This thesis examines the effectiveness of a new curriculum for the preparation of midwives. Data were collected over a three year period in seven case study institutions, from women who had their babies in one large maternity unit and from a professional network of experienced midwives whose role is to advise the statutory body regulating midwifery programmes in England. The overall intention of the study was to improve the pre-registration midwifery curriculum locally and influence national policy and guidelines. Action research provided the framework for the study where a multi-method approach was largely qualitative to attempt to capture the context and complexity in which the midwifery education programme operates. The research explores and compares curriculum intentions with the perceived experiences of the curriculum as reported by key stakeholders. The development of a holistic integrated model of a competent midwife provided the framework for discourse on curriculum effectiveness, the design of an assessment matrix and recommendations for curriculum improvement. Overall the three year pre-registration route into midwifery was found to be an effective preparation for contemporary midwifery practice as judged against a model of a competent midwife. However there was evidence to suggest that not all students were equipped to practice competently and confidently in contexts of uncertainty and change in the health service. Factors which emerged as influencing curriculum effectiveness related to: recruitment and selection, curriculum structure, appropriateness and robustness of assessment schemes, the preparation of and support for assessors and the role of the midwife teacher in assessment in practice settings. Diagnosing problems and initiating actions as a collaborative process formed an important part of designing and implementing an ideal curriculum in changing and constrained health and higher education contexts. The need for on-going dialogue, critical reflection and research to facilitate and assess learning more effectively in the caring professions emerged as necessary to ensure only competent practitioners have a licence to practice.

<i>Background</i>. Today, Mendelson's syndrome (pneumonitis following the aspiration of gastric contents) is a major cause of the small, but apparently irreducible number of maternal deaths associated with anaesthesia. Previous research has been directed at the relationship between the physical characteristics of the aspirate and the severity of the ensuing pneumonitis. Prophylaxis, logically based on this knowledge has been directed at reducing the volume and increasing the pH of the stomach contents of women in labour, and at specific measures to reduce the risk of aspiration at the induction of anaesthesia. Despite this, the maternal mortality attributed to Mendelson's syndrome remains essentially unchanged. The operation of an additional, but previously unconsidered variable might explain both the apparent increase in severity of Mendelson's syndrome and the failure of prophylaxis. This thesis reports attempts to elucidate the place of lung water content in this context. <i>Review of the literature and theoretical discussion</i>. This falls into two distinct but inter-related categories: (a) Circumstantial evidence, already existing in the literature for lung water handling being altered in pregnancy and the puerperium, for example the reports of B₂ sympathomimetics inducing pulmonary oedema when used for tocolysis. (b) A detailed review of the present understanding of the pathogenesis of pulmonary oedema, together with the alterations in maternal physiology which accompany normal pregnancy. The two have not previously been considered in conjunction. From this base it is possible to proceed to a theoretical prediction of the consequences of such common interventions as the use of intravenous fluids, oxcytocics and endotracheal intubation under light general anaesthesia. <i>Clinical Study - Normal Primagravidae</i>. Twenty normal primagravidae were investigated for evidence of increased lung water. Detectable increases were found in seven. There was a positive correlation with plasma volume and water turnover. <i>Clinical Study - Pre Eclampsia</i>. Seventeen primagravidae having a pregnancy complicated by pre eclampsia were investigated for evidence of increased lung water. Detectable increases were found in six. There was a positive correlation with fluid balance. <i>Mouse Model</i>. The lungs of pregnant and non pregnant MF1 mice were examined by electron microscopy to confirm and if possible elucidate the expansion of the interstitial tissue detected by the clinical study. A stereological method of point counting allowed volumetric quantification of the tissue components and measurement of surface areas and thicknesses. The results showed that in pregnant mice: (1) Total lung volume was increased but not significantly; (2) The volume and surface area of alveolar lining cells was increased; (3) Pulmonary blood volume was unchanged; (4) Capillary surface area was unchanged; (5) The interstitial compartment was expanded. Within this compartment: The cellular component was unchanged The volume of collagen was unchanged The amorphous component was enlarged Basal lamina volume was increased <i>Appendix A</i>. A magnetic resonance imaging method of lung water measurement was developed with the intention of using it in pregnancy but was not sufficiently sensitive for this purpose.

This ethnographic study using participant observation, aimed to explore the issue of informed consent to procedures undertaken during the intrapartum period. It involved recruiting 100 healthy women, who went into labour spontaneously at term, at the point they were admitted to the labour ward. The data collection took place in a large teaching hospital in an East Midlands city from April 1997 until December 1999. The subjects (health professionals and women) were observed throughout the labour until the woman and baby were transferred to the postnatal area. Follow-up interviews were conducted with the woman and midwives, within 24 hours, using a semi-structured format based on the observations. The study revealed that it was difficult to obtain informed consent during labour. Contrary to professional belief, not all women wanted to be fully informed about intrapartum care and procedures, or wanted anything other than a pain free and easy labour that they perceived the western medical-technocratic model of care would offer them. Although the midwives' knowledge of legal and ethical issues concerning consent was variable and limited in the majority of cases, they attempted to empower women to make intrapartum choices. However, this was often constrained by the culture of the labour ward environment and the extent to which they adhered to policies and procedures. In cases where medical intervention became necessary, a minority of midwives felt personally disempowered. The obstetricians and paediatricians observed, appeared to be less effective communicators than anaesthetists, often leaving it to the midwife to explain issues to the woman. It is envisaged that these findings, as well as the stereotypical models of the labouring woman and the attending midwife that developed, and the resulting recommendations, be used in partnership between maternity service and education providers to ensure that health professionals not only have effective communication and interpersonal skills, but also are more conversant with the legal and ethical implications of consent.

This thesis examines the function of discursive paradigms in the process of subjectivisation and the formulation of objects in the development of the human sciences. The history of childbirth practices exemplifies the operations of paradox and paradigm, and of epistemic changes and continuities, in relation to medical, ethical, and pedagogic discourses. The recent past has brought rapid change in the practices and outcomes of parturition with regard to technologisation, and the improvement in mortality rates. The achievement of technological childbirth has a complex and paradoxical history, and should be understood other than as an inevitable and progressive phenomenon of scientific endeavour, or as a conspiracy of patriarchy which victimises and subjugates women as a matter of intentionality. The histories of the parturient and of the midwife are only partially linked. An examination of childbirth history reveals some of the implications of phallogocentricity for the history of women and for the constitution of gender and gender relations. Midwifery has its own unique but unmistakeable place in the historical discourse of pathologisation and professionalisation - and cannot be regarded simply as an arena of masculine appropriation. The mechanisms for change in parturial practices have been developing to facilitate the modifications of recent history since around 1800, but there are discursive resonances which are linked also to changes in pedagogic organisation which began in the Middle Ages. Further, in order to analyse and evaluate the history of parturition over the past two hundred years, it is necessary to examine the paradigmatic structures based upon dialectical reasoning which have dominated the development of the human sciences since antiquity. Childbirth provides examples of many historical exigencies which informed a panoply of disparate effects, but it is also in many respects unique and anomalous. An exploration of the operations of power, knowledge and influence in this sphere, reveals as much in terms of its resistances as its susceptibilities, to medical appropriation. The history of childbirth is unusual insofar as the technologies and innovations that developed in relation to it, were in fact, slow to be implemented. Evidence of such paradigmatic dysjunction is provided by the examples of the use of forceps, asepsis and anaesthesia in the nineteenth century. This thesis addresses aspects and effects of professionalisation, and the increasingly disciplinary implications of expert discourses for the pregnant and parturient woman in the twentieth century.

"I know that every day I am gaining experience ... learning more" (Int. 6(a)) This thesis examines the social practices and associated learning that shape the meaning of midwifery for new members of the profession. In doing so it explores the extent to which the implications of practice either liberate or circumscribe midwives' identity formation. The thesis further suggests how this identity formation may impact upon commitment to a long term career in midwifery. The theoretical framework for this thesis acknowledges that continuing professional development and evidence of recognised learning activity is, for all midwives, a professional requirement. However, less attention has historically been paid to the unstructured, unintended and relatively informal learning that occurs within and throughout midwives' involvement in everyday practice. It is through these forms of learning, and drawing upon data elicited through surveys, interviews and diaries, that this thesis seeks to make a contribution. Using a social model of learning, particularly through Wenger's (1998) work on communities of practice, the development of identity is presented as a negotiated process mediated to a greater or lesser degree by workplace relationships. Whilst relationships with pregnant women form an important element of this process, the thesis argues that collegial relationships generally assume greater importance and impact on the development of identity and meaning for newly qualified midwives. By situating the everyday experiences of newly qualified midwives within a broader theoretical debate about social learning, identity and the making of meaning, this thesis suggests that the contemporary 'doing' of hospital based midwifery remains within what are fairly narrowly prescribed, contested, yet firm boundaries. The development, existence and negotiation of these boundaries is central to the space which pregnant women, midwifery and midwives can occupy. These boundaries are simultaneously hierarchical, intra professional and personal. Furthermore, in practice, these boundaries are frequently unclear and rapidly changing. Whilst this contributes to a potentially dynamic opportunity for identity formation, the thesis demonstrates how this also transpires to contribute to an unstable, frustrating and frequently challenging context particularly for newly qualified members of the profession. Overall, this thesis contributes to an understanding of the development, or lack of development, of midwifery practice at theoretical, conceptual and practical levels. Viewing practice as social learning offers a new perspective on the opportunities and challenges inherent in the current model of care. Simultaneously it suggests a new perspective on the recruitment crisis faced by the profession and accordingly the opportunity for new potential solutions.

The aim of this study was to assess risk factors to PTSD following childbirth incorporating a longitudinal design. Since the introduction of DSM-IV (APA, 1994) there has been an awareness in the literature that women can develop PTSD following childbirth. The first study in this thesis provides a comprehensive review of the literature in this area and the clinical implications of the disorder. The aim of the second study was to investigate the factor structure of a questionnaire measure (PLDQ) that has been used in past studies to assess women's perceptions of labour and delivery. The findings from this study indicate that the PLDQ consists of three internally reliable factors that can assess a woman's perception of pain, staff support/care and fear during labour and delivery. The scale can differentiate among women on these factors according to type of delivery. The aim of the third paper was to assess risk. factors to PTSD across time in the antenatal period, appraisal factors during delivery with the PLDQ, and maintenance factors in the postnatal period. There is an absence of studies in the literature that assess risk factors to PTSD over time. The results of this study indicate that postnatal depression (PND) and a negative appraisal of staff support and care during labour and delivery can predispose women to PTSD at 5-8 weeks following delivery. At 10 -14 weeks the relationship between PTSD and PND was still consistent. The clinical implications of the research are discussed for screening women at risk of PTSD following childbirth, assessment of a woman's appraisal of a difficult labour and delivery and the provision of support in the postnatal period.

No description available.

One of the crucial events during mammalian embryogenesis is the process of implantation. Implantation enables the embryo to invade the uterine endometrium and to gain access to the maternal circulation. The attachment reaction requires a highly coordinated dialogue between the implanting blastocyst and the receptive uterus, known as the embryo-uterine cross-talk. Since the blastocyst expresses multiple Wnt genes, in this study, we have characterized the role and regulation of the Wnt/-catenin pathway in embryo-uterine communication. Using a transgenic mouse that reports Wnt signalling through the canonical pathway, we have demonstrated that the Wnt/-catenin pathway was transiently activated in the regions of the uterine luminal epithelium apposed to the blastocyst at the time of implantation. Activation of this pathway within the endometrium depended on the presence of the blastocyst and required the oestrogen surge. We further demonstrated that activation of the Wnt/-catenin pathway was essential for proper implantation to occur. One possible mechanism that regulates the responsiveness of the luminal epithelium to Wnt is the regulation of components of the Wnt pathway. We show that there is dynamic pattern of expression of the components of the Wnt pathway at the time of implantation. Furthermore, we demonstrate that LIF signalling is required for the expression of a subset of these Wnt components in luminal epithelial cells at the time of implantation. Our results demonstrate that the LIF and Wnt signalling pathway form a network involved in coordinating the process of implantation As Wnt/ß-catenin signalling is essential for embryo attachment, we proposed / Le processus de l'implantation embryonnaire joue un rôle crucial lors du développement des mammifères. L'implantation de l'embryon est un processus extrêmement complexe au cours duquel l'embryon va d'abord s'apposer, puis adhérer à l'endomètre pour ensuite y pénétrer. Ultérieurement, il a été démontré que le blastocyste exprime plusieurs gènes de la famille Wnt. C'est pour cette raison que dans cette thèse, j'ai décidé caractériser le rôle et la régulation de la voie de signalisation Wnt/-catenine lors du dialogue materno-fœtal. Nous avons utilisé une souris transgénique qui permet de contrôler la voie de signalisation Wnt/-catenine. Ainsi, nous avons démontré que la voie de signalisation Wnt/-catenine était activée de façon transitoire dans les cellules épithéliales du lumen de l'utérus, dans la région adjacente au blastocyte au moment de l'implantation. L'activation de cette voie de signalisation dépend de la présence du blastocyste et de la sécrétion d'oestradiol. Nous avons également démontré que l'activation de la voie de signalisation Wnt/-catenine était essentielle au processus d'implantation embryonnaire. Par la suite, nous avons examiné la possible interaction entre la voie de signalisation Wnt et LIF. En effet, dans les souris mutantes pour le gène LIF, la voie de signalisation Wnt/-catenine n'est pas activée. Grâce à la technique de rt-PCR, nous avons caractérisé le profil d'expression des récepteurs Frizzled, des co-récepteurs LRP, des antagonistes sFRP et DKK et des gènes Wnt dans les souris mutantes pour le gène LIF et dans les souris de type sauvage. Nous avons démontré que les composa

Thesis (M. P. H.)--University of Hong Kong, 2005. / Also available in print.

Thesis (Ph.D.)--University of Adelaide, Dept. of Obstetrics and Gynaecology, 2005? / "March 2005" Includes bibliographical references (leaves 148-164). Also available electronically.