause the baby to swallow that sip of water during the water birth. Odent (1998) recommends 4-5 minutes clamping the umbilical cord after delivery. But according to Austin, Bridges, Markiewicz and Abrahamson (1997) clamping delay cord can result in polycythemia, based on the hypothesis that the warm water to prevent vasoconstriction of umbilical cord blood of so many mothers transferred to the infant (vasoconstriction occurs when contact with air).
E. Aspiration of Water and Drowning.
There are various criticisms about water birth, where the risk of drowning if the baby inhaling water or breathing in water. Theoretically, the risk of aspiration of water in a water birth around 95percent. Risk of entry of water into the baby's lungs can be avoided by lifting the baby is born as soon as possible to the surface of the water. Elongation phase of soaking resulted in a lack of oxygen, water embolism, and bleeding. Warm water to prevent blood clots after childbirth, and also the risk of infection. According to the British Medical Journal (BMJ) in June 2005, the babies by themselves will not breathe until exposed to air, except for experiencing asphyxia caused suppression rope center. Based on study estimated 38percent of babies born with a water birth at risk of drowning. In November 2005, doctors in New Zealand found four newborn incidence of nearly drowning. This may indicate why they believe that the facts better and more able to prove the importance of security in this labor, and the presence of other risks such as intense respiratory distress and other respiratory problems.
B. Morbidity and Mortality
Similarities maternal morbidity and mortality in low risk deliveries in suggesting that water does not substantially improve perinatal outcomes buruk.50 The National Surveillance in the study did not find differences in perinatal morbidity and mortality among infants born with water birth compared with conventional delivery, otherwise capital pregnant women giving birth in water deliveries satisfy.research gained experience of large-scale water-birth in England between the years 1994-1996 showed picture of perinatal mortality from birth with a water birth was 1.2 per 1000 live births (95percent CI 0.4 to 2.9 ) 50 and perinatal mortality of conventional childbirth was 8.4 per 1000 live births (95percent CI 0.7 to 2.3). Found no valid reports of infant deaths due to aspiration or inhalation of water on the 150 000 medical records from around the world between the years 1985-1999 on a water birth.

In August 1999 the British Medical Journal published a study between April 1994-March 1996 on 4032 infants born with a water birth, which concluded that perinatal mortality is not substantially higher in childbirth with water birth compared with births in low risk pregnant women who labor using the British Paediatric Surveillance konvensional.The mention of the death or the need for special treatment in infants who labor in the water of the year 1994-6. It describes the ratio of the total number of people who give birth in water. There were five perinatal deaths of over 4032 Water Birth (1.2 /1000). one baby died in utero, one was born dead after the baby is born without treatment because of pregnancy that is hidden, three postnatal death by specific causes; herpes infection, brain hemorrhage after childbirth fast, hypoplastic lungs. infants (including three postnatal death) which require special handling and 15 suffered respiratory problems including one aspiration of water, one "freshwater drowning", five baby's cord broke, six maternal deaths that did not use the pool of labor. Similar perinatal mortality in low risk births, but data on the causes incomplete. Researchers concluded there was no substantial evidence of increased risk.

This is similar to the results of the audit described by The British Paediatric Surveillance Unit in 1999. Babies who require special handling 8.4 /1000 live births compared to conventional labor 37 /1000 live births even with the management risk home birth get 9.2 /1000 live births that require special handling. Some literature mentions the low rate of morbidity water birth. In research Water Birth A Near-Drowning Experience has handled four neonates who teraspirasi water and pulmonary edema is more than 18 months of age. On the radiological picture of pulmonary edema found in the fetus suffered extensive, with Tachypnoea transient (2 of four cases there was no information about the birth process in the water, while one of four fetuses had hyponatremia). According to research Experience with under-water birth. Underwater birth is now considered as an acceptable method of delivery. Security into consideration, the main concern in cases of drowning, but from 19,000 underwater birth there were no reports of adverse things. Underwater birth is safe and beneficial if used appropriately in patients with low risk.
 
PATHOPHYSIOLOGY
Pain Reduction
Gains derived by this delivery method is the reduction in pain when the labor lasted. This is caused by circumstances which the uterine blood circulation for the better, less abdominal pressure, and increased production of endorphins (stress-related hormone). Soak in water during childbirth will ease the pressure on the abdomen mother, and float resulted in more efficient uterine contractions and better blood circulation. This causes the circulation of the uterine muscle and blood oxygenation for the better. Childbirth in water to give flexibility to the mother to move freely, to give a feeling of more relaxed and comfortable, so that pregnant women be able to concentrate on delivery, and therefore the condition of the mother comfortable then the circulation of blood and oxygen from the placenta into the fetus going better, the baby's body temperature is warm according to the mother's body temperature. Good body temperature will affect the baby's oxygenation, so that the baby is able to adapt to the environment outside the womb with good.4, 25.27 A study in Switzerland found that babies born in water Apgar score five minutes on average significantly higher.

Warm water and pressure from the pool whirlpool is one source of pain relief during labor by reducing the burden of gravity naturally, so that pregnant women may change position without load when soaking in air.2 Soaking in warm water can stimulate physiological responses in the mother pregnant, so it can reduce pain, including redistribution of blood volume, which will stimulate release of oxytocin and vasopressin, which will increase the level of oxytocin in the blood. In addition, there is hypothesized that warm water will be able to relax the muscles and subsequent mental cause increased release of catecholamines, which allows increased perfusion, relaxation and contraction of the uterus, so as to reduce the pain of labor contractions and shortening phases.
 
Aspiration Risk Reduction
There are several factors that prevent the baby breathing water during childbirth. First, there are inhibiting factors which are average on every baby. Babies in the womb get oxygen from the placenta through the umbilical cord and breathe by moving the intercostal muscles and diaphragm with a regular pattern since the age of 10 weeks gestation. The fetus receives oxygen through the umbilical cord during pregnancy until the time when the umbilical cord is cut or the placenta separates from the uterine wall, an average of 2-10 minutes after birth to 30 minutes. Work diaphragm and intercostal muscles, causing more blood flow to vital organs including the brain so it can be seen a decrease Beat Fetal Movement (FBM) on the biophysical profile. At 24-48 hours before the onset of spontaneous labor, the infant experienced increased levels of prostaglandin E2 from the placenta that causes the slowdown and cessation of breathing movements. The average visible muscle movement of approximately 40percent. When the baby is born and prostaglandin levels are still high, infant to respiratory muscles is not simple work, it was the first inhibitory response.

Response second obstacle is the fact that babies are born experiencing acute hypoxia or lack of oxygen. This is a response to the birth process. Hypoxia causes apnea and swallowing, not breathing or crowded. If the fetus is experiencing severe oxygen shortage and long, then crowded can occur after birth, water may be inhaled into the lungs. If the baby is in trouble during labor, will widen the variability recorded on Fetal Heart Rate, this resulted in prolonged bradicardia, so rescuers would ask her to leave the pool before the baby is born.

The third factor that inhibits the baby in response to breathing while in the water, the temperature difference. Water temperature was made according to maternal body temperature. According to Paul Johnson neonatal respiratory mechanism is stimulated by changes in air pressure. Pool water temperature similar to the amniotic fluid which can be inhibiting factors. Recent research and observation in Germany, Japan, and Russia suggests that the low temperature at the time of birth contribute to the vigorous pulmonary baby.Cairan produced in the lungs and which chemically resemble the gastric juices. This fluid will come out through the mouth and swallowed by the fetus. Water is a hypotonic solution and lung fluids present in the fetus are hypertonic. If the water past the larynx, can not cross the lung, as based on the fact that hypertonic solutions denser and prevent hypotonic solution join or enter into it.

Another important obstacle is the Dive reflex (reflex dive / mammallian diving reflex) that surrounds the larynx. Larynx wrapped by kemoreseptor or taste buds. Larynx has five times more taste buds than the tongue. So, when the solution on the back wall of the throat, past the larynx, the taste buds interpret the kinds of substances and the glottis automatically closes, so the solution will be swallowed, not inhaled. Newborns are very smart and can detect the substance of what was about it, can differentiate between amniotic fluid, water, milk, and milk is caused by the baby's condition Reflex.in Dive average (viewed from the Fetal Heart Rate monitoring during labor), a combination of factors- The above factors prevent the baby breathing in the water until the baby is above the surface of fetal air.Pernapasan first time this has happened after the face is on the surface of the water, which will stimulate the mammalian diving reflex associated with air pressure in the region face trigeminus nerve. In the first infant respiratory happen is by changing the fetal circulation to the baby's circulation, the closure of the shunt on the heart, making the pulmonary circulation, changing the pressure in the lungs, pushing out fluids that will prepare the room and allow the lungs exchange oxygen and carbon dioxide. This process may take several minutes to start in full. During the time the baby is still receiving oxygen from the umbilical cord. There is no threat that the baby will inhale water during the birth process due to inhaling oxygen trigger will not be there until the baby's head contacts with udara.7 According to the BMJ in June 2005, the babies by themselves will not breathe until exposed to air, except for experiencing asphyxia which suppression caused by the umbilical cord.
Shortening phase Childbirth
Labor in water is sometimes associated with a decreased intensity of contraction, causing a slowdown of labor. But experts agree that the labor of water has to be evaluated case by case basis. Some hospitals adopted the law "5 cm", ie pregnant women allowed into the pool when it is in active labor with cervical dilation of more than five pregnant cm.Ibu into the water during the first stage of labor believed to be less useful.39 There is no strong evidence criteria when it is appropriate to soak in the first stage of labor, so labor this early would be better if treated with mobilization than bath.5 There are also reports that water sometimes give effect to slow down and even stop labor if used too early and many reported that the contraction is less effective if the mother is too early bath.
Reducing Postpartum Hemorrhage
The loss of the mother's blood during birth is very little water. The average blood loss at birth water 5.26 g / l were significantly lower than 8.08 g/l.3 birth land of blood loss at labor is difficult to be assessed particularly if caused by a helper who is less experienced in childbirth in water.
 
INDICATIONS AND CONTRAINDICATIONS
Terms-Terms
a. Low-risk pregnant women
b. Pregnant women do not experience vaginal infections, urinary tract, and skin.
c. Maternal vital signs within normal limits, and infant CTG average (baseline, variability, and no acceleration
d. Ideally, the warm water is used for relaxation and pain management after reaching 4-5 cm cervical dilatation.
e. The patient agrees to follow the instructions rescuers, including out of the pool where the bath if necessary.

Criteria / Indications
a. Mother's choice.
b. Average ≥ 37 weeks gestation.
c. Single fetal head presentation
d. Do not use tranquilizers.
e.  spontaneous rupture of membranes
- <24 hours.
f. Non-clinical criteria such as staff or equipment.
g. No complications of pregnancy (preeclampsia, uncontrolled blood sugar, etc.). There was no bleeding.
h. Normal heart rate.
i. Clear amniotic fluid.
j. Spontaneous delivery or after using misoprostol or pitocin.

Contra indications
a. Infection can be transmitted through the skin and blood
b. Infection and fever in the mother.
c. Herpes genitalis.
d. HIV, Hepatitis.
e. Abnormal heart rate.
f. Excessive vaginal bleeding
g. Macrosomia. Mekoneum condition that requires constant monitoring.
LABOR PROCEDURES
Some of the instrumentation essential to be prepared on a water birth labor method include:
a. Water thermometer.
b. Thermometer mother.
c. Doppler waterproof.
d. Gloves.
e. Work clothes (apron).
f. Nets to remove impurities.
g. Knee pads, pillows, set of instrument deliveries.
h. Shower warm water. i. Portable / permanent pool.
j. Towels, blankets.
k. Warmer and infant resuscitation equipment.

  
During the Labor
1. Mother came into the water bath is recommended when the cervical opening 4-5 cm with uterine contractions well. Mom can take delivery position preferred.
2. Observation and monitoring, among others:
a. Fetal Heart Rate (FHR) with Doppler or fetoskop every 30 minutes during the active first stage of labor, then every 15 minutes during the second stage of labor. Auscultation performed before, during, after contraction.
b. Thinning and opening of the cervix and fetal position. Vaginal examination (VT) can be done in the water or on the request while the patient out of the water for inspection.
c. Status amniotic sac, in case of rupture of membranes, check the FHR, and check for cord prolapse. If mekoneum amniotic fluid, the patient must leave the pool.
d. Maternal vital signs checked every hour, with the temperature every two hours (or as needed). If the mother had a headache, check vital signs, teach the mother to catch his breath during a contraction.
e. Mother hydration. Dehydration is evidenced by the existence of maternal and fetal tachycardia, and increased maternal body temperature. If signs and symptoms of dehydration occur, mothers were given a solution. If not managed to put an IV Ringer's lactate (RL).
 
3.Management of stage II
a. Straining should be physiological. Mother allowed straining spontaneous, oxygen and carbon dioxide imbalance risk in maternal-fetal circulation is reduced, and also will be able to exhausting the mother and baby.
b. Delivery, if possible methods of "hand off". This will minimize stimulation.
c. Palpation of the umbilical cord is not needed when the baby's head is born, because the umbilical cord can be separated and loosened when the baby is born. To minimize the risk of umbilical cord disconnected improperly, avoid pulling when the baby's head into the water. The umbilical cord is clamped and cut do when the baby is still there in the water.
d. Babies should be born completely in the water. Then as soon as possible brought the surface of a "gentle". When the baby has been born baby's head above the water surface and his body still in the water to avoid hypothermia, preventing mother-to-infant transfusion. When the baby's head is above water, do not soak them again. 4. Management of third stage a. Active management and psychology still be given until the mother came out of the pond. b. When the active management of third stage, Syntometrine can be given. c. Estimate bleeding <> 500 ml.
d. Suturing the perineum may be delayed for at least one hour to eliminate water retention in the network (if bleeding is not excessive)
 
During straining and Childbirth
1. Mother took the attitude that feels safe and comfortable for him. The freedom of movement that allows mothers to take the right position for birth.
2. The birth of the baby's head is facilitated by a gentle push of uterine contractions. Gloves used helper to deliver the baby. Chock perineum, massage, and press gently if necessary. Mother can control the drive head with his hand.
3. Manipulation of the head is usually not necessary to have the baby because the water has the ability to float. However, patients need to stand up to help reduce or cut and clamp the umbilical cord loops. Minimize stimulation reduces the risk of respiratory distress.
4. When a baby is born, the baby's head is controlled with a gentle motion, face down, and emerged from the water no more than 20 seconds. The fetus can be rested on the mother's chest while cleaning the nose and mouth, if necessary. Handling should see also the length of cord so as not to break. Then the baby is given a blanket, and on the monitor.
5. Ideally, the mother and infant is assisted out of the water to birth the placenta. The umbilical cord in the clamp and cut, and the infant is dried with a towel and wrapped and then given to other rescuers, family, or nurse. My mother was helped out of the pool. The placenta can be born in the water or out depending on the helper. Mothers should be encouraged breastfeeding as soon as possible after birth to help the contractions of the uterus and placenta expenditure. The risk is theoretically associated with warm water relaxing effect on the muscles of the uterus including placenta solusio, embolic water and increased bleeding.
 
Guidelines, POLICY & STRATEGY
Guidelines & Policy
There are few data on the frequency and outcome of labor and birth in water. The systemic review by the Cochrane Library Highlights stated that although no significant side effects were reported, the possibility of adverse neonatal outcomes could not be diabaikan.16 Some existing research, suggests that soaking in water for a water birth provides significant gains in output delivery. Benefits include relaxation, reduce pain contraction, pemendekkan phase of labor, reduction of augmentation, analgesia, episiotomy, and perineal trauma.

A review of some literature and clinical experience shows this method is safe for both mother and fetus, if you follow the instructions tepat.41 The Royal College of Obstetricians and Gynecologists published a guideline on how to minimize the occurrence of complications at birth with a water birth method such as by controlling the temperature water, soaking pool hygiene, avoid soaking for too long, consider using isotonic water, consider leaving the pool at the final stage, and using an agreed protocol to prevent unexpected complications. At an estimated 50percent maternity units provide labor and delivery facilities in the water. Every maternity unit should have, or should develop policy and guide the implementation of water use in labor and delivery. This should be supported by the best evidence available, consult with your supervisor and inform users.

Each maternity unit has, develop a policy the use of water birth, including:

A. Professionalism
Help mothers give birth in water should consider the competency helper. Less experienced operator, should be given opportunities for education, training and guidance. Professional development is done continuously in order to meet service requirements in order to improve the quality of water birth.
 
B. Information
All pregnant women are given information about a water birth. Service providers are required to provide guidance about the delivery process until the mother to understand and comprehend.

C. Instrumentation
a. The existence of local policies regarding responsible for equipment.
b. Unit entirely appropriate equipment safety standards, and under supervision by the Ministry of Health.
c. All equipment must be cleaned and dried after use in accordance with infection control policies. Disposible filters should ensure the pool free of feces and other debris. Helper must use universal precaution and infection control follow the instructions.
d. Monitoring fetal heart using Doppler underwater as practical standards set by the Current National Institute for Health and Clinical Excellence Guidelines.
 
D. Safety and Health
Local infection control policies will protect users of water birth, and guarantee the implementation of universal precaution. If a pregnant woman lifted her out of the water and cause the baby's head is exposed to air, and the umbilical cord are visible, then the baby should be removed from the water to avoid the risk of premature gasping.

E. Other Issues:
a. Temperature
1. Understand the basic physiology of hyperthermia in the mother and baby. Local instructions will set the target temperature to be used during labor and birth in water.
2. Maternal temperature, water and the room will be checked regularly. A comfortable temperature setting for the mother to avoid the occurrence of hyper / hypothermia
3. In the first stage of labor, the recommended temperature between 34-370C (95-101oF), this temperature will be checked and recorded every 15 minutes.
4. In the second stage of labor the water temperature ranges from 37 to 37.50 C, checked and recorded every 15 minutes.
5. Maintain room temperature between 22-280C, not too hot which may be at risk of dehydration, temperature checked and recorded every hour.
6. Maternal body temperature checked when entering the pool for the data base and measured every hour for the water, if the mother's body temperature is more than 37.50 C method of delivery is canceled.
7. Mother is expected to drink water at least one liter per hour during the soaking.
8. The existence of controversy over the use of water temperature between 34-370C (95-101oF), researchers in Sweden recommend the mother to adjust the water temperature is comfortable for her body.
b. Analgesia
Local Guide use of anti-pain can be consulted with anesthesia.
c. Birth
Local Guide to the midwife during labor practices.
Local clues that can explain in detail the steps in an emergency. All the rescuers, and pregnant women who use these birthing methods must know and understand the steps.

Strategies to Enhance Security and Convenience
The use of water-birth method is generally given to pregnant women who are qualified and indications. But during 2001, found three pregnant women with ex-SC, can also use the method of water birth with no problems and did not found a bad outcome. Audit of water birth on the other, it was reported that the former SC 10 women who planned to use a water birth deliveries are all successful in the average in the water. Although the study was conducted in limited cases, this suggests the possibility that water birth is safe to use in patients with ex-SC. Strategies to improve the safety and comfort of water birth method can be carried out include:

A. Water Temperature Control
The temperature of water in the pool should be comfortable for the mother, the body temperature of 370C may be ideal. Water temperature should not exceed 370C, because there is a risk of redistribution to the skin and hypotension, which allows reducing placental perfusion. Sweat pose a risk of maternal dehydration during a long soak. Mother should be encouraged to drink to prevent dehidrasi.11 In 1997, Michel Odent recommends water temperature 98.60 F (370C) or lower. Most hospitals record the temperature every two hours.

B. Keeping Swimming Cleanliness
During the average labor pool can be contaminated by amniotic fluid, blood, feces. This can increase the risk of neonatal infection and / or postpartum, and may also increase the risk of the officer. Pseudomonas contamination is important to note. There are theories about blood-borne viruses, but can not find evidence in practice. In the surveillance study, only three infants were reported infected with neonatal herpes and one which does not relate to soak in the water. Although the risk of serious infections attributable to low, but to minimize the contamination of water, the pool will comply with hygiene procedures to reduce the risk of infection.

C. Avoiding Prolonged Immersion
The study on 200 pregnant women who compare policies to soak before the opening of the cervix after the opening of five inches and five inches, showed that mothers who entered an early dip into the labor pool will be much longer and require oxytocin and epidural analgesia.

D. Minimize Risk of disconnection Cord
This mechanism occurs when a baby is born as soon as possible brought to the surface of the water, if the short umbilical cord will cause excessive tension on the umbilical cord.

F. Optimizing Early Neonatal Respiration
The warmth and the baby's head in water immersion during labor would inhibit inspiration. Reduced inhibition occurs when the head came out of the warm water, or when air enters the upper respiratory tract. In addition, cold atmosphere is a strong stimulator of respiration. Exposure to cold would stimulate the respiratory reflex when the baby is raised to the surface air.Pernapasan baby usually begins when the chest is born. Breathing in water first birth occurs when a baby's face is above the water surface. Water likely to be inhaled into the lungs. In a surveillance study of 37 infants there are two sipped water, one described as teraspirasi water, and a freshwater drowning. However, physiological data suggest that the babies will be protected from inhalation during his stay in the water, unless there is asphyxia.

G. Consider Isotonic Water Use
Could theoretically occur hemodilution and circulation overload, therefore recommended to reduce the risk of adding salt to the water to be isotonic. One pool 909 liters of water, added nine pounds of salt. Normal saline did not stimulate the vagal reflex larynx, but is easier teraspirasi than water.

H. Consider Leaving the Swimming At Final Stage
Warm water has a relaxing effect on uterine muscle, theoretically increasing bleeding occurred after the birth of the placenta or retained placenta. The loss of blood during childbirth is difficult to be estimated because the spread in the water, if the placenta was born in the water. The combination of vasodilatation and increase in hydrostatic pressure could theoretically increase the risk of embolism of water.

Safety and efficacy of this delivery for the baby has not been established, therefore this labor should still be considered experimental procedures and design of randomized Controller Trials (RCT) which right.71 RCOG Statement no. 1, January 2001 stating that the Cochrane Library and the Cochrane Register of Controlled Trials is a systemic reviews and RCTs relevant, as well as paper, MEDLINE, Embase, and Cinhal. Birthing pool used must be specially designed and should not be used by just anyone. The water temperature should also be regulated body temperature is always equal to the mother during childbirth. Accuracy is important to prevent temperature shock when the baby rolled into the pond. Sterility of the water also need to be considered so as not to cause infection in the mother or the baby.72 In the exercise, the birth process does not only need help a doctor obstetrics and gynecology alone, but was helped by the medical team include: midwives, nursery nurses, nurse on duty for set tools, as well as a pediatrician who will check immediately when the baby is born. Presence or absence of the incoming water as well as other disorders can be directly detected and can be overcome with good. Length of labor depends on each mother, could be two to four hours, even if there is a one-hour fast, but if the process is running long, the mother may experience hypothermia.

Further study and depth is being intensively conducted to improve the safety and convenience of the method of water birth. If pregnant women meet criteria for attention to hygiene, water-birth method is safe for mother and bayi.19, 30.31 Generally low risk mothers and their infants who do a water birth is very good prognosis, because it is theoretically possible to soak in water during labor to benefit the psychological and physiological which will help the mother in the face of normal birth, including pain reduction, improved self-control, blood pressure decreased, and enhancing the Royal College of Obstetricians diuresis.The and Gynecologists and the Royal College of Midwife believe that to achieve the best services required organizing a water birth delivery system facilities and support structures as well as competent personnel to service, which is responsible for the development of services and ensure that mothers can get information, advice, and assistance from the professional.40 There is an increasing number of hospitals that routinely has been providing this facility in the United States and Europe, plus various data about its safety, as well as more experienced service providers to the risks and benefits with the handling and monitoring procedures are more stringent, then it is expected to contribute in improving the security of this method.
 
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