The present doctoral thesis focuses mainly on the experiences of 20 women and men of becoming and being parents of a prematurely born child and on their perceptions of their contacts with health and medical care services. An additional aim was to investigate the utilisation of health care during the first year of life and its relation to high-risk diagnoses in the neonatal period. Data were obtained by interviews of the 20 sets of parents to infants born at a gestational age of <34 weeks with no serious congenital defects. These parents were interviewed 1-2 weeks after the infant’s birth and at 2, 6 and 18 months of age. The interview texts were subjected to phenomenological and content analysis. Data was also obtained from the records of 36 infants born at a gestational age of <31 weeks and with a birth weight of <1500 g and 36 full-term infants. The records included information regarding contact with health care services including the child health centres (CHCs) and the outpatient clinics of the paediatric and ophthalmic clinics. Finally data from the other two quantitative studies were obtained from three questionnaires: Quality of Care from The Patient’s Perspective, The Swedish Parenthood Stress Questionnaire and The Toddler Behaviour Questionnaire. The result of the studies showed that the utilisation of health care by the very low birth weight infants was higher than that by the fullterm infants in paediatric and ophthalmic outpatient clinics. High-risk diagnoses in the neonatal period did not correlate with utilisation of care except for visits to the paediatric outpatient clinic, especially planned visits. The internalisation of parenthood was described by the parents as a time-dependent process, with four syntheses of experiences – alienation, responsibility, confidence and familiarity. The development and construction of the mothers’ and fathers’ parental identity followed a pattern that could be summarised into three themes: Unexpected start of parenthood, integration of parenthood into the sense of identity and recognition of parental identity. Important turning points in experiences of parenthood often occurred when the infant could be removed from the incubator, when it was discharged from the ward, and when the infant appeared normal compared to full-term infants. The quality of care was judged, from the parents’ and nurses’ perspective. In general the subjective importance of the given care was rated higher than the care actual given in both neonatal care and care at the CHCs. Higher ratings were given to neonatal care compared with the care at CHSs for medico-technical competence. It was also of importance, of both parents, to receive an optimal identity-oriented approach and socio-cultural atmosphere in the neonatal care and the care at the CHSs. High-risk diagnoses in the newborn did not affect the answers. Parental stress of very preterm children, at 18 months of age, did not differ notably from those parents of children born somewhat less premature, but they assessed their children as being rather later in the development of social behaviours. Parents of children who had had a difficult neonatal period were not more stressed when the child was 18 months old than those who had no problems in the neonatal period. In sum, this research project showed that the parents’ expectations and experiences of becoming mothers and fathers in preterm birth was a process of integrating the unexpected start of parenthood into the parents’ sense of identity and their way of being. When the parents developed a relationship with the infant, actively participated in its care on the basis of their own preferences, and received recognition as parents, this process was strengthened. It is therefore important that the professional caring of the staff should meet and involve the natural caring of the parents.

In dieser retrospektiven Pilotstudie zum Einsatz von rekombinatem, aktivierten Faktor VII bei Frühgeborenen (Schwangerschaftswoche < 32, Geburtsgewicht < 1750 g) mit intraventrikulären Hirnblutungen wurden anhand sonografischer Untersuchungen der Blutungsprogress sowie die Nebenwirkungen der Therapie im Vergleich zur Standarttherapie mit Fresh Frozen Plasma untersucht. Die Auswertung erfolgte in zwei Gruppen: innerhalb des Gesamtkollektives und innerhalb der Matching-Gruppe. Es zeigte sich in beiden Auswertungsgruppen ein signifikant geringerer Blutungsprogress in der Therapiegruppe. Außerdem konnte ein früherer Blutungsstopp in der Therapiegruppe nachgewiesen werden. Ein erhöhtes Nebenwirkungspotential von rekombinantem, aktivierten Faktor VII war in diesem Patientenkollektiv nicht eruierbar. Weiterführende prospektive, randomisierte, multizentische Studien zur Evaluation dieses vielversprechenden Therapieansatzes werden empfohlen.

Approximately 1 in 11 births in the United States are preterm (gestation). Within the United States, there are huge racial disparities for risk of preterm birth, an issue understudied and rarely addressed by research in the field. There is a wealth of biological knowledge surrounding pregnancy and labor, but causes for preterm birth are poorly understood. A genetic factor that has been shown to play a key role in many biological processes crucial to a healthy pregnancy and timely labor is microRNA (miRNA). MiRNA have an active role in the regulation of various tissues, especially developing tissues like those found in the placenta and uterus. Additionally, oxidative stress has been shown essential to placental development and the initiation of labor. Here, a study is proposed that aims to address the effect of oxidative stress on myometrial miRNA expression, specifically the miR-200 family and miR-199/214 cluster. This work also underscores the importance of addressing racial disparities with regards to preterm labor during research, while bringing up ethical considerations for conducting such research. The thesis will conclude with an outline of the many considerations vital for discussing the research and analysis of preterm birth disparities using a feminist, antiracist, queer self-reflexive analysis.

The experience of becoming a mother is a personal and social experience influenced by individual characteristics, friends and family, and the infant. The journey to become a mother encompasses concepts of maternal competence and responsiveness. The purpose of this study was to examine maternal competence and responsiveness to the infant in mothers of late preterm infants compared to mothers of full term infants. The conceptual model for this work was based on the work of Reva Rubin describing maternal identity and role development. Maternal competence and responsiveness are components of maternal role and are influenced by social support, maternal self-esteem, well-being, stress and mood. In addition, infant temperament and perception of infant vulnerability influence development of maternal competence and responsiveness. A non-experimental repeated measures design was used to compare maternal competence and responsiveness in two groups of postpartum mothers. One group consisted of mothers of late preterm infants 34-36, 6/7 weeks gestation. The second group consisted of mothers of term infants, >/=37 weeks gestation. Both primiparas and multiparas were included in the study. Data was collected in the initial postpartum period prior to discharge from the hospital and again at six-weeks postpartum. No statistically significant differences in development of maternal competence or responsiveness between mothers of LPIs and term infants were identified. This study adds to our knowledge concerning outcomes of mothers of late preterm infants and development of competence and responsiveness.

Preterm birth, birth prior to 37 weeks gestation, is the leading cause of neonatal mortality and morbidity worldwide. While the uterine cavity and amniotic fluid largely remain sterile throughout gestation, bacterial infections can occur and are associated with preterm birth and/or preterm premature rupture of the fetal membranes (PPROM). Sneathia amnii can be detected as a component of the vaginal flora in healthy women; however, it’s also associated with bacterial vaginosis and preterm birth. Sn35, an isolate of S.amnii, was identified and sequenced through the Vaginal Human Microbiome Project at VCU. Our objective was to classify potential virulence determinants in Sn35 and we successfully identified a putative zinc endopeptidase. The zinc endopeptidase appeared to cleave itself in a site-specific manner under calcium-depleted conditions, resulting in a truncated protein. The truncated protein did have collagenase activity and bacteriolytic activity as well.

Preterm birth, defined at birth before 37 weeks gestation, affects millions of newborns worldwide every year. Preterm birth is a leading cause of infant morbidity and mortality. One major cause of preterm birth is preterm premature rupture of membranes (PPROM), which can be triggered by bacterial infection and inflammation. A bacterial species that has been implicated in preterm birth and other obstetric complications is Sneathia amnii. The goals of this study were to observe cytopathogenic effects caused by S. amnii strain Sn35 and identify putative virulence factors causing those effects. Sn35 was able to adhere to, invade, and damage/kill various host cell lines. We characterized these virulence attributes. A putative virulence determinant was identified, and a fragment of the protein was expressed for polyclonal antiserum production. Antiserum was used to characterize the expression and subcellular localization of the protein in Sn35. However, antiserum was unable to prevent cytopathogenic effects.

Oral feeding competency is a primary requirement for preterm infant hospital release. Currently there is no widely accepted method to objectively measure oral feeding. Feeding consists primarily of the integration of three individual feeding events: sucking, breathing, and swallowing, and the objective of feeding coordination is to minimize aspiration. The purpose of this work was to quantify the infant feeding process from signals obtained during bottle feeding and ultimately develop a measure of feeding coordination. Sucking was measured using a pressure transducer embedded within a modified silicone bottle block. Breathing was measured using a thermistor embedded within nasal cannula, and swallowing was measured through the use of several different piezoelectric sensors. In addition to feeding signals, electrocardiogram (ECG) signals were obtained as an indicator of overall infant behavioral state during feeding. Event detection algorithms for the individual feeding signals were developed and validated, then used for the development of a measurement of feeding coordination. The final suck event detection algorithm was the result of an iterative process that depended on the validity of the signal model. As the model adapted to better represent the data, the accuracy and specificity of the algorithm improved. For the breath signal, however, the primary barrier to effective event detection was significant baseline drift. The frequency components of the baseline drift overlapped significantly with the breath event frequency components, so a time domain solution was developed. Several methods were tested, and it was found that the acceleration vector of the signal provided the most robust representation of the underlying breath signal while minimizing baseline drift. Swallow signal event detection was not possible due to a lack of available data resulting from problems with the consistency of the obtained signal. A robust method was developed for the batch processing of heart rate variability analysis. Finally a method of coordination analysis was developed based on the event detection algorithm outputs. Coordination was measured by determining the percentage of feeding time that consisted of overlapping suck and breath activity.

Neutrophils infiltrate myometrium and decidual tissue prior to parturition. Activated neutrophils release reactive oxygen species (ROS) and tumor necrosis factor α (TNFα), which might increase expression of pro-labor genes such as matrix metalloproteinase-1 (MMP-1), progesterone receptor (PR) A/B ratio, and cause demethylation of DNA. These changes might cause labor. Decidual tissue was obtained from consented, healthy women at term (37+ weeks of gestation) not in labor (no contractions, without cervical effacement), term labor and preterm labor (under 37 weeks of pregnancy). Decidual and myometrial cells in culture were treated with (1) ROS, (2) TNFα, or (3) 5-aza-2’-deoxycytidine. Total RNA was extracted, converted to cDNA and evaluated by qRT-PCR for MMP-1, PR-A+B and PR-B. TNFα increased MMP-1 by 17 fold in decidual cells and more than 12 fold in myometrial cells. PR-A/B was increased by 5.6 fold in decidua. ROS up-regulated MMP-1 by 6 fold and elevated the PR-A/B ratio by 4.5 fold in decidual tissue. DNA demethylation increased MMP-1 by about 4 and 11 fold in decidual and myometrium, respectively. The PR-A/B ratio was increased by 4 fold in decidua and the PR-B was decreased by 40% in the myometrium due to DNA demethylation. Decidual tissue in preterm labor showed a 7-fold increase in MMP-1 over term laboring and over a 15-fold increase over term not in labor tissue. In conclusion, MMP-1 expression and PR-A/B ratio was increased by neutrophil products possibly through a mechanism of DNA methylation in decidua and myometrium. Preterm decidua showed a dramatic increase in MMP-1 over normal labor tissue. TNFα and ROS increased expression of MMP-1 to possibly initiate parturition. These data might help explain mechanisms responsible for preterm labor unrelated to infection or premature rupture of membranes.

ETUDE 1- Le traumatisme de l’accouchement prématuré et de la césarienne, un sentiment de culpabilité, une anxiété et une ambivalence envers l’enfant et l’équipe médicale ont été rapportés. Des difficultés dans l’investissement du lien mère-enfant et dans l’accès au rôle de mère ainsi que l’importance du partage d’expérience avec des femmes ayant accouché avant-terme ont également été identifiés. Enfin, des signes de dépression postnatale et de stress posttraumatique ont été relevés. ETUDE 2- 53% des participantes ont rapporté un score à l’IES-R indiquant un probable ESPT. La présence de symptômes de dépression postnatale (ß = 0,40, p< 0,05), de difficultés pendant la grossesse (ß= 0,20, p< 0,05), la perception maternelle de l’enfant comme étant vulnérable (ß = 0,17, p< 0,05), l’insatisfaction de la grossesse (ß = -0,13; p< 0,05) et des cognitions maternelles mal-adaptées (ß = -0,12, p< 0,05) étaient indépendamment associés à l’intensité des symptômes d’ESPT. ETUDE 3- 3 profils de femmes ont été identifiés: les parturientes au profil « dépressif », « faible niveau de symptômes » et les mères du groupe « dépressif anxieux traumatisé ». Nos résultats démontrent également une forte comorbidité entre troubles anxieux et dépression postnatale ainsi que l’influence négative des symptômes de dépression postnatale sur le lien mère-enfant. ETUDE 4- 64,3% des femmes de l’échantillon ont rapporté un score à l’EPDS indiquant une possible dépression postnatale. Le placement de l’enfant sous assistance respiratoire (ß = 0,23, p< 0,05), le type de prématurité (ß= 0,16, p< 0,05), et la baisse de la qualité de la relation conjugale (ß = -0,39, p< 0,05) étaient indépendamment associés à l’intensité des symptômes de dépression postnatale. / STUDY 1- Trauma of premature birth and c-section, feelings of guilt, anxiety, ambivalence towards the infant, the medical staff and the infant’s hospital discharge, were all part of their perception. Furthermore, difficulties for mothers to define themselves as such and the importance of sharing with women who have been through the same experience were evidenced. Postpartum depression and PTSD symptoms were also highlighted. STUDY 2- 53% of participants scored above the cut-off for probable PTSD. Increased postpartum depressive symptoms (ß = 0.40, p< .05), difficulties during pregnancy (ß= 0.20, p< .05), maternal perception of infant vulnerability (ß = 0.17, p< .05), decreased satisfaction with delivery (ß = -0.13; p< .05) and cognitions relating to role change (ß = -0.12, p< .05) were independently associated with PTSD symptoms. STUDY 3- 3 profiles were highlighted: “depressive”, “low level of symptoms” and “anxious-depressive-traumatized” mothers. Our findings also evidenced a high comorbidity between anxious and depressive symptoms as well as a negative impact of postpartum depression on mother-infant bond. STUDY 4- 64.3% of our sample reported a score on the EPDS highlighting a probable postpartum depression. Having an infant who experienced ventilator support (ß = 0.23, p< 0,05), type of prematurity (ß= 0.16, p< 0,05), and decreased quality of marital relationship (ß = -0.39, p< 0,05) were independently associated with the intensity of postpartum depressive symptoms.

Bakgrund: Varje år behöver mer än 10 000 nyfödda barn i Sverige vård på en neonatalvårdsavdelning. Vårdtiden präglas av åtskilliga blodprovstagningar som orsakar barnet smärta och ökat vårdlidande. Sjuksköterskans ansvar innefattar att agera för barnets bästa i alla situationer, men det kan saknas tydliga riktlinjer för hur detta ska ske på arbetsplatsen. Syfte: Syftet med studien är att beskriva sjuksköterskors resonemang och arbetssätt vid blodprovstagning på barn på neonatalvårdsavdelning, samt att undersöka hur barnets bästa finns i fokus vid proceduren. Metod: Studien utformades med en kvalitativ studiedesign i avsikt att generera kunskap om sjuksköterskornas erfarenheter vid blodprovstagning. Tolv intervjuer genomfördes utifrån en semistrukturerad intervjuguide med sjuksköterskor verksamma vid en neonatalvårdsavdelning på ett svenskt universitetssjukhus. Den insamlade datan analyserades genom en induktiv innehållsanalys. Resultat: Vilken stickmetod sjuksköterskorna använde var anpassat efter barnet och situationen. De såg till barnets förutsättningar och planerade provtagningen efter vad barnet klarade av, i samråd med föräldrarna. Sjuksköterskorna strävade efter föräldranärvaro vid provtagningen och åtog adekvata smärtlindringsmetoder i den mån som situationen tillät. Slutsats: Sjuksköterskorna hade genomgående barnets bästa i fokus vid provtagningsproceduren. De såg en komplexitet i sin roll att både vara den som orsakar barnet smärta, men även vara den som ska minska barnets vårdlidande. / Background: Every year, more than 10 000 newborn children require hospitalization in a neonatal intensive care unit. During this time, they are subjected to several painful blood sampling procedures that will cause them suffering to some extent. The nurses’ responsibility is to act on what is best for each child at all times but clearer guidelines for how that should be executed in practical nursing care might be needed. Aim: To describe the reasoning and the working manner of the nurses when performing blood sampling on children. The study also aims to examine how the child’s best interest is taken into account before and during this procedure. Method: A qualitative design was used for this study. Semi-structured interviews were conducted with 12 registered nurses who work in the neonatal intensive care unit at a Swedish University Hospital. Collected data were analysed using inductive content analysis. Results: Regardless of which technique the nurses chose when performing blood sampling it was assessed as the most appropriate one for each child. They took the children’s prerequisites and ability to cope into account and planned the procedure in consensus with their parents. Nurses strove to encourage parents to stay close to and support their children when blood sampling was conducted, and adequate analgesic actions were undertaken. Conclusion: Nurses had the children’s best at heart all through the process of blood sampling. Their role as both inflicting and relieving pain was considered to be complex in the aim to avoid suffering.