Philosophiae Doctor - PhD / Methods to improve women’s health have become an urgent global priority. Development of clinical guidelines is viewed as a way of improving the quality of health care in South Africa. At present there are no physiotherapy guidelines for women post-caesarean section delivery (CSD) and post-hysterectomy, which are the most common procedures performed by obstetricians and gynaecologists. South African women have the highest HIV-prevalence rates in the world, but there is a global dearth of literature on common postoperative complications for this cohort of women. The aim of this study was to provide evidence supporting the development of physiotherapy clinical guidelines relevant for HIV-infected and HIV non-infected women following caesarean section delivery and hysterectomy. The overall design of the study was prospective, descriptive and explanatory, with longitudinal, comparative and cross-sectional components incorporated at the different phases of the study. An amalgamated four-phase conceptual framework with specific objectives per phase was used to achieve the study aim. Phases 1 and 2 were conducted at four public hospitals in KwaZulu-Natal. Phase 1 identified the long-term complications and quality of life for HIV-infected and non-infected women post-CSD (N=310) and hysterectomy (N=101) over a six- month period; phase 2, which was cross-sectional in nature, identified treatment strategies and complications described by physiotherapists (N=31) for this cohort of women. Purposive probability sampling and purposive convenient sampling was used to select potential participants for phases 1 and 2. A self-administrated questionnaire with close and open-ended questions was used in the first two phases of the study. During phase 3, a systematic review and Delphi method (N=12) were used to investigate current management strategies of representative physiotherapists. Purposive sampling was used to select the participants who are considered as experts in the field of women’s health, for the Delphi study. The information from phases 1 to 3 was collated in phase 4 to provide the evidence to inform the development of the clinical guidelines. Phase 1 revealed that physical health complications commonly persisted for at least six months and negatively affected the quality of life of women post-CSD or post-hysterectomy. Phase 2 showed that very few patients post-CSD and hysterectomy were being referred for physiotherapy, and of those referred, the main problem being treated was respiratory complications. A systematic review of the literature yielded only one article relevant to the outcome of management of patients post- hysterectomy, thus illustrating the dearth of literature in this area. The experts who were consulted for the Delphi study suggested treatment techniques for the postoperative complications identified in phase 1, and consensus was reached on the techniques in the second Delphi round. The results were then collated in the final phase and presented in tables containing the identified problem, treatment and best available evidence to move towards the development of the guidelines. The common postoperative morbidities that were identified in this study can be prevented or treated with physiotherapy, but information is needed in this area to guide treatment practices. The prevention of postoperative complications can result in a decrease in demand for services, thereby reducing the current strain on the health system. The current study contributed to 18 of the 23 criteria in the appraisal of guidelines for research and an evaluation tool. The conceptual framework used to generate the evidence can also be employed in other facets of health care. In order to improve the quality of health care rendered to women, health care professionals require a complete picture of their patient. This research adds to the body of knowledge in an area where there is a dearth of literature and provides a platform to develop clinical guidelines. No national research exists that compares the postoperative complications of HIV-infected and non-infected women, which is essential to enable comprehensive care of HIV-infected women. The guidelines that will be developed can improve the quality of health care rendered to women, and establish the role of physiotherapists in this area.

京都大学 / 0048 / 新制・課程博士 / 博士(社会健康医学) / 甲第21033号 / 社医博第87号 / 新制||社医||10(附属図書館) / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 中山 健夫, 教授 木原 正博, 教授 西渕 光昭 / 学位規則第4条第1項該当 / Doctor of Public Health / Kyoto University / DFAM

Thesis (MMed)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: Background: During caesarean section mothers can be in different positions. Theatre tables could be tilted laterally, upwards, downwards or flexed and wedges or cushions could be used. There is no consensus on the best positioning at present. Objectives: We assessed all available data on positioning of the mother to determine if there is an ideal position during caesarean section that would improve outcomes. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (September 2009), PubMed (1966 to 14 September 2009) and manually searched the references of retrieved articles. Selection criteria: Randomised trials of women undergoing caesarean section comparing different positions. Data collection and analysis: Two authors assessed eligibility, trial quality and extracted data. Results: We identified 17 studies with a total of 683 woman included. We included nine studies and excluded eight studies. Included trials were of variably quality with small sample sizes. Most comparisons had data from single trials. This is a shortcoming and applicability of results is limited. The incidence of air embolism was not affected by head up versus horizontal position (risk ratio (RR) 0.91; 95% confidence interval (CI) 0.65 to 1.26). We found no change in hypotensive episodes when comparing left lateral tilt (RR 0.11; 95% CI 0.01 to 1.94), right lateral tilt (RR 1.25; 95% CI 0.39 to 3.99) and head down tilt (mean difference (MD) -3.00; 95% CI -8.38 to 2.38) with horizontal positions or full lateral tilt with 15-degree tilt (RR 1.20; 95% CI 0.80 to 1.79). Hypotensive episodes were decreased with manual displacers (RR 0.11; 95% CI 0.03 to 0.45), a right lumbar wedge compared to a right pelvic wedge (RR 1.64; 95% CI 1.07 to 2.53) and increased in right lateral tilt (RR 3.30; 95% CI 1.20 to 9.08) versus left lateral tilt. Position did not affect systolic blood pressure when comparing left lateral tilt (MD 2.70; 95% CI -1.47 to 6.87) or head down tilt (RR 1.07; 95% CI 0.81 to 1.42) to horizontal positions, or full lateral tilt with 15-degree tilt (MD -5.00; 95% CI -11.45 to 1.45). Manual displacers showed decreased fall in mean systolic blood pressure compared to left lateral tilt (MD -8.80; 95% CI -13.08 to -4.52). Position did not affect diastolic blood pressures when comparing left lateral tilt versus horizontal positions. (MD-1.90; 95% CI -5.28 to 1.48). The mean diastolic pressure was lower in head down tilt (MD -7.00; 95% CI -12.05 to -1.95) when compared to horizontal positions. There were no statistically significant changes in maternal pulse rate, five-minute Apgars, maternal blood pH or cord blood pH when comparing different positions. Authors' conclusions There is limited evidence to support or clearly disprove the value of the use of tilting or flexing the table, the use of wedges and cushions or the use of mechanical displacers. Larger studies are needed. / AFRIKAANSE OPSOMMING: Agtergrond: Tydens keisersnitte kan moeders in verskillende posisies wees. Teater tafels kan lateraal, opwaarts, afwaarts of gebuig word, of 'n wig en kussings kan gebruik word. Op die oomblik is daar geen konsensus oor die beste posisie nie. Doelwitte: Ons het alle beskikbare data oor die plasing van die moeder ondersoek, met die doel om 'n ideale posisie vir 'n verbeterde uitkoms tydens 'n keisersnit vas te stel. Metodes: Ons het die “Cochrane Pregnancy and Childbirth Group's Trials Register“ (September 2009), PubMed (1966 tot 14 September 2009) deursoek en die herwinde artikels se verwysings per hand nagegaan. Keuringskriteria: Gerandomiseerde proewe van vroue wat keisersnitte ondergaan het, is in verskillende posisies vergelyk. Data insameling en analise: Twee outeurs het die kwaliteit, die geskiktheid en data van die studie beoordeel. Resultate: Ons het 17 studies geidentifiseer wat 'n totaal van 683 vroue ingesluit het. Ons het nege studies ingesluit en agt uitgesluit. Die ingeslote studies was van wisselvallige gehalte en die monster groepe was klein. Die meeste vergelykings het data van enkele studies gegee. Dit is 'n tekortkoming en die bruikbaarheid van die resultate is beperk. Die plasing van kop-op teenoor horisontale posisie het die voorkomssyfer van lug embolisme nie geaffekteer nie.(risiko verhouding RR 0.91;95% 95% vertroue interval Cl 0.65 tot 1.26). Daar is geen hipotensiewe veranderinge gevind toe 'n vergelyking gemaak is tussen linker laterale kantel (RR 0.11; 95% Cl 0.01 tot 1.94) regter laterale kantel (RR 1.25; 95% Cl 0.39 tot 3.99) en kop-af kantel (“mean difference” MD -3.00; 95%Cl -8.38 tot 2.38) teenoor horisontale posisies of volle laterale kantel met 'n 15 grade kantel nie (RR 1.20;95% Cl 0.8. tot 1.79). Hipotensiewe episodes het verminder met hand verplasers (RR 0.11; 95% Cl 0.03 tot 0.45), 'n regter lumbale wig in vergelyking met 'n regter bekken wig (RR 1.64; 95% Cl 1.07 tot 2.53) en 'n vermeerdering van die regter laterale kantel (RR3.30; 95% Cl 1.20 tot 9.08) teenoor die linker laterale kantel. In die vergelyking tussen die posisie van linker laterale kantel (MD 2.70; 95% Cl -1.47 tot 6.87) of kop-af kantel (RR 1.07; 95% Cl 0.81 tot 1.42) teenoor horisontale posisies, of volle laterale kantel met 15 grade kantel (MD -5.00; 95% Cl -11.45 tot 1.45) het die posisie nie die sistoliese bloeddruk geaffekteer nie. Hand verplasers het 'n verminderde daling in gemiddelde sistoliese bloeddruk veroorsaak in vergelyking met linker laterale kantel plasing (MD -8.80;95% Cl-13.08 tot -4.52). In die vergelyking tussen linker laterale kantel en horisontale posisie was daar geen effek op die diastoliese bloeddruk nie (MD -1.90; 95% Cl -5.28 tot1.48). Die gemiddelde diastoliese druk was laer in die kop-af kantel (MD -7.00; 95% Cl -12.05 tot -1.95) in vergelyking met horisontale posisies. In die vergelyking tussen die verskillende posisies was daar geen betekenisvolle statistiese veranderinge in die moeder se polstempo, vyf minute Apgartellings, moederlike bloed pH of naelstringbloed pH nie. Outeur se gevolgtrekkings: Daar is beperkte getuienis om die waarde van kantel, buiging van tafel, die gebruik van wieë en kussings of die gebruik van maganiese verplasers te ondersteun of totaal te verwerp. Groter studies is nodig.

Thesis (MMed)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: The Objective: To review the difference in short term neonatal and maternal outcomes among singleton infants with breech presentation delivered by vaginal or elective caesarean section route at term, at Tygerberg Academic Hospital (TBH) in Cape Town. The study design was a retrospective case control study. Method: Part I A total of 120 patients were selected. 60 vaginal breech deliveries and 60 elective caesarean sections for breech presentation (comprising the control group). 60 cases of vaginal deliveries were collected and 60 control cases of planned elective caesarean sections, where the indication for CS was breech presentation, were collected in the same manner. Part II Nineteen registrars completed a questionnaire regarding their subjective experiences of vaginal breech deliveries at Tygerberg Academic Hospital. Results: Part I An analysis of the results found statistically significant differences in maternal ages between the two groups, with younger women delivering by CS; gravidity and parity was lower in the CS group; blood loss was observed to be higher in the CS group with more women requiring a blood transfusion when compared to vaginal delivery; there were more neonatal admissions in the vaginal delivery group as well as more birth trauma, neonatal seizures and death in this group; Apgar scores were higher in the CS group and finally, neonates born by CS were more commonly discharged at the same time as their mothers in the CS group. Part II When analyzing the registrar questionnaire it can be noted that although clinicians are performing an adequate number of breech vaginal deliveries, with an average of 10 deliveries per year, the skills training for clinicians is invaluable. Not all registrars learned skills from a senior clinician and skills training in skills labs are essential for initial and even continual training of these clinicians. It is suggested that these skills training programs be made compulsory for all registrars and that a biyearly attendance and completing of such a course be mandatory for those wishing to work in the labour ward. Conclusions: Although not statistically significant, there was more morbidity and mortality associated with vaginal breech delivery. / AFRIKAANSE OPSOMMING: Doel: Om die korttermyn neonatale en moederlike uitkomste van enkeling swangerskappe met stuitligging wat vaginaal of met elektiewe keisersnee verlos is by die Tygerberg Akademiese Hospitaal in Kaapstad, te bepaal. Die werkstuk is ‘n retrospektiewe gekontroleerde-gevallestudie. Metode: Deel 1 ‘n Totaal van 120 pasiënte is gekies. 60 gevalle van vaginale stuitverlossings en 60 kontrolegevalle van beplande elektiewe keisersnitte waar die indikasie stuitligging was. Deel 2 Negentien kliniese assistente het die vraelys oor hul persoonlike ervaring van vaginale stuitverlossing by die Tygerberg Akademiese Hospitaal ingevul. Resultate: Deel 1 ‘n Ontleding van die resultate wys statisties betekenisvolle verskille in die moederouderdom van die twee groepe, met meer jong vroue wat met keisernit geboorte gee. Graviditiet en pariteit was laer in die keisersnit-groep. Bloedverlies was hoër in die keisersnit-groep en in vergelyking met die vaginale verlossings met meer vroue wat bloedoortapping benodig. In die vaginale verlossingsgroep was meer neonatale toelatings nodig asook meer geboortetrauma, neonatale konvulsies en sterftes. Apgar-tellings was hoër in die keisersnitgroep en neonate wat met ‘n keisersnitte gebore is, is meer dikwels saam met hul moeders ontslaan. Deel II Ontleding van die vraelys vir kliniese assistente wys dat hoewel klinici ‘n genoegsame getal van gemiddeld 10 vaginale stuitverlossings per jaar uitvoer, vaardigheidsopleiding vir klinici van onskatbare waarde sal wees. Nie alle kliniese assistente leer vaardighede by senior klinici nie en opleiding in ‘n vaardigheidslaboratorium is noodsaaklik vir die aanvanklike en selfs voortdurende opleiding van dié kliniese assistente. Dit word voorgestel dat hierdie vaardigheidkursusse verpligtend gemaak word vir alle kliniese asssistente en bywoning en voltooiing van die kursus twee maal per jaar verpligtend moet wees vir diegene wat in ‘n kraamsaal wil werk. Gevolgtrekking: Vaginale stuitverlossings, hoewel nie stastisties betekenisvol nie, het met meer morbiditeit en sterftes gepaardgegaan.

With one in two women delivering surgically, Iran has one of the highest rates of cesarean section (CS) worldwide. CS overuse in low-risk pregnancies potentially exposes women to Maternal Near-Miss (MNM) morbidity with minimal health benefits. This thesis studied obstetric care quality and MNM at hospitals with high rates of CS in Tehran, Iran. In Study I, we investigated whether audits of CS indications and feedback influenced CS rates at a general hospital. Subsequent to the audit, a 27% reduction in the risk of primary CS was found. In Study II, characteristics of MNM were investigated at university hospitals between 2012 and 2014. During a 26-month period, 82 MNM cases were identified using the WHO MNM approach. Severe postpartum hemorrhage (35%), severe preeclampsia (32%), and placenta previa including abnormally invasive placenta (10%) were the main three causes of MNM. Iran has a huge influx of migrants from Afghanistan. Women with antepartum CS and those who lacked health insurance, almost all Afghans, had increased risk of MNM. In Study III, audits examined whether MNM care quality differed between 54 Iranians and 22 Afghans and whether near-miss events were preventable. A majority of MNM cases (62%) arrived at hospital in a moribund state and obstetric care was more suboptimal for Afghans than Iranians (adjusted odds ratio 5.1, 95% confidence interval 1.2–22.6). Moreover, MNM was commonly (71%) potentially preventable and professionals with suboptimal practice were involved in 85% of preventable cases. In Study IV, a qualitative interview study was conducted to explore care experiences of Afghan MNM survivors. Discrimination, insufficient medical attention, and ineffective counseling were the main experiences. To a lesser extent, poverty and low education were perceived as contributing factors to delays in accessing care. This thesis emphasizes the importance of high-quality care for preventing undesirable maternal outcomes. The audit method along with interviews was useful to determine quality and equity gaps in care provision. Policymakers and professionals should consider these gaps when structuring programs to reduce adverse maternal outcomes.

Introduction: Approximately 3% to 4% of all pregnancies at term will have a fetus with a breech presentation. Studies have shown that the US has almost completely abandoned vaginal delivery for breech presentation through the influence of the "Term Breech Trial" (TBT) which concluded that a policy of planned caesarian section would reduce perinatal mortality, late neonatal mortality, and serious neonatal morbidity by approximately two-thirds for term fetuses. However, the recommendations are still being challenged by others.Objectives: The purpose of the study was to describe who in Virginia is having a vaginal delivery for a breech presentation and to determine if there is a difference in birth outcome based on mode of delivery for breech presentation of term infants.Methods: This population-based study used all birth records for term infants with breech presentation delivered between 1996 and 2005. Data were obtained from the Center for Health Statistics at the Virginia Department of Health. Descriptive statistics were done to characterize vaginal and caesarean section deliveries. These methods were compared using logistic regression for infant mortality and 5-minute Apgar scores as dependent variables.Results: In Virginia, over the last ten years, the prevalence of vaginal deliveries dropped from 13.1% to 6.6% for full term infants with a breech presentation, a decrease of almost 50%. Black women, younger mothers between the ages of 12 and 24, and women with less than or equal to a high school education had the highest occurrence of vaginal births. In the logistic models, the risk for infant death was highest for black women [OR = 1.93; (1.56, 2.38)], women with more than 13 prenatal visits [OR = 1.25; (1.02, 1.53) for 13-15 visits, OR = 2.33; (1 .82, 2.98) for >15 visits], infants who had a low birth weight [OR = 2.8 1 ; (2.08, 3.79)], and women who had a vaginal delivery [OR = 1.42; (1.10, 1.84)] The characteristics that were associated with a lower 5-minute Apgar score for breech infants delivered vaginally included the mother's method of payment, [Medicaid OR 1.75; (1.03, 2.97) and self pay OR 2.33; (1.13, 4.83)], low birth weight [OR = 2.54; (1.24, 5.22)], and delivery type [OR = 4.71; (2.95, 7.52)].Discussion/Conclusions: Our data showed that women who have a vaginal delivery for a term breech infant were more likely to be black, 12-24 years of age, no private insurance, and fewer prenatal visits and was associated with higher infant mortality and lower 5-minute Apgar scores. However, our results indicated that these infants had other significant problems, as indicated by the association with a high number of prenatal visits. Therefore, having physicians who are experienced in delivering breech infants vaginally, careful exclusion of risk factors and, educating the patient about the risks and complications of a vaginal delivery for breech fetuses could help decrease the potential risks for the mother and the infant.

Submitted by Cássia Santos (cassia.bcufg@gmail.com) on 2014-09-03T10:17:49Z No. of bitstreams: 2 Tese Hugo Campos Oliveira Santos.pdf: 2080957 bytes, checksum: 336f5cb1ae89058f6495b2a2af051029 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2014-09-03T10:17:49Z (GMT). No. of bitstreams: 2 Tese Hugo Campos Oliveira Santos.pdf: 2080957 bytes, checksum: 336f5cb1ae89058f6495b2a2af051029 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2013-12-18 / Caesarean section is a surgical technique utilized to deliver the fetus from the uterus and an increase in this surgical procedure can be noted around the world. In Brazil, approximately 40% of total deliveries occur in this way, it is estimated that caesarean section corresponds to 80% of deliveries in private assistance between 2008 and 2012. Diabetes complicates gestation and pregnancy complicates diabetes, this combination increases the possibility of flawed scarring process, which may cause esthetic, psychological and clinical problems. The Low-Level Laser Therapy (LLLT) is an ally for the treatment of a number of wounds – accelerating cell metabolism and reducing inflammatory and infectious processes. The objective of this study was to evaluate the effects of AlGaInP LASER (660nm) treatment regarding wound healing quality and hypertrophic scar prevention in patients with gestational diabetes undergone caesarean section. The clinical study was performed at Hospital das Clínicas of the Federal University of Goiás, after Ethics Committee approval (CEP/HC.053/11). In the period between November (2011) and May (2013) 90 patients divided into 3 groups were assessed: Group A: LASER (3 Joules/cm2), Group B: LASER (6 Joules/cm2) and Group C (Control – no treatment). Caesarean incision was photographed in the periods: T1 (1day), T2 (2days), T3 (3days), T4 (15days) and T5 (30days). Photos were used in order to calculate mean area and standard deviation. The area of the photographs was analyzed and calculated in pixels with specific software (Software Image J – NIH/USA), measuring, thus, the wound contraction in percentage (%). The calculation was performed by the caesarean scar area reduction and the increase of incision contraction percentage (recovery) throughout the periods for each group. Contraction results (%) with regard to wound area were significant (p<0.05) for all groups studied, according to Kruskal Wallis’, Mann-Whitney’s and Wilcoxon’s tests. Groups treated with LASER (A and B) presented higher edge contraction, being 89% the scar reduction of Group A (p<0.001) and 81% of Group B (p<0.05), when compared to control group (73%). However, Group A demonstrated higher wounded area reduction when compared to group B, especially in the period between the 3rd and the 15th day from the postoperative (p<0.001). It was verified that the better performance of Low-power LASER (AlGaInP) occurred in the time reported in the literature as scarring process inflammatory stage (≤7days). Inflammatory process reduction may have contributed to reducing scarring time, increasing wound contraction percentage, benefitting, thus, the incision esthetic aspect throughout 30 days of treatment. During the study, occurrence of hypertrophic scars was not observed in any of the experimental groups in the period of 60days from the postoperative. / A cesárea é uma técnica cirúrgica utilizada para retirar o feto do útero, nota-se atualmente um aumento dessa cirurgia em todo o mundo. No Brasil, aproximadamente 40% do total de partos são realizados por essa via, estima-se que a cesariana corresponda a 80% dos partos na assistência privada entre 2008 a 2012 . O diabetes complica a gestação, e, a gravidez complica o diabetes, essa combinação aumenta as chances de falhas no processo de cicatrização, o que pode acarretar problemas estéticos, psicológicos e clínicos. O LASER de baixa potência (LBP) é um aliado para o tratamento de uma variedade de ferimentos – acelerando o metabolismo celular, reduzindo os processos inflamatório e infeccioso. Esse estudo tem por objetivo avaliar os efeitos da terapia a LASER AlGaInP (660nm) quanto à qualidade da cicatrização e da prevenção de cicatrizes hipertróficas em pacientes com diabetes gestacional submetidas à cirurgia cesárea. A pesquisa clínica foi realizada no Hospital das Clínicas da Universidade Federal de Goiás - UFG, após aprovação do Comitê de Ética (CEP/HC.053/11). Entre novembro de 2011 e maio de 2013 foram avaliadas 90 pacientes divididas em 3 grupos: Grupo A: LASER (3 Joules/cm2), Grupo B: LASER (6 Joules/cm2) e Grupo C (Controle - sem tratamento). A incisão cesárea foi fotografada nos tempos: T1 (1dia), T2 (2dias), T3 (3dias), T4 (15dias) e T5 (30dias). As fotos foram utilizadas para calcular a área média e o desvio padrão. A área das fotografias foi analisada e calculada em pixels por meio de programa específico (Software Image J – NIH/USA). Mensurando, assim, a contração da ferida em percentagem (%). O cálculo foi realizado por meio da redução da área da cicatriz cesárea e a percentagem de contração da incisão em decorrer do tempo para cada grupo. Os resultados da contração (%) em relação à área da ferida foram significativos (p<0,05) para todos os grupos estudados, conforme testes de Kruskal Wallis, Mann-Whitney e Wilcoxon. Os grupos tratados com LASER (A e B) tiveram maior contração das bordas, sendo de 89% de redução da cicatriz para o grupo A (p<0,001) e de 81% para o grupo B (p<0,05), quando comparados ao grupo controle (73%). Porém, o grupo A demonstrou maior redução da área da ferida, quando comparado ao grupo B, principalmente no período entre o 3º e 15º dias do pós-operatório (p<0,001). Verificou-se que a melhor atuação do LASER de baixa potência (AlGaInP) ocorreu no tempo relacionado na literatura como fase inflamatória do processo de cicatrização (≤ 7dias). A redução do processo inflamatório pode contribuir para reduzir o tempo de cicatrização, aumentando a percentagem de contração da ferida, favorecendo assim, o aspecto estético da incisão no decorrer de 30 dias de tratamento. Durante o estudo, não foi observado ocorrência de cicatrizes hipertróficas em nenhum dos grupos experimentais no período de até 60dias do pós-operatório.

This poststructuralist qualitative study explored the discourses constructing women’s choice for a caesarean section in the absence of clinical indications, in the talk and texts of women, midwives, an obstetrician, professional journals and the media publications. The study affirms inscriptions surrounding choice in childbirth are shaped discursively through a multiplicity of discourses underpinned by social and institutional practices. With advances in technology, childbearing women have a greater variety of options from which to choose. Controversial, is the option of a caesarean section, regardless of clinical need. The issue is depicted in both professional and popular discourse as contentious, complex and contradictory. Its momentum into the 21st century, as a new object of obstetric discourse, has been played out on a number of platforms. In this thesis I draw from the theoretical ideas of French philosopher Michel Foucault, to examine this complex debate. I argue there is a volatile moment in the history of childbirth in which an explosion of discourses have sculptured choice for a caesarean, in the absence of clinical indications, out of a repartee of autonomy, convenience, desire, fear and risk. In this precarious moment, new meanings joust with the old on a shifting terrain awash with rhetoric that co-opts, competes, and contradicts to bring about a caché of mutable ‘truths’. Whether caesarean, as an optional extra, can be explained in terms of a libertarian imperative, an embodiment of lifestyle, the satiation of desire, the attenuation of fear or the avoidance of risk, the democratisation of this choice has exposed a pathologising paradox, whereupon the normal emerges as the abnormal, and the abnormal emerges as the normal. The deconstruction of choice through a poststructuralist lens has enabled insight into how contradiction and contest befall the ‘order of things ’ and in so doing, provides new openings for contemplating the discursive positioning of women through the competing discourses of childbirth.

<p><strong>Syfte:</strong> Syftet med denna studie är att beskriva hur pappor upplever ett akut kejsarsnitt.</p><p><strong>Metod: </strong>Deskriptiv studie med kvalitativ design. Semi-strukturerade intervjuer genomfördes med tio pappor som varit med om ett akut kejsarsnitt.  </p><p><strong>Resultat: </strong>I studien framkom positiva upplevelser av akut kejsarsnitt så som ett bra bemötande av personalen och en känsla av att bli omhändertagen. Personalen uppfattades som proffsiga, trevliga och snälla. Det var framförallt efter det akuta kejsarsnittet som pappor upplevde en delaktighet då de själva fick ta hand om barnet. De såg då sin roll som betydelsefull. Pappans<em> </em>upplevelser av det akuta kejsarsnittet kan också<em> </em>vara kaotisk och traumatisk. Det fanns en önskan om psykologiskt stöd efter det akuta kejsarsnittet. Pappor upplevde att de inte kunde hjälpa till med så mycket praktiskt under själva kejsarsnittet utan de upplevde mer att de var ett mentalt stöd för mamman. Det fanns upplevelser av bristande information, både före, under och efter det akuta kejsarsnittet.</p><p><strong>Slutsats: </strong>Då det framkom i studien att det fanns en önskan om psykologiskt stöd bör det införas rutiner för att fånga upp dessa pappor och en möjlighet att erbjuda dem hjälp. Vad gäller information bör riktlinjer utformas för att pappor ska känna att de är väl informerade genom hela förloppet, informationen bör individanpassas. En informationsbroschyr om akut kejsarsnitt kan utformas och finnas tillgänglig på förlossningsavdelningar som ett led i informationsgivning.</p><p><strong>Nyckelord: </strong>Pappa, akut kejsarsnitt, upplevelser.</p>

Syfte: Syftet med denna studie är att beskriva hur pappor upplever ett akut kejsarsnitt. Metod: Deskriptiv studie med kvalitativ design. Semi-strukturerade intervjuer genomfördes med tio pappor som varit med om ett akut kejsarsnitt.   Resultat: I studien framkom positiva upplevelser av akut kejsarsnitt så som ett bra bemötande av personalen och en känsla av att bli omhändertagen. Personalen uppfattades som proffsiga, trevliga och snälla. Det var framförallt efter det akuta kejsarsnittet som pappor upplevde en delaktighet då de själva fick ta hand om barnet. De såg då sin roll som betydelsefull. Pappans upplevelser av det akuta kejsarsnittet kan också vara kaotisk och traumatisk. Det fanns en önskan om psykologiskt stöd efter det akuta kejsarsnittet. Pappor upplevde att de inte kunde hjälpa till med så mycket praktiskt under själva kejsarsnittet utan de upplevde mer att de var ett mentalt stöd för mamman. Det fanns upplevelser av bristande information, både före, under och efter det akuta kejsarsnittet. Slutsats: Då det framkom i studien att det fanns en önskan om psykologiskt stöd bör det införas rutiner för att fånga upp dessa pappor och en möjlighet att erbjuda dem hjälp. Vad gäller information bör riktlinjer utformas för att pappor ska känna att de är väl informerade genom hela förloppet, informationen bör individanpassas. En informationsbroschyr om akut kejsarsnitt kan utformas och finnas tillgänglig på förlossningsavdelningar som ett led i informationsgivning. Nyckelord: Pappa, akut kejsarsnitt, upplevelser.