Diss. (sammanfattning) Stockholm : Karolinska institutet, 2006. / Härtill 4 uppsatser.

Purpose The objective of this thesis is to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). Four gaps are identified for management of OBPI in Canada: 1) The historic poor use of evidence, 2) Timing of referral to multidisciplinary care, 3) Indications and timing of operative nerve repair, and 4) Distribution of expertise in Canada. Methods The guideline is intended for all providers delivering perinatal care, and all specialists delivering care to OBPI patients. The consensus group was composed of clinicians representing each of Canada’s ten multidisciplinary centres. An original systematic review comparing the effectiveness of primary operative versus nonoperative management, and a review of Canadian OBPI epidemiology were completed. Quality indicators for referral to a multidisciplinary centre were established. Recommendations were based on best evidence, and interpretation of this evidence by clinical experts. An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori following RAND procedures. Results Nerve repair reduces functional impairment in OBPI versus nonoperative management of similar patients, and modern microsurgery has low incidence of major adverse events. The quality of evidence was low. Residual impairment is underestimated and uncharacterized in nonoperative literature. OBPI incidence was at least 1.24 per 1000 births in Canada, and consistent over the study period. The strongest risk factors for OBPI were comorbid humerus fracture, shoulder dystocia and comorbid clavicle fracture. Most patients were not referred to a multidisciplinary centre. The guideline group approved seven recommendations. Discussion Recommendations address the identified gaps in care, and guide identification, referral, treatment and outcome assessment for OBPI. The process established a new network of opinion leaders and researchers for further guideline development, and multicentre research. The next step is to facilitate the implementation of the recommendations. / Thesis / Master of Science (MSc)

Title: Prevalence of asymmetric lateral disability on musculoskeletal apparatus in the neonatal age and infancy. Objective: The purpose of this research thesis was to compile issues of possible types of asymmetric musculoskeletal impairment observed in neonates and infants, identify potential causes of these asymmetries and lateral predilection for reported types of asymmetries. The main subject of discussion are just found lateral predilection of asymmetries and relationship of their causes with prenatal, perinatal or postnatal period. Methods: This thesis is structured in the form of literary research and has descriptively- analytical character. Results: On the basis of the analysis of available sources about the asymmetric musculoskeletal impairment in neonates and infants a comprehensive picture of possible types of these impairment, their causes and lateral predilections was made. The vast majority of reported asymmetric impairment seems related to prenatal or perinatal period. Key words: asymmetry in infancy, birth injuries, congenital defects, positional preference

Title: The biomechanical effects of levator ani muscle laceration injuries after vaginal delivery Objectives: The aim of this thesis is to sum up current knowledge about the normal structure and function of levator ani muscle and findings about dysfunctions of a pelvic floor. By means of biomechanical instruments to analyse how the lower part of levator ani muscle closes (puborectalis muscle) during unilateral avulsion lesion. On the basis of computer simulation of biomechanical properties of the pelvic floor during avulsion lesion to describe the theoretical solutions for the therapy of the main types of dysfunctions of the pelvic floor. Methods: Biomechanical analysis was used with a help of computer model of muscular pelvic floor with a help of the ABAQUS model. This model with matched properties of muscular tissue was influenced by the standard pressure which influences the pelvic floor for a person of 80 kilos standing at rest. This model simulated unilateral avulsion lesion and biomechanical variables were observed during compensatory activation of uninjured parts of levator with the activity 100%, 50% and 10%. The map of the muscular tone and the rate of movement of the muscles of the pelvic floor were evaluated. Results: Only minimal movement is observed in the intact pelvic floor during...

O desenvolvimento de um método eficiente de avaliação prognóstica precoce seria de grande utilidade na seleção de lactentes com plexopatia braquial obstétrica para cirurgias de reconstrução do plexo braquial. Realizamos uma eletroneurografia bilateral em 33 bebês com plexopatia braquial obstétrica entre 10 e 60 dias de vida. Foram avaliadas e comparadas lado a lado as amplitudes dos potenciais de ação musculares compostos dos nervos axilar, musculocutâneo, radial proximal, radial distal, mediano e ulnar. Os bebês foram seguidos clinicamente até os seis meses de vida, quando foram submetidos a uma avaliação da força de vários grupos musculares e a uma prova funcional. Uma redução da amplitude do potencial de ação muscular composto em qualquer nervo do membro acometido maior ou igual a 90% da amplitude do potencial do membro sadio correlacionou-se com um resultado clínico ruim aos seis meses de idade (p < 0,01). A acurácia prognóstica da eletroneurografia foi de 91% para as lesões do tronco superior, 97% para as lesões do tronco médio e 100% para as lesões do tronco inferior. Nossos resultados indicam que a eletroneurografia parece ser um instrumento útil na avaliação prognóstica precoce de pacientes com plexopatia braquial obstétrica / Early prognostic assessment of obstetric brachial plexopathies would be a major step for rational selection of infants for brachial plexus surgery. We performed bilateral electroneurography of Axillary, Musculocutaneous, proximal Radial, distal Radial, Median and Ulnar nerves in 33 babies (age 10 - 60 days) with obstetrical brachial plexus lesions in order to compare the amplitude of compound muscle action potentials (CMAPs). The babies were followed up for six months and the outcome was classified according to muscle power score and functional performance. A CMAP amplitude reduction in any nerve of the injured side superior or equal to 90% of CMAP amplitude of the normal side was related to an unfavorable clinical result at age of six months (p < 0,01). The prognostic accuracy of electroneurography was 91% for the upper trunk, 97% for the middle trunk and 100% for the lower trunk. Our results indicate that electroneurography seems to be a useful tool for very early prognostic assessment of obstetric brachial plexopathies

This thesis explores women’s experiences of maternal birth injuries, focusing on how gender and sexuality norms affect diagnostics, everyday life and healthcare in Sweden. The empirical material consists of 383 answers to an online questionnaire. The theoretical approaches are centred on how bodies are viewed and valued in a Western society, especially in connection to the social construction of health and illness in relation to gender and reproduction. Existing medical descriptions of maternal birth injuries are explored in comparison to the participants’ own definitions. No clear definition is found and the analysis demonstrates that maternal birth injuries can cause both mental and physical injuries/consequences, arising from both vaginal and caesarean births, and a shift away from mainly focusing on physical damage caused by vaginal delivery is suggested. Everyday life is affected in several ways by the complications that the birth injuries lead to, and many participants suffer severely, both physically and mentally. A majority of the participants seek care for these complications, and their experiences of Swedish healthcare reveal an attitude wherein maternal birth injuries are seen as something normal. Many do not receive sufficient care, if treated at all, and gender and sexuality norms affect how medical personnel act and speak. This demonstrates patriarchal structures, medical hierarchies and heterosexual norms within Swedish healthcare, which devalue female-coded bodies as well as their pain and pleasures. Hence, this thesis addresses the importance of researching the effect of underlying structures on care of women in general, and of maternal birth injuries in particular. / Den här uppsatsen handlar om förlossningsskador och utgår från kvinnors erfarenheter av bemötande och behandling i Sverige. Materialet består av 383 enkätsvar. De teoretiska utgångspunkterna fokuserar på hur kroppar är värderade samt hur sjukdom och hälsa är socialt konstruerade, speciellt i relation till genus och reproduktion i västerländska kontexter. Existerande medicinska förklaringar av förlossningsskador jämförs med deltagarnas egna definitioner och det framkommer att ingen entydig definition existerar. Nuvarande fokus är främst på fysiska skador från vaginala förlossningar men eftersom analysen visar att kejsarsnittsförlossningar också kan leda till förlossningsskador samt resultera i både mentala och fysiska komplikationer/skador, föreslås ett vidgande av innebörden i termen. Vardagen påverkas påtagligt för de flesta med förlossningsskador, och många lider både fysiskt och mentalt. En majoritet av deltagarna har sökt vård men deras erfarenheter av svensk sjukvård visar på flera brister och främst en attityd av att förlossningsskador är något normalt. Flertalet får bristfällig vård om de ens behandlas, och normativa föreställningar om genus samt sexualitet påverkar hur personalen talar och agerar. Underliggande patriarkala maktstrukturer och medicinska hierarkier som nedvärderar kvinnligt-kodade kroppars erfarenheter, lust och smärta blir framträdande. Den här uppsatsen visar därför på vikten av att utforska underliggande strukturers påverkan på vård av kvinnor generellt och speciellt i relation till förlossningsskador.

O desenvolvimento de um método eficiente de avaliação prognóstica precoce seria de grande utilidade na seleção de lactentes com plexopatia braquial obstétrica para cirurgias de reconstrução do plexo braquial. Realizamos uma eletroneurografia bilateral em 33 bebês com plexopatia braquial obstétrica entre 10 e 60 dias de vida. Foram avaliadas e comparadas lado a lado as amplitudes dos potenciais de ação musculares compostos dos nervos axilar, musculocutâneo, radial proximal, radial distal, mediano e ulnar. Os bebês foram seguidos clinicamente até os seis meses de vida, quando foram submetidos a uma avaliação da força de vários grupos musculares e a uma prova funcional. Uma redução da amplitude do potencial de ação muscular composto em qualquer nervo do membro acometido maior ou igual a 90% da amplitude do potencial do membro sadio correlacionou-se com um resultado clínico ruim aos seis meses de idade (p < 0,01). A acurácia prognóstica da eletroneurografia foi de 91% para as lesões do tronco superior, 97% para as lesões do tronco médio e 100% para as lesões do tronco inferior. Nossos resultados indicam que a eletroneurografia parece ser um instrumento útil na avaliação prognóstica precoce de pacientes com plexopatia braquial obstétrica / Early prognostic assessment of obstetric brachial plexopathies would be a major step for rational selection of infants for brachial plexus surgery. We performed bilateral electroneurography of Axillary, Musculocutaneous, proximal Radial, distal Radial, Median and Ulnar nerves in 33 babies (age 10 - 60 days) with obstetrical brachial plexus lesions in order to compare the amplitude of compound muscle action potentials (CMAPs). The babies were followed up for six months and the outcome was classified according to muscle power score and functional performance. A CMAP amplitude reduction in any nerve of the injured side superior or equal to 90% of CMAP amplitude of the normal side was related to an unfavorable clinical result at age of six months (p < 0,01). The prognostic accuracy of electroneurography was 91% for the upper trunk, 97% for the middle trunk and 100% for the lower trunk. Our results indicate that electroneurography seems to be a useful tool for very early prognostic assessment of obstetric brachial plexopathies