Two thirds of pregnant women experience low back pain and one fifth experience pelvic pain, which can adversely affect daily lives. Reflexology may be helpful for general low back pain. Therefore, the aim of this research was , to investigate reflexology for the management of low back and/ or pelvic pain (LBPP) during pregnancy. Ninety primiparous women, were randomised to receive usual care, six reflexology or footbath treatments. Primary outcome measures were the Visual Analogue Scale (VAS) for pain frequency and intensity. Saliva samples were analysed for beta endorphin and cortisol concentration. Heart rate (HR), blood pressure (BP), intervention expectations and satisfaction and labour duration were recorded. Sixty-four women completed the trial. Adherence to the reflexology, usual care and footbath groups were 80%, 83.33% and 50% respectively. The reflexology group demonstrated a Mean Clinically Important Change in VAS pain frequency (1.64cm). Second stage of labour was significantly shorter (p=O.05) in the reflexology group compared to usual care (44.3 minutes). Beta endorphin and cortisol were reduced along with a significant reduction in systolic blood pressure (p=O.03) in the reflexology group but an increase in diastolic blood pressure (p=O.Ol) was observed in the footbath group. Reflexology was more helpful than footbaths (p=O.OOl), however, treatment satisfaction in both groups was high (p=O.07). Findings indicate a fully powered RCT in this area is feasible; however, a footbath is not a suitable sham treatment. The results suggest that reflexology acted to reduce pain, disrupting the cycle of pain and stress, leading to a reduction in BP, cortisol and beta endorphin. It is likely that reflexology acts by deactivating the HPA axis and sympathetic function and enhances the vagal pathways, having an overall effect on the psychoneuroimmunological functioning. Reflexology may be helpful for managing pregnancy related LBPP, by reducing physiological and psychological stress and enhancing positive emotions.

Background: There is an unsubstantiated conviction among clinicians that a significant reduction In amniotic fluid volume is a poor prognostic sign for pregnancy, even when it is an isolated finding. This belief has led to the inculcation of serial ultrasound assessments of amniotic fluid volume into the antenatal assessment of fetal well being with the aim of improving perinatal outcomes by closer monitoring and earlier delivery. In reality, there is no strong evidence base for this practice, while there are significant risks associated with premature delivery. There may also be cost and resource implications for the practice. Objective: The aim of this thesis was to investigate whether isolated oligohydramnios is significantly associated with adverse pregnancy outcomes in otherwise uncomplicated pregnancies, and to investigate the underlying associated maternal, fetal and placental aetiological factors. Materials and Methods: Amniotic fluid volumes were measured using ultrasound in 3328 low-risk pregnancies between 19 and 41 weeks. These were otherwise uncomplicated pregnancies recruited at the antenatal booking visit following a normal 1st trimester screening result (a negative 11-14 week combined nuchal translucency ultrasound and maternal serum-biochemistry fetal structural and chromosomal abnormality screening test). Maternal characteristics (age, parity, ethnicity, socioeconomic status, weight, smoking and alcohol consumption) during the course of the pregnancy, Placental characteristics (site, position and maturity), and Fetal renal blood flow parameters were also studied and analysed for possible associations. Results: Isolated oligohydramnios occurred more frequently with advancing maternal age and lower parity. However, maternal ethnicity, weight and socioeconomic status did not have any direct influence on the occurrence of isolated oligohydramnios and neither did the maternal life style factors studied. Increasing placental maturity was significantly associated with significantly reduced amniotic fluid but neither the placental site nor location was. There was a significant association between oligohydramnios and poor perinatal outcome as judged by meconium staining of amniotic fluid during labour, emergency Caesarean delivery for fetal compromise, an increased requirement for neonatal resuscitation and endotracheal intubation. In the population of pregnancies studied, there was no significant correlation between isolated oligohydramnios and a suspicious or pathological cardiotocogram during labour. However, a low birth weight less than 2500 g at birth, admission to the neonatal intensive care unit, a prolonged length of neonatal intensive care unit stay, and perinatal deaths were all significantly associated with oligohydramnios. No association was seen with either a low Apgar score or a low fetal arterial cord blood pH. Conclusion: This study showed that an isolated reduction in amniotic fluid volume even in an otherwise uncomplicated pregnancy is significantly associated with a poor perinatal outcome, and can therefore not be safely ignored. This finding justifies the continued assessment of amniotic fluid volumes.

Concerns have been expressed regarding low morale and problems with recruitment and retention in UK midwifery. Evidence suggests that integrated midwifery practice may exacerbate these difficulties and impact on the emotional aspects of work. This thesis explored how a range of midwives experienced emotion at work. focusing on sources of emotion and how emotions were managed. The study was conducted in three phases, with the data obtained informing and complementing each other. A multi-method ethnographic approach was utilised, using focus groups, interviews and observations. In Phase One, focus groups were conducted with student midwives on both eighteen month and three year programmes (n = 27). Themes generated were then explored further with qualified midwives in Phase Two (n = 11) and Phase Three (n = 29). Qualified midwives represented a broad range of clinical locations, length of clinical experience and occupational status. Thematic data analysis indicates that community and hospital environments present midwives with fundamentally different work settings that have diverse values and perspectives. The result is two primary occupational identities and ideologies, which are in conflict. Hospital midwifery is dominated by meeting service needs, via a universalistic and medicalised approach to care; the ideology is, by necessity, 'with institution'. Community-based midwifery is more able to provide an individualised, natural model of childbirth reflecting a 'with woman' ideology. This ideology is officially supported, professionally and academically. However, there is no clear match between ideology and context, and this impacts on occupational identity. Managing these conflicting ideologies requires emotion work. Emotion work strategies, learned during socialisation, reflected 'affectively neutral' or 'affectively aware' approaches. A theoretical framework is proposed, which identifies interrelationships between context, occupational identity, occupational ideology and emotion management. The dilemmas created by conflicting occupational ideologies need to be understood in order for low morale in midwifery to be addressed

Two thirds of pregnant women experience low back pain and one fifth experience pelvic pain that can adversely affect women's lives. There is evidence demonstrating benefits of reflexlogy for managing general low back pain. Therefore, this research aimed to investigate the feasibility of conducting a randomised controlled trial (RCT) investigating reflexology in the management of low back and/ or pelvic pain (LBPP) during pregnancy. Overall 90 primiparous women (mean age 30.9 +/- 5.6 years) participated in a feasibility RCT in an inner-city maternity unit. Women were randomised to usual care, a reflexology or footbath intervention. Primary outcome measures were; the Visual Analogue Scale (VAS) for pa in frequency and intensity. Qualitative data on women's experience of the RCT and their experience of LBPP were collected via focus groups after the intervention period. Biochemical physiological and labour data were also collected. In total 64 women completed the study period; retention rates for the reflexology group were 80%, usual care group 83.33% and footbath group 50%. The reflexlogy group demonstrated a Mean Clinically Important Change (MCIC) in VAS pain frequency (1.64cm). Second stage of labour was shorter in the reflexology group (73.56 minutes +/-53.78) compared to the usual care group (117.92minutes +/ -56.15), th is was statistically significant (p=0.045). A lesser increase in cortisol and decrease in beta-endorphin were found in the reflexlogy group. There was a statistically significant reduction in systolic blood pressure (p=0.03) in the reflexology group and a significant increase in diastolic blood pressure (p=O.Ol) in the footbath group. Qualitative data indicate that women perceive health-professional management of pregnancy-LBPP as insufficient. Results indicate it is feasible to conduct an RCT in this area, although a footbath is not suitable sham treatment. Reflexology may be helpful for pregnancy-LBPP; however to confirm this, a fully powered trial is required. Furthermore, management of pregnancy-LBPP needs to be re-evaluated.

AIMS: The aims of this research are to explore the effects of brief antenatal psychotherapy on the reduction of the number interventions and complications of childbirth. Also, the exploration of the in-depth understanding of antenatal anxiety, the tracking of psychic change in pregnancy and finally, the identification of service dimensions to be improved, when working with women with antenatal anxiety.

At the feto-maternal interface, trophoblast cells express membrane bound receptors; their modulation plays a vital role in achieving immune recognition and self-tolerance needed for pregnancy to develop. Trophoblasts exhibit selective expression of the HLA class la (HLA-C) and Ib (HLA-G, -E, -F) antigens and are also able to recognise pathogen associated molecular patterns (P AMPs) through TLRs. The role of these later molecules in pregnancy is not fully understood, it is likely they form the first line of defence against infection. The hypothesis derived from the above is that some selectively expressed gene products of the HLA gene family form preferential physical associations, which contribute to the function of HLA at the fetomaternal interface and the maternal recognition of the fetus. It is also hypothesised that trophoblast responses to individual bacterial or viral infection might be different from responses to dual infection and that viral infection might sensitise the trophoblast for concomitant bacterial infection. In the course of these studies a novel method that allows detection and quantification of HLA class I molecules for an accurate measurement of the degree of co localisation on trophoblast choriocarcinoma cells, ACH-3P and JEG-3 was developed. Trophoblast responses to TLR-3 ligand poly(I:C) and TLR-4 ligand LPS were investigated by monitoring cell proliferation, cytoskeletal morphology, NF-KS and COX-2 activation and nanoscale LC-MSIMS analysis of membrane proteins. Our data shows that the cell-surface HLA class I molecules HLA-G, -E and -C form preferential heterotypic associations and HLA-GIHLA-E colocalisation is induced by progesterone and lipopolysaccharide. Dual infection cause a declined cell growth, cytoskeletal alterations and differential protein expression. It is postulated that at the fetomaternal interface, both the innate and adaptive immunity are functionally modulated and this facilitates the maternal immune adjustment for the semi-allogenic fetus as well as pathogen recognition.

Multiple mechanisms underlie the tolerance shown by the maternal immune system; one of these involves the selective expression of cell surface Human Leukocyte Antigen (HLA) receptors. HLA receptor biosynthesis and display requires multiple intracellular mechanisms including interaction with the cytoskeleton. Previous studies on somatic cells other than trophoblasts have shown that HLA receptor distribution is linked to the cytoskeleton. It is postulated that the cytoskeleton is responsible for the structural integrity of the cell, specifically in implantation, as the extra-villous trophoblast (EVT) cytoskeletal proteins are essential for endometrium invasion and cell adhesion. To gain an understanding of the role of the cytoskeleton on feto-maternal interactions the trophoblast cytoskeleton in relation to HLA was examined. All trans retinoic acid (A TRA) and Cytochalasin D (Cyto D), both known to alter the cytoskeleton were studied on the established EVT model cells JEG-3, and ACH-3P. The presence, expression pattern and topographical distribution of the HLA receptors and cytoskdetal proteins on both cell lines were studied using advanced bioimaging techniques. These in vitro studies confirm previous knowledge suggesting a highly selective pattern of HLA class I antigens and suggest interaction between loci products known as HLA-C and HLA-G. The cytoskeleton products actin, talin and integrins were also detected in both the trophoblast cell lines. Qualitative and quantitative co-localisation studies with confocal microscopy suggest interaction between HLA-G and actin filaments. The effect of ATRA and Cyto D followed a similar trend in all the proteins of interest (HLA-G, actin filaments, talin and integrins) indicating that these three proteins form a single a single oligomeric and functional structure. This study favors the hypothesis that interactions between HLA molecules and cytoskeleton structures contribute to tolerogenic mechanisms operating during human pregnancy development.

The aim of this thesis was to examine a large cohort of women undergoing pregnancy assessment before 12 weeks gestation, collecting demographic, symptom and ultrasound data. I aimed to examine the role of prior risk factors and initial ultrasound findings in the prediction of first trimester viability of these pregnancies. Further, I aimed to develop and validate models to counsel women in future about the likely chance of viability for any individual pregnancy. The hypotheses were: (1) There are prior risk and ultrasound factors that can predict likely pregnancy viability, (2) These factors can be used to predict pregnancy loss or ongoing viability in any particular pregnancy and (3) In predicting outcome, both mathematical models } and 'simple rules' (for everyday clinical use) can perform well. ) The prospective study included 1881 women, with median age 32 years and median gestational age at presentation of 50 days. 46% presented with bleeding and 36% with pain. The final outcome was an ongoing pregnancy in 885 (61.7%) and early pregnancy loss in 550 (38.3%) women. Both 'prior risks' (maternal age and bleeding score) and ultrasound factors (gestation and yolk sac size and fetal heart beat) predicted viability. Mathematical models developed showed that these factors used separately and when combined together predicted viability with accuracy. The final scoring system using both demographic and ultrasound variables together was proven to be highly accurate in prediction of pregnancy viability, performing with a sensitivity of 0.92, specificity of 0.73, positive predictive value of 84.7% and negative predictive value of 85.4%. All 3 study hypotheses were proven. The conclusion of this study is that using routinely collected demographic and ultrasound data an accurate individualised likelihood of ongoing viability can be offered to women in early pregnancy with and without symptoms of pain or bleeding.

Introduction: Intermittent auscultation [IA] is the monitoring method recommended for low risk women and is an integral part of a physiological approach to labour. With the increase in midwife-led units and midwife-led care within the obstetric unit and availability of home births, a greater need for IA is likely. However, few recent studies are available on the technique of auscultation as it is an under researched aspect of midwifery care possibly due to the widespread use of electronic fetal monitoring [EFM]. Thus improvement in the technique of IA has not been addressed. Further studies are needed to add to the body of knowledge and provision of evidence-based care, and increase the safety for the woman and her baby. Literature: Evidence from randomised controlled trials of EFM versus lA has demonstrated that IA is associated with lower rates of Caesarean section and instrumental delivery without any difference in perinatal mortality or morbidity. The only disadvantage to IA is an increased rate of neonatal seizures. However in one large study there was no significant difference in these children at three years of age. Little is known about doctors' opinions of lA, although a number of studies have investigated midwives' opinions of fetal monitoring which included lA. A fear of litigation was expressed and lack of reassurance when EFM was not used. Anxieties regarding deskilling and loss of confidence in providing care in physiological labour were also stated. Use of EFM during staff shortages was also described. Literature on the technique of auscultation was sparse, and the exact way that it was performed was not known although national guidelines recommend counting for 60 seconds. No recent studies have investigated the actual technique of auscultation. Some authorities thought that counting in a different way could improve the accuracy of lA, although most of the studies had either a small sample size or were conducted in an experimental setting. There has been little evaluation of IA in clinical practice and practitioners' opinions of the instruments and what can be detected has not been investigated. Aim: The aim of the thesis is to identify the best practice for auscultation of the fetal heart [FH] in labour and to make recommendations for midwifery practice. Objectives: To explore midwives' and doctors' perceptions of the current practice for auscultation of the FH and the alternative strategies of four episodes of 15 seconds and six episodes of 10 seconds. To explore midwives' practice standards and safety for auscultation of the FH using a mannequin. To compare the current practice of auscultation of the FH for 60 seconds for assessment of the baseline rate [BLR], accelerations and decelerations with the alternative strategies of four episodes of 15 seconds and six episodes of 10 seconds in the clinical setting. To conclude the best listening strategy to detect the BLR, accelerations, decelerations, and baseline variability [BLV] of the fetal heart rate pattern based on the above studies. Methods: A self completion survey questionnaire was administered to midwives and doctors (n=200) in order to explore the current practice of auscultation of the FH and the alternative strategies of four episodes of 15 seconds and six episodes of 10 seconds. An · experimental study using an auscultation mannequin (n=lO) to assess midwives' practice standards in an experimental setting. A study of labouring women (n=32) and midwives (n=21) were recruited to perform the auscultations to assess the counting strategies in clinical practice. The mannequin study was conducted from May to August, 2004; the survey was conducted from January to December, 2005, and the clinical study, January, 2008 to December, 2009. Results: Midwives and doctors had differing perceptions of the instruments and counting strategies for lA. Both professions preferred the hand-held Doppler and thought it could detect the heart rate characteristics. Some thought it could also detect BLV. The Pinard stethoscope was least favoured, although significantly more midwives than doctors thought it could detect the heart rate characteristics although not BLV. The 60 second counting strategy was thought to be the best method and the four episodes of 15 seconds were thought more possible than the six episodes of 10 seconds. The studies using an auscultation mannequin confirmed that it was possible to perform the counting strategies with the Pinard stethoscope and listening to the loud volume mode which was similar to listening to a hand-held Doppler in an experimental setting, although the sample size was small. The Pinard stethoscope was more accurate when the baseline FH rate was between 80-120 BPM and listening to the loud volume mode was more accurate when the heart rate was between 160-180 BPM. Auscultation was less accurate when the heart rate was more than 160 BPM. The 60 second count was more accurate for counting the BLR and the four episodes of 15 seconds and the six episodes of 10 seconds were more accurate for detecting accelerations and decelerations. In the clinical setting the second count was more accurate for detection of the BLR than the four episodes of 15 seconds or six episodes of 10 seconds. Where there was an error it was largely negative and indicated under counting. Insufficient data was obtained to support the effectiveness of the multiple counting strategies in detecting decelerations. Conclusions: Midwives and doctors had different perceptions of the practice of auscultation which supported the continued inclusion of lA in mandatory fetal monitoring updating sessions. Auscultation could be performed with either the hand-held Doppler or Pinard stethoscope. The 60 second counting strategy was more accurate for counting the BLR and should be continued. Insufficient data was obtained to confirm the effectiveness of the four episodes of 15 seconds and six episodes of 10 seconds for detection of decelerations. Further investigation is required into the technique of auscultation.

Background: A first-trimester prenatal screening test for pre-eclampsia was launched in 2010. It differs from previously assessed prenatal screening tests. AIMS: (i) To assess the psychological benefits and consequences of providing a first trimester screening test for pre-eclampsia. (ii) To assess the acceptability of the test amongst pregnant women and healthcare professionals. Methods: A mixed methods approach was taken. Five consecutive studies using primary and secondary data from UK pregnant women and their healthcare providers were conducted: (i) a systematic review, (ii) a qualitative study (pregnant women); (iii) a qualitative study (healthcare professionals); (iv) a case control study; (v) a discrete choice experiment. Results: A first trimester screening test for pre-eclampsia has the potential to positively change health behaviours, but could also decrease self-monitoring. The impact appears to differ depending on whether the woman is concerned with the potential consequences to herself or her fetus. Health professionals are concerned with the clinical utility of the prenatal screening test, and on its potential to medicalise the pregnancy pathway. However, there does not appear to be an association between the amount of technological monitoring and birthplace preference. A discrete choice experiment showed overwhelming support for the introduction of this test. Conclusions: There is no evidence that this new prenatal screening test will cause harm to pregnant women. Women appear to welcome the additional information it provides. Receiving a positive pre-eclampsia screening test result presents potential opportunities for health-promotion interventions. To make the most of these opportunities, it will be important for clinicians to understand how women perceive and respond to this screening test; the self-regulation model provides a useful framework in which to do this. This work provides a framework for assessing the psychological impacts of the many emerging prenatal screening tests that lack a diagnostic test or risk-reduction intervention.