Thesis (M.D.)--University of Pennsylvania, 1804. / Microform version available in the Readex Early American Imprints series.

Thesis--Columbia University. / Includes bibliographical references (leaves 141-153).

Thesis (Ph. D.)--University of Wisconsin--Madison, 1989. / Typescript. Vita. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references (leaves 495-515).

Portfolio Abstract Introduction The psychological experience of giving birth has been found to have a long-lasting impact upon the wellbeing of the woman and the mother-infant interaction (Ayers, Eagle, & Waring, 2006). Research has been carried out to investigate what influences the psychological experience of giving birth and contributes to these longlasting consequences. The interaction between the woman and the health professional has been shown to influence the psychological experience of birth (Ford & Ayers, 2011; Söderquist, Wijma, & Wijma, 2006). Despite these findings, obstetricians are a relatively neglected health profession within the birth research literature. Furthermore, obstetricians’ involvement or ability to contribute towards positive birth experiences has not been fully researched. Women have either emphasised the importance of the support they received from obstetricians or criticised the lack of support they received (Howarth, Swain, & Treharne, 2012; Simkin, 1991; Simkin, 1992; Waldenström, Hildingsson, Rubertsson, & Rådestad, 2004). The role of any caregiver during labour and birth is suggested to be important for influencing the psychological experience of birth (Anderson, Melvaer, Videbech, Lamont, & Joerhensen, 2012). However, obstetricians attend medically complex births where there may be mother of baby medical complications. Such births have attracted debate in the research literature. Complex medical births are argued to constitute a risk factor for negatively influencing the psychological birth experience and impacting upon the long-term wellbeing of the mother and infant-mother interaction (Anderson et al., 2012). However, other research has suggested that complex births are not always a risk factor for experiencing birth negatively and that the psychological (Nilsson, Thorsell, Hertfelt-Wahn & Ekström, 2013; Simkin, 1991, Simkin, 1992). Objectives The objective of this research project was to investigate the way obstetricians talk about giving birth, or ‘obstetric discourse’ and how obstetricians ‘constructed’ a positive birth experience. This research project aims to initiate the thorough investigation of spoken obstetric discourse, so that future research may build upon these findings. Previous literature has investigated the discourse about birth via interviews without obstetricians being the primary sample (Douché & Carryer, 2011) and has considered the discourse produced by obstetricians more broadly from published documents (Kitzinger, 2007; Licqurish & Evans, 2015) . However, there has been a lack of investigation about the spoken discourse of obstetricians. By adding focus to spoken obstetric discourse this study may potentially add variance to the data. Discourse is argued to be influenced by the context in which it takes place. Therefore research moving forward in this area may benefit from including varied contexts. Discourse analysis strives to highlight variance rather than a similarity (Potter & Wetherell, 1987). Striving to highlight similarities is argued to be invalid and accused of omitting potentially useful data from the research literature (Potter & Wetherell, 1987). Methodology The underlying theory and the accompanying methodology of discourse analysis was used to meet the objectives of this research project. A social constructionist epistemological stance was taken towards the gathering of knowledge in this research project. A social constructionist epistemology is compatible with discourse analysis due to the shared assumptions about language constructing experiences. From this theoretical framework, language is an important target for analysis because it is argued to shape human experience in terms of constricting or enabling what may be said, done or felt (Willig, 2013). More specifically, language is argued to create reality rather than accurately describe it. This study used a hybrid model of discursive psychology and Foucauldian discourse analysis. This involves analysing local discursive techniques such as disclaimers, contrasting and inferences about internal states, while also analysing wider social influences and the discourses available to the participants. For example, the discourse of medicine may be argued to be an available discourse for those who work in the field of medicine to draw upon to influence their own discourse. Obstetric discourse in the form of spoken language was gathered from semi-structured interviews with eight practising obstetricians. Results The findings of the analysis suggested that the participants constructed a positive psychological birth experience in varied ways and used multiple rhetorical devices when doing so. The results are reported in two broad categories; the participants’ contrast of ‘obstetric births’ with so called ‘ideal births’ and the use of claims about women’s internal states during labour. The participants’ responses to questions about positive birth experiences were to construct ‘obstetric births’ and ‘ideal births’ in contrast with one another. The births that obstetricians attended were constructed using medical discourse, which emphasised medical complications and medical interventions. This category of birth was presented as a challenging birth type within which to facilitate positive psychological experiences. Obstetric births were contrasted with what were termed ‘ideal births’. Ideal births were described as medically ‘normal’ births that did not require an obstetrician’s intervention. These births were associated with midwifery and presented as a category of birth within which interpersonal relationships between the woman giving birth and the midwife may facilitate a positive psychological birth experience. The rhetorical device of contrasting appears to function here to emphasise difference and key features of obstetric births. The participants made claims about the internal states of women in labour. Internal mental states are not analysed to ascertain whether they are accurate or not within a discourse analysis methodology. Claims were made about women’s experience of pain and anxiety. Such claims are viewed as discursive devices that have certain functions within the discourse. Within this study, inferences about internal mental states appeared to have a possible function to present the women in labour as less able to communicate and difficult to have a discussion with. Communication was presented as a factor that may facilitate a positive psychological birth experience. A function of these claims about internal states may be to construct positive births as difficult to facilitate with women during labour due to their internal mental states. Discussion The results of this analysis are considered in light of discourse analysis theory and the writings of Foucault. Discourse analysis has been described as a ‘theory-method’ because it makes certain claims about how language creates reality (Potter, 1997). Further consideration is given to the appropriateness of applying other psychological theories from Menzies Lyth’s (1960) research into social defences. Suggestions for further research and the possible clinical implications of this study are considered.

Introduction Approximately one in five women experience abdominal pain and/or vaginal bleeding in early pregnancy. This usually prompts referral to an Early Pregnancy Assessment Unit where an ultrasound scan will be performed. Following the ultrasound, either a certain or uncertain diagnosis will be made. Certain diagnoses may be positive, i.e. a viable intrauterine pregnancy, or negative, i.e. a non-viable or ectopic pregnancy. Uncertain diagnoses occur when there is ambiguity regarding either the location or the viability of the pregnancy. Up to 25% of women attending an Early Pregnancy Assessment Unit are given such a diagnosis at their initial visit. All women with a diagnosis of either a pregnancy of unknown location or uncertain viability need to be followed-up until a definitive diagnosis can be made. At present this is haphazard and protracted, commonly taking up to two weeks to resolve and requiring multiple visits for various different investigations. This takes a considerable amount of time and costs a not insignificant amount of money. Furthermore, in the time taken to make a definitive diagnosis, a stable woman with an unknown miscarriage or ectopic pregnancy may become unstable and require immediate resuscitation, life-saving blood transfusion and/or emergency surgery. Aims The aim of this PhD was to develop methods to minimise the number of women given uncertain diagnoses in early pregnancy, or to at least minimise the duration of uncertainty if the diagnosis is unavoidable. Several different studies were undertaken in an attempt to accomplish this. Studies We initially undertook a prospective cohort study to determine the levels of anxiety generated by uncertain diagnoses in early pregnancy was undertaken. Women with uncertain diagnoses were found to be significantly more anxious (as measured using the standardized short form of Spielberger’s state-trait anxiety inventory) than their counterparts given certain diagnoses (23±0.79 versus 14±6.6), even if these certain diagnoses were not associated with an ongoing pregnancy. This study served to further justify the main objective. We then performed a systematic review and meta-analysis to identify and determine the diagnostic accuracy of various different ultrasonographic features to predict (a) an intrauterine pregnancy prior to visualization of embryonic contents and (b) a tubal ectopic pregnancy in the absence of an obvious extra-uterine embryo. This study identified the double decidual sac sign as a potential marker to be able to accurately differentiate a true gestation sac from a pseudosac with a sensitivity of 82% (95% CI, 68-90%), specificity of 97% (95% Ci, 76-100%), positive likelihood ratio of 30 (95% CI, 2.8-331) and negative likelihood ratio of 0.19 (95% CI, 0.10-0.35). The quality of the studies included in the meta-analysis however precluded the use of the double decidual sac sign in clinical practice without further validation As a consequence, we carried out a prospective study following STARD guidelines to determine the diagnostic accuracy of the double decidual sac sign to predict an intrauterine pregnancy prior to visualization of embryonic contents using modern, high-resolution transvaginal ultrasound. This study found that the double decidual sac sign predicted an intrauterine pregnancy with a sensitivity of 94% (95% Ci, 85-98%), specificity of 100% (95% CI, 16-100%) and overall diagnostic accuracy of 94% (95% CI, 88-100%). The positive and negative predictive values are 100% (95% CI, 94-100%) and 33% (95% CI, 4.3-78%) respectively whilst the positive likelihood ratio was infinite and the negative likelihood ratio was 0.06 (95% CI, 0.02-0.16). These results suggest that the meta-analysis under-estimated the ability of the double decidual sac sign to differentiate between a true gestation sac and a pseudosac. Subsequently, we conducted a study incorporating off-line analysis of ultrasonographic images to determine the inter- and intra-observer reliability of the double decidual sac sign to predict an intrauterine pregnancy prior to ultrasonographic visualization of embryonic contents. This involved fifteen observers from around the United Kingdom remotely assessing a selection of two-dimensional images from 25 of the diagnostic accuracy study participants. There was significant (p < 0.01) agreement amongst the observers but the level of agreement was only ‘fair’, reflected by kappa statistics of 0.25, 0.33 and 0.21. Following a period of focused training, the inter-observer reliability significantly increased demonstrated by kappa statistics of 0.70, 0.63 and 0.53. The intra-observer reliability ranged from ‘substantial’ (K=0.65) to ‘almost perfect’ (K=0.92). These results demonstrate that the double decidual sac sign has the potential, after training, to be both reliable and precise, making it a very useful ultrasonographic sign in clinical practice. Finally, we undertook a prognostic research study, following REMARK recommendations, investigating the ability of five serum biomarkers to predict pregnancy outcome in women with pregnancies of uncertain viability. Candidate biomarkers included Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), soluble FMS-like Tyrosine Kinase-1 (Flt-1), serum TNF-Related Apoptosis Inducing Ligand and Interleukin-15. Serum concentrations of Ang-2 and Flt-1 were significantly lower in pregnancies of uncertain viability that were subsequently proven to be viable than those that were subsequently proven to be non-viable (Ang-2 1510pg/ml versus 2365pg/ml and Flt-1 103pg/ml versus 202pg/ml). Furthermore, there were statistically significant (p < 0.01), linear (p-value for trend < 0.01) associations between Ang-2 and Flt-1 concentrations and subsequent pregnancy viability such that women with a pregnancy of uncertain viability and Ang-2 concentrations greater than or equal to 2666pg/ml were 64% less likely to have a viable pregnancy than those with Ang-2 concentrations less than or equal to 1382pg/ml and women with a pregnancy of uncertain viability and Flt-1 concentrations greater than or equal to 142pg/ml were 50% less likely to have a viable pregnancy than those with Flt-1 concentrations less than or equal to 87pg/ml. These findings suggest that Ang-2 and Flt-1 may be useful in the prediction of pregnancy viability in cases of uncertainty. Discussion One of the biggest challenges in early pregnancy ultrasonography is accurate differentiation between a true gestation sac and a pseudosac. Pseudosacs, although rare, are strongly suggestive of an ectopic pregnancy, hence it is an important distinction to make, ideally as soon as possible. Both appear initially as intrauterine fluid collections or ‘empty sacs’. Whilst experts may claim that it is not difficult to differentiate between the two structures, in clinical practice, many of the individuals undertaking the scans in early pregnancy do not claim to be experts. Traditional teaching has always been to wait until either a yolk sac or fetal pole are visualized within the sac before confirming a definite intrauterine pregnancy. Although safe, inherent with this approach is that an intrauterine fluid collection is visible using transvaginal ultrasound from around day 28 but a yolk sac is not visible until at least day 35. If an ultrasound is undertaken during this time, an ‘empty sac’ will be seen and uncertainty will ensue. Application of the results from the studies described above could potentially revolutionize the care of women with diagnostic uncertainties in early pregnancy. Firstly, the confirmation that uncertain diagnoses in early pregnancy are highly anxiogenic, means that Early Pregnancy Assessment Units can now justify the allocation of resources to help alleviate this distress. This is crucial if we are to improve the holistic nature of the care provided to women with complications of early pregnancy. / Furthermore, the discovery that the double decidual sac sign can accurately predict an intrauterine pregnancy prior to visualization of embryonic contents (and therefore effectively exclude an ectopic pregnancy) means that we can rationalise follow-up, improve consistency and minimise error in the management of women with ultrasonographic evidence of an empty sac in early pregnancy. Although it could be argued that utilization of the double decidual sac sign does not minimise the number of women given uncertain diagnoses in early pregnancy, merely swap concerns regarding location to ones regarding viability, in clinical practice it is the potential consequences of pregnancies of unknown location that are most hazardous, both because of the immediate threat to health and the future threats to fertility. Furthermore, if the findings from our prognosis study are confirmed, and appropriate threshold levels for our biomarkers determined, it may be possible to minimise the duration of uncertainty for women with pregnancies of uncertain viability to hours rather than weeks. Using a combination of approaches therefore, we have achieved the overall aim of this thesis in minimising diagnostic uncertainties in early pregnancy, the clinical benefits of which are multifold. Not only does it reduce anxiety for women, but also prevents unnecessary investigations from being performed in those with an intrauterine pregnancy and minimise morbidity and mortality, permit earlier, potentially less invasive intervention and possibly preserve future fertility for women with an ectopic pregnancy.

<p> Malnutrition has long permeated Nepal, causing stunting and developmental delays in the youth. While there are many factors that contribute to malnutrition, early feeding practices, including breastfeeding and colostrum usage among Nepali mothers, . The objective of this study was to determine if there was a significant correlation between specific breastfeeding practices, the usage of colostrum to infants and other demographics, knowledge related to breast feeding, colostrum practices and cultural customs concerning the Nepali mothers. A survey was distributed to 94 Nepali women in six different regions of Eastern Nepal. The survey consisted of 64 questions related to demographics, practices concerning breastfeeding, breastfeeding knowledge, early feeding practices and usage of colostrum. Prenatal education was significantly related to colostrum knowledge score (<i>p</i> = 0.38). Hindu/Buddhist women were more likely to choose answers that aligned with research concerning the giving of food other than breastmilk (&lt; 6 mos of age) and chose more answers that aligning with research on the knowledge score, than compared to Christian women (<i>p</i> = 0.005, <i>p</i> = 0.002, <i>p </i> = 0.003). Significant results also showed that Christian women are more likely to practice chappaudi (sleeping in an outside shed during menstruation) than compared to Hindu/Buddhist women (<i>p</i> = .007). These results contradict current literature. A limiting factor includes Christian women answering yes to the question, while handwriting that the practice is for Hindu women. Thus, the data may be skewed due to being unable to include these other hand-written information that the women provided. Further research needs to be explored comparing family&rsquo;s income to usage of colostrum and breastfeeding practices. More research also needs to investigate how the health of the mother leads to malnutrition of the child.</p><p>

This thesis describes the development of a novel system to grade the ‘difficulty’ of an embryo transfer (ET) procedure. A systematic review of the prevalence of ‘difficult’ ET has revealed marked heterogeneity across the literature with no real consensus ‘definition’ or ‘grading system’ available for clinicians to use. A new systematic approach to grading ET procedures has been proposed and tested. It has the ablity to predict IVF outcomes accurately and has proven to be reliable. The ‘difficult’ ET procedure has been shown in this thesis to be detrimental to IVF outcomes when a fresh single blastocyst is transferred. All embryos of different qualities are affected to some degree by a difficult ET, but it appears that high quality blastocysts are proportionally more affected than the lower quality embryos, which have a lower potential to implant, though the mechanism is not clear. The embryo transfer time (ETT) is fundamental in determining the implantation potential of a single blastocyst. Once the ET procedures takes longer than ‘120-seconds’ and ETT is prolonged, there is a significant impact on both pregnancy and clinical pregnancy rates. The detrimental impact of increasing ETT on pregnancy rates was found to be independent of an embryo’s quality. The ETT appears to be a more accurate way to predict IVF outcomes than a stratified grading scale, though combining a descriptive scale with ETT may offer the optimum grading system. This thesis has shown that embryo cooling during ET loading and discharging may be significant. The morphokinetic data evaluated in developing mouse embryos has suggested that embryo hatching may be affected by embryo cooling, but further work is needed to confirm this effect. The ‘novel’ grading system proposed here combines both ETT with a systematic grading system and is based on strong evidence acquired in this work. It has been shown to be reliable and easy to use but it remains for this ‘new’ system to be tested and integrated into clinical practice.

Thesis (MTech (Radiography))--Peninsula Technikon, Cape Town, 2000 / Ultrasound has, until recently, been regarded as a sophisticated diagnostic modality, reserved for tertiary health care. In reality, it is a cost-effective, reliable and safe modality that is highly suited to primary health care. Secondary level centres provide the only access to ultrasound for many of the obstetric primary health care patients, as primary health care has limited ultrasound resources. The increasing monthly statistics, at one secondary centre, bares witness to the need for ultrasound in primary health care. At the time of this study ultrasound scans were not routine for every obstetric patient. Experience indicates that only the patients who clinically suggest a possible risk are referred for ultrasound to confirm, or rule out problems. However, there are a number of complications, which have little or no early clinical indications. [Palmer, 1995:285] This means that many of the problems encountered are often in late gestation and they have a marked bearing on the obstetric management of the patient. This was a retrospective study, of approximately 1000 patients attending an ultrasound department at a secondary centre. Most of the obstetric patients that were sent for an ultrasound examination came from the primary health care centres in the region.

<p> Breastfeeding support has increased over the past 2 decades, especially in the workplace. The Patient Protection and Affordable Care Act of 2010 provided several protections for working, breastfeeding women. Prior to the passage of this legislation, the North Dakota State Legislature amended SB 2344 to create an Infant Friendly business designation available to any business or organization in the state providing specified lactation accommodations for their employees. While this amendment has been in effect since 2009, and the first cohort of businesses was designated in 2011, there has been no evaluation of this designation to determine effectiveness. The purpose of this research is to examine the difference in breastfeeding continuation rates between women working for Infant Friendly and non-designated businesses, and to identify how intention, self-efficacy, and other worksite factors influence breastfeeding duration. An 85 item online questionnaire was developed and distributed using various sampling methods to working women across the state of North Dakota. T-tests, Analysis of Variance, and forward step-wise regression were used to analyze results. While there was no statistically significant difference in breastfeeding duration between designated and non-designated businesses, there was a 3-month difference in duration between continually designated businesses and those letting their designation lapse. Participants disagreed that breastfeeding education was available from their employers. With regard to intention, women who intended to exclusively breastfeed did so with a four month longer duration than those with other feeding intentions, although the results were not statistically significant. Women who perceived only minor challenges with combining breastfeeding and working, and those with greater self &ndash;efficacy for breastfeeding had longer breastfeeding durations as well. While the designation is a starting point for worksite breastfeeding support, it could be more comprehensive. Adding a policy promotion and breastfeeding education component to the designation may improve awareness and use of accommodations, making the designation more impactful. These additions may also aid in increasing breastfeeding intention and self-efficacy among working women, and decrease the perception of barriers.</p><p>

<p> The old practice of separating the mother-baby-dyad was without measurable benefits to mothers or their infants. Evidence has shown that skin-to-skin care (SSC) prevents hypothermia and hypoglycemia, decreases crying during painful procedures in newborns, and reduces maternal anxiety, stress, and postpartum depression. Rooming-in care (RIC) has been linked to an increase in the rate of breastfeeding and mother-infant interaction, as well as a decrease in the infant morbidity rate. This project assessed the effect of an educational intervention to increase rates of SSC and RIC in an obstetric unit, in addition to measuring nurses&rsquo; attitudes and barriers in relation to SSC and RIC. The obstetric nurses received educational content related to SSC and RIC based on Kotter&rsquo;s model of change. A pre and postintervention evaluation showed a significant increase in the rates of SSC and RIC from pretest of 10%, to posttest of 96%; and RIC from pretest of 10% to posttest of 92%. Using a Wilcoxon test, a significant difference was found from pretest to posttest for every subscale score of the Mother-Newborn Skin-to-Skin Contact Questionnaire and Nurse Attitudes and Barriers to nonseparation Scale (<i>p</i> &lt; 0.001), with the exception of belief about obstacles for SSC, which yielded a nonsignificant change (<i>p</i> = 0.57). This DNP project led to changes in the organization&rsquo;s culture, including the closure of the well-baby nursery. This project promoted social change across the organization, in that the team health care providers delivered evidence-based, standardized, unbiased, and family-centered care to the mother-baby dyad. </p><p>