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LD2668 .T4 1962 N66

<p>This study was to determine if any difference exists in the rates of cesarean birth, emergency room visits and preterm birth in African-American women who participated in CenteringPregnancy^&reg; group prenatal care in comparison with those in traditional prenatal care. Prenatal care under this model emphasizes risk assessment, health promotion, social support and education in a group setting of between eight and twelve patients. The effectiveness of CenteringPregnancy has had favorable clinical and behavioral outcomes, as well as high patient and provider satisfaction. Since few studies have researched outcome variables, this study was to answer if CenteringPregnancy prenatal care is related to improved birth outcomes than traditional prenatal care. Leininger&rsquo;s Transcultural Nursing Theory guided this study to provide a comprehensive and culturally sensitive nursing approach in caring for pregnant African-American women. The population was a convenience sample of African-American women between the ages of 15 and 38 years of age. A retrospective chart review was utilized for data collection and a total of 61 CenteringPregnancy charts and 62 traditional prenatal care charts were reviewed looking at the rates of preterm births, cesarean births and emergency room utilization between the two groups of women. A bivariate statistical analysis using the <i> t</i>-Test was utilized to describe any differences between the patients in the two different types of prenatal care and a chi-square was used to analyze any difference in frequency of preterm births and cesarean births between the two types of prenatal care. The results indicated that African-American women receiving CenteringPregnancy prenatal care had fewer preterm births than African-American women in traditional prenatal care (1.6% vs 11.3%). However, there was no evidence found that African-American women receiving CenteringPregnancy prenatal care had less cesarean births or utilized the emergency room during their pregnancies less frequently. </p>

The success of any civilisation rests on a number of factors, to include their ability to procreate and produce heirs. This given, the health of women in any society is of most importance given their primary role in both birth and raising children. The study of medicine dedicated to the care of women in ancient Egypt is of vital importance and to this end, various archaeological finds have been consulted and analysed. Information in the field gynaecology shows a relatively advanced discipline with many overlaps with modern medicine and modern pharmacopoeia. Information on obstetrics is more limited with reliance on mythological texts, inscriptions, artifacts, conjecture and deductive reasoning required. A lot of areas still require exploration in the field and the study raises issues for future research / Biblical and Ancient Studies / M.A. (Ancient Near Eastern Studies)

The effects of undertaking a regular exercise programme during and following pregnancy were investigated with healthy primigravid women within Ayrshire Central Hospital, Irvine. A randomised control trial was used with subjects being randomly assigned to either a control group who continued with the existing antenatal education programme or an exercise group who had the addition of participating in an aerobic exercise programme. In early pregnancy, no significant differences were found between the groups in relation to activity levels or mean scores of psychological variables with the exception of the control group having significantly more positive scores for perceptions of body image. During and following pregnancy, the exercise group maintained their scores on all psychological variables i.e. perceptions of coping assets (positive psychological well-being), coping deficits (negative psychological well-being), physical well-being, body image, somatic symptoms experienced, attitudes to marital relationships, sex and pregnancy. In contrast, the control group tended to have significant reductions in perceptions of the ability to cope (positive psychological well-being), physical well-being, body image, somatic symptoms experienced, attitudes to marital relationships, pregnancy and sex during pregnancy in addition to an increase in perceived coping deficits (negative psychological well-being).The exercise group participated in a significantly higher number of episodes of physical activity sessions than the control group. No significant relationship was noted between frequency of physical activity and responses to psychological indictors in post pregnancy. In conclusion, women who participated in regular physical activity tended to have a protection against a reduction of psychological well-being as measured by a variety of psychological constructs. The maintenance in psychological well-being was experienced both during and following pregnancy and there was no indication of any risk to the pregnancy or the baby. This was in contrast to the significant reduction in psychological well-being experienced by the women in the control group during the same period.

Obesity is a global health problem and the current available evidence from the literature suggests that obese women may suffer from a wide spectrum of reproductive complications. The current understanding of obesogenic effects on the peri-implantation endometrium is limited and has become an important research topic as the emerging clinical evidence from the published studies indicate the possible role of the endometrium. The first part of this thesis addresses the clinical question of whether an early pregnancy outcome is affected by the body mass index and whether there is any difference in time taken to achieve pregnancy in obese women with recurrent miscarriage when compared to normal weight women. The results are in chapters 3 and 4, where we demonstrated that obese women were more likely to have miscarriage of empty gestational sac or anembryonic pregnancies. In recurrent miscarriage context, the obese women were more ‘super-fertile’ suggesting the possible loss of an endometrial ability to select normal from abnormal pregnancies. The second part of this thesis provides an analysis of the peri-implantation endometrial stromal compartment in normal weight and obese women. In chapter 5, using immunohistochemical methods it was shown that there was no difference in the uterine natural killer cell and macrophage density in the peri-implantation endometrium of different weight groups. This suggests that the endometrial dysfunction in obese women with reproductive failure does not appear to be immune cell mediated. In chapter 6 it was shown that the clonogenecity of endometrial mesenchymal stem cells (W5C5+) was significantly negatively correlated with the BMI. The obese women had significantly reduced cloning efficiency of W5C5+ cells when compared to normal weight women, suggesting of a possible sub-optimal regenerative capacity of the endometrium in obese women. Finally, chapter 7 showed a potential association between obesogenic environment and impaired stromal cell decidualisation. Using an in-vitro model, it was shown that there was no significant difference in the expression of decidualisation markers (PRL and IGFBP1) in the decidualising endometrial stromal cells from normal weight women when compared to high BMI women. However, when the stromal cells were decidualised in an artificial obesogenic environment, the PRL expression was significantly inhibited in the presence of supernatant from adipose tissue explants of obese women when compared to normal weight women. In summary, the findings from my work have provided an understanding of the peri-implantation endometrium in obese women and evidence to suggest that the endometrial stromal function is possibly facilitated by metabolic influences.

Dysfunction of the myometrium is a major contributor to preterm labour. The current limitations to effective management of preterm labour is in large part due to our, as yet, incomplete insight into the mechanisms that underlie uterine excitability. The uterus goes through a period of activation towards the end of pregnancy during which the myometrium develops the ability to deliver the baby. Gap junctions are among the most important molecular entities involved in this activation process. In this thesis, a mathematical model based on FitzHugh-Nagumo dynamics is used to study the role that gap junctions play in controlling the excitability of the myometrium. Spatial heterogeneity is introduced into the network through stochastic assignment of coupling strengths based on physiological statistics. It is demonstrated that heterogeneity amplifies the ability of a locally applied stimulus to generate global activity and that the ability of the stimulus to excite the network is strongly dependent on the local spatial correlation structure of the couplings. In networks driven by a pacemaker cell, large coupling strengths preclude activity by reducing the frequency of the stimulating oscillations. The model is extended to incorporate voltage-dependent gap junctions. It is established in the literature that gap-junctional conductance is dependent on the transjunctional voltage of neighbouring myocytes. Two conductance relationships have been observed corresponding to gap junctions composed of connexin-43 or connexin-45 proteins. It is demonstrated here that networks with only connexin-45 proteins are unable to exhibit global excitability whereas networks with connexin-43 proteins always display full activity. The mathematical models are supported by analysis of human and rat RNA expression data which shows that connexin-45 is down-regulated at term. It is hypothesised that connexin-45 blocks activity in the uterus throughout gestation, and is down-regulated at term to allow the uterus to deliver the powerful contractions associated with labour.

The competence of oocytes to mature and undergo fertilization and embryonic development is known to be influenced by the conditions under which their maturation occurs. Suboptimal maturation in vitro currently limits the use of immature oocytes for embryo creation. This project examines the relationship between the conditions of in vitro maturation of human oocytes and aspects of their subsequent developmental competence through the in vitro creation and analysis of research embryos. This work is essential in defining effective and safe conditions for the use of human immature oocytes in programmes of clinical treatment to alleviate infertility. Human immature oocytes were exposed in vitro to various concentrations of meiosis activating sterol (FF-MAS), an endogenous mediator of follicle and oocyte function, or epidermal growth factor (EOP), in the absence of other hormonal support. Their survival and further development relative to controls were measured by assessing the proportions maturing, fertilizing by sperm injection (ICSI), and cleaving in vitro. Image analysis was used to measure various dimensions of oocytes and embryos daily. A pilot study of chromosome and spindle configurations at meiotic metaphase was also conducted. The major findings of this project are that FF-MAS supplementation of maturation medium has different positive effects upon immature oocytes arising from patient groups having different endocrine profiles and yielding differing oocyte populations. FF-MAS at 30J.lg/ml promotes survival of oocytes from unstimulated patients with polycystic ovaries (p<O.02S) and promotes maturation of oocytes from gonadotrophin-stimulated patients undergoing ICSI treatment (p<O.OS). A response to FF-MAS in terms of oocyte growth was evident in immature oocytes from both types of patients (p<O.05). Mature, immature and atretic oocytes from patients with pca became significantly different in terms of oocyte diameter when cultured in FF-MAS (10 or 30J.lg/ml), contrasting with those cultured in control conditions, or obtained from patients undergoing ICSI treatment. However, significant (p<O.OS) enlargement of oocyte diameter between oocyte recovery and the day of insemination occurred when oocytes from patients undergoing ICSI were cultured with FF-MAS. The proportion of mature oocytes fertilized by ICSI was not affected by FF-MAS in the maturation culture but there was a non-significant tendency towards an improved chance of cleavage when FF-MAS was present. Embryonic development beyond early cleavage was not observed, despite conditions supportive of blastocyst production from in vivo matured oocytes, suggesting that developmental competence remained compromised even in the presence of FF-MAS. A pilot study to ascertain whether the incidence of spindle defects or chromosome irregularities in in vitro matured metaphase oocytes was influenced by the presence of FF-MAS gave equivocal results. This project has confirmed that the ongoing development of in vitro matured oocytes may be affected by the conditions of their maturation. Specifically it has demonstrated for the first time the positive effects of FF-MAS upon human immature oocyte development in vitro, and provided the first quantitative non-invasive analysis of oocyte growth during maturation under various conditions in vitro.

Glucocorticoids have been implicated in many processes including successful embryo implantation, placentation, and the growth and development of the fetus. Glucocorticoid treatment has been advocated as a treatment to improve reproductive outcome for a number of reasons. Prednisolone treatment has been associated with improvement in clinical outcome in women with recurrent miscarriage and improvement in outcome of In Vitro Fertilisation. Steroids have been found to reduce the high levels of uterine natural killer cells which have been associated with recurrent miscarriage and recurrent implantation failure. Glucocorticoids stimulate peri-implantation human chorionic gonadotrophin secretion from trophoblast of early human embryo and accelerate trophoblast growth and invasion. Elevated uterine NK cell levels during the implantation window are associated with reproductive failure and can be repressed by oral glucocorticoids. We have shown that decidualizing human endometrial stromal cells profoundly up regulate the expression and activity of 11beta-hydroxysteroid dehydrogenase type 1, the enzyme that converts inert cortisone to active cortisol; thus establishing a local cortisol gradient and activation of glucocorticoid and mineralocorticoid receptors. We also found that elevated levels of uterine natural killer cells in the stroma underlying the surface epithelium of endometrium are associated with defective decidualization of resident stromal cells, inadequate cortisol biosynthesis and suboptimal induction of corticosteroid-dependent enzymes involved in lipid droplet accumulation and retinoid transport pathway. Thus, impaired decidualization limits the induction of a local cortisol gradient in the stroma underlying the surface epithelium. This in turn accounts for possible inappropriate recruitment of uterine natural killer cells and suboptimal expression of metabolic genes involved in lipid biosynthesis and retinoid storage pathway. Based on the findings, we postulate that patients suffering recurrent miscarriage associated with high uterine NK cell density may benefit from corticosteroid treatment in early pregnancy; although this assumption will need to be tested in a larger clinical trial.

Different patterns of care and a range of lead professionals have influenced care provision in relation to childbirth. The role of a midwife has been influenced by historical factors, research and service changes within the National Health Service. Little is known about how the role of the midwife is perceived. This study explored the views of women and midwives relating to the role of the midwife. Mixed methods of data collection were utilised. In the first phase of the study 4 focus groups (a total of 9 women) were performed. In the second phase of the study longitudinal interviews were conducted. A total of 10 women participated in this phase. The interviews were performed at 4 different time points of their childbearing experience. A total of 40 interviews were conducted. Additionally diaries from the 10 women were completed, to capture information between the interview time points. Following the initial exploratory phase , a postmodern feminist technoscience theoretical stance underpins the second phase of this study; in particular it draws on the work of Donna Haraway. Haraway’s notion of ‘situated knowledges’ provides the opportunity to locate the views of women and midwives. This provided the opportunity to utilise her notions of ‘modest witness’, ‘cyborg’, ‘goddess’, ‘material-semiotic’ and connect to their perceptions. One facet of the study’s originality lies in matching the women’s and midwives’ ‘situated knowledges’, by interviewing the 10 midwives who were present at each of the 10 women’s birth experiences. Analysis using thematic networks was used to construct basic, organising and global themes. The findings indicate that the use of technology has a powerful influence on women’s perceptions in relation to the role of the midwife. Women and midwives connected with technology through material-semiotic connections, which has led to cyborgification within a consultant led model of care and birth environment. Women overwhelmingly perceived that birth was safer in hospital, due to the presence of technology and doctors; doctors were perceived as the decision maker and the midwife as a ‘handmaiden’. ‘Being’ and ‘doing’ midwives were recognised. The midwives were all situated in a different place within these categories, depending on their values and experiences. Generally the ‘doing’ midwives were free to ‘do’, as they supported the biomedical culture of the environment they were working in. ‘Being’ midwives supported the natural elements of the birth process, they adapted to the role of a ‘hybrid’ midwife within a consultant led environment, interchanging their technological skills for normality skills when they were secluded from interferences of the medicalised culture. This study provides evidence to inform practice developments within midwifery and makes a contribution to feminist theorising. It asserts that the culture of childbirth in contemporary society is technological, medically led and the normal birth process is not valued. This has contributed to cyborgification of women and midwives within a consultant led setting. An advancement of Haraway’s theory has been made from the emergence of the way in which the ‘being’ midwife morphs into a ‘doing’ midwife when she feels that she has to conform to the medicalised culture of the environment or from women’s expectations of their birth experience.