There is evidence that Eating Disorders (ED) may have implications for fertility, pregnancy and, diet and growth in their children. However, few large longitudinal investigations have been conducted. Women with ED have an increased risk for adverse obstetric outcomes; one proposed pathway is via elevated psychopathology during pregnancy, and consequently foetal overexposure to cortisol and corticotrophin-releasing-hormone, which may in turn have implications for stress regulation in their children. The aim of this thesis was to investigate the effects of ED on fertility and pregnancy, as well as specific aspects of infant and child development. Five interrelated studies were undertaken, utilising two separate methodological approaches. First, a large (n= 12,254) longitudinal birth-cohort was employed to investigate fertility and attitudes towards pregnancy in women with and without ED, and longitudinal patterns of diet and growth in their children. Second, maternal psychopathology and cortisol levels during pregnancy, and potential associations with obstetric outcomes, were investigated in a clinical sample of women with and without ED (n=88). At eight weeks post-natal, infant cortisol levels in response to stress were investigated in a sub-sample of mother-infant dyads (n=59). The findings suggest that women with ED take longer to conceive and more frequently experience negative feelings towards their pregnancy than women without ED. Women with active ED showed persistently high levels of psychopathology and differential diurnal cortisol patterns during pregnancy, which were associated with lower birth weights and shorter gestations. Furthermore, children of women with ED were found to experience elevated cortisol levels, and some differences in dietary patterns and growth trajectories. The general strengths and limitations of these investigations are presented and areas for future research are considered.

Gaining large amounts of weight during pregnancy may contribute to development of obesity and is associated with poor outcomes. Therefore managing gestational weight gain is important to reduce the risk of complications. This thesis aims to explore clinical and personal management of gestational weight gain and to discover how pregnant women can be best supported to maintain physical activity and healthy dietary behaviours. This is achieved through a programme of research comprising three related studies. Study One explored the antenatal clinical management of weight and weight gain through one-to-one interviews with Antenatal Clinical Midwifery Managers across Wales (n=11). Findings showed wide variation in management of weight from unit to unit. Although midwives believed pregnancy to be a perfect opportunity to encourage healthier behaviours, many identified barriers preventing them discussing weight with women. In Study Two semi-structured interviews with pregnant women (n=15) investigated views on personal weight management during pregnancy. Again pregnancy was seen as an ideal time to improve health behaviours due to a perceived increase in motivation and many women identified specific goals. However, in the face of various barriers, it was apparent that the motivation which initially identified healthy lifestyle goals was unable to sustain this behaviour throughout the pregnancy. Finally Study Three looked at the feasibility and acceptability of a midwife-led intervention informed by the two preliminary studies. The ‘Eat Well Keep Active’ intervention programme designed to promote healthy eating and physical activity in pregnant women (n=20) was based upon the Self Determination Theory framework for enhancing and maintaining motivation and utilised motivational interviewing. Results indicated that the intervention was received well by participants who reported that it positively influenced their health behaviours. The ‘Eat Well Keep Active’ programme may be a suitable intervention to encourage and facilitate women to pursue a healthier lifestyle throughout their pregnancy.

It is acknowledged that society's image of a midwife is synonymous with delivering a new life and new beginnings to a family. In essence the midwife is recognized as occupying a pivotal position at key times in a woman's life. Thankfully, almost all pregnancies result in a healthy baby, however to achieve a positive outcome the midwife is constantly striving to give quality care during the antenatal, intranatal and postnatal periods. The primary focus of this study is the utilisation of a phenomenological framework to capture an understanding of what it is like to be a midwife, from a differing and rarely considered angle. The literature provides increasing evidence as to the impact on mothers and fathers of having a stillborn baby. However, few studies have sought to ascertain what does it mean to be a midwife and experience delivering a stillborn baby or being party to that event. A phenomenological approach allowed the lived experiences of twelve midwives to be captured by means of semi- structured taped interviews. After transcribing the interviews the data was analysed by means of a constant comparison approach. Thirty conceptual categories were organised into six conceptual themes that provided the fundamental nature of those twelve midwives lived experience of the phenomenon called a stillbirth event. The data analysis is taken to a further level through reflection upon the emergent implications for midwifery practice and education. That activity culminated in the formulation of a main proposal that being, requesting the midwifery profession to consider the advantages to midwives of being able to access a support framework, which provides the opportunity for guided reflection.

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This thesis investigated practice variation among midwives during the third stage of labour. The study aimed to identify and explain the variety of ways midwives managed the third stage and to see if it was possible to identify midwife characteristics associated with different third stage management practices. Initially emphasis was placed on models of midwifery care in labour and the mechanism by which midwives developed expertise in third stage management. A qualitative approach was used based upon the principles of grounded theory with the constant comparative method utilised to collect and analyse multiple types of data simultaneously. Fifty one midwives employed in two NHS trusts were interviewed with the practice of a further seven midwives observed. An analysis of computer records also took place together with analysis of twenty eight editions of two midwifery textbooks published throughout the 20th century. Multiple types of third stage management were described with inter and intra practice variation revealed among midwives. The complexity of third stage care was exposed through the identification of 22 aspects to third stage practice with between two and five care options available for each aspect. A theory of contingent decision making for the third stage of labour was revealed which explained how midwives adopted different forms of care through a complex decision making process which was contingent on the learning opportunities midwives were exposed to, the context in which practice decisions were made and the philosophical underpinnings of midwifery care. Practice variation was explained within this multi-factorial framework. The thesis highlights the difficulties in standardising midwifery practice and questions the validity of doing so. In this study practice variation in third stage care was a reflection of the individuality of midwives and the way midwives chose to individualise the care of women. In light of this a reappraisal of comparative studies in third stage management is needed together with an evaluation of the role of practice guidelines which attempt to standardise practice.

Part One: Literature Review - Background: The birth plan was introduced as a means of addressing the medicalisation of childbirth. However there is evidence of conflict existing between patient and caregiver regarding its use. Additionally research has begun to reveal the potential adverse effects of the use of a birth plan and its possible implications. This article aimed to review that evidence. Method: Five databases were systematically searched and quality was assessed based upon standardised data extraction tools (Peersman, Oliver & Oakley, 1997) and Gough’s (2007) Weight of Evidence scale. Results: Eleven articles met inclusion criteria. A systematic approach was adopted to review the limited robust evidence base and conflicting results were discovered regarding the positive impact of the birth plan upon birth experience. Conclusions: The review highlighted a dearth of rigorously conducted research in this area. The articles were variable in their quality and in their support of the birth plan facilitating positive birth experiences. Indeed two studies reported that plans may create negative birth experiences. Routine creation of a birth plan may thus be questionable. Part Two: Research Report - Background: The birth plan is widely utilised and yet the research base is limited in its methodology and equivocal in its findings. Given the potential importance of experiences of childbirth upon the mental and physical well-being of both the mother and child, this research aimed to explore these experiences of birth with specific reference to the use of the birth plan. Method: Interviews constructed and conducted in accordance with Interpretative Phenomenological Analysis were undertaken with six primiparous women postnatally. Data from verbatim transcripts were then analysed informed by the same phenomenological perspective. Results: Analysis revealed a number of common and idiographic themes. The super-ordinate themes identified across transcripts were: - narratives that undermine the role of the birth plan, alternative approaches to the written birth plan and knowledge. Discussion: Some of the phenomenology reported by participants resonated with previous published literature. However the current data presented richer accounts of disadvantages as well as benefits. Clinical implications of these findings are discussed. Part Three: Critical Appraisal - Reflections on the overall research process, areas of learning and development, methodology issues and limitations of the study are provided.

Worldwide, a significant number of diabetic pregnancies end up in caesarean sections (CS). This has been documented in several studies, but none have ever addressed this high caesarean section rate in terms of myometrial contractility. I intended to investigate the hypothesis that the high caesarean section rate seen in diabetic pregnancies is due in part to reduced myometrial contractility, but potentially treatment of the individuals diabetic disease with insulin could also be a contributor to decreased myometrial contractions. In order to test this hypothesis I examined spontaneous contractility in and responses to high potassium depolarisation in myometrial strips dissected from myometrial biopsies obtained with full consent from women undergoing caesarean section to test if contractile activity differed between the two groups. I also investigated the histology of sections from both groups of women to see if the diabetic disease caused any alterations in myometrial muscle content and collagen deposition. To examine the effects of insulin, strips of myometrium diabetic and non-diabetic women and 22day pregnant Wistar rats were exposed to increasing doses of insulin and the response in contractility were measured. In some experiments intracellular Ca signals were simultaneously measured to also see if insulin had an effect on intracellular calcium signalling. To investigate insulin's mechanism of action Ouabain (Na pump inhibitor), tetraethylammonium (K channel inhibitor) and M~CD was added to contracting myometrium combined with insulin. The expression of insulin receptors was also examined in the myometrium from diabetic and non-diabetic women and related to the different responses to insulin seen in both groups. Preliminary experiments to examine the insulin signalling pathway in the myometrium were also carried out by examining the expression of pAkt in response to known concentrations of insulin. Myometrial contractility in diabetic women was found to be impaired compared to non- diabetic women, whereby the force of myometrial contractions was significantly reduced in diabetics. I also found that insulin caused a significant dose dependent decrease in the force of myometrial contractions in pregnant rats and both diabetic and non-diabetic women, which was mirrored in the underlying calcium transients. When Ouabain was added to contracting myometrium in combination with increasing concentrations of insulin, the negative effect of insulin on contractility was inhibited for all concentrations. TEA also significantly inhibited the negative effect of insulin on myometrial contractility. Preliminary investigations using M~CD in combination with insulin showed that there may also be a role for caveolae in the mechanism of insulin action in the myometrium. The effect of insulin on myometrial contractility was more marked in non-diabetic women compared to diabetics. To address this expression of insulin receptor beta subunit in the myometrium from both groups was quantified by immunohistochemistry and western blotting. The results showed a significant reduction in the amount of IR~ expressed in the myometrium of diabetic women compared to non-diabetics. As myometrial contractility was shown to be impaired in diabetics, the reasons for emergency caesarean sections over the last 10 years at Liverpool Women's Hospital were investigated. The results showed that diabetic women had a high chance of emergency caesarean section due to delay in the first stage of labour than non- diabetics which supported our in-vitro findings of poor myometrial contractility in diabetic women. In conclusion this study showed that myometrial contractility is reduced in diabetic women and that insulin the main treatment for diabetes further reduces contractility. Therefore these results may in part explain the high caesarean section rate seen in diabetic pregnancies.

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