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A study of psycho-emotional condition was carried out in 408 women during opioid analgesia in different delivery stages with estimation of the changes in reactive and personal anxiety and rank pain index (RPI). The obtained data suppose that analgetic effect of opioids is carried out especially through the sensor component of RPI. On the other hand, the evaluated (targeted) and the effector components of psycho-emotional condition after administration of opioids have changed insignificantly and not evidently. The effect of medicamental analgetics on emotional component of pain perception in every stage of labour had it own features. This should be taken in account while practical work.

Aim: This study presents the findings a meta-ethnographic study reporting women's perceptions and experiences of traumatic birth., Background: Childbirth is viewed by many as a life transition that can bring a sense of accomplishment. However, for some women, birth is experienced as a traumatic event with a minority experiencing post-traumatic stress. A traumatic birth experience can have a significant impact on the physical and emotional well-being of a woman, her infant and family., Data Source: The CINAHL, MEDLINE, Scopus and PubMed databases were searched for the period January 1994 to October 2009 using the keywords birth trauma, traumatic birth, qualitative research, birth narrative and birth stories., Review Methods: A meta-ethnographic approach was used. Quality appraisal was carried out. An index paper served as a guide in identifying particular findings and comparing them with other findings. This 'reciprocal translation' process started with a search for common themes, phrases and metaphors., Results: Ten qualitative studies were included in the final sample. Six major themes were identified: 'feeling invisible and out of control', 'to be treated humanely', 'feeling trapped: the reoccurring nightmare of my childbirth experience', 'a rollercoaster of emotions', 'disrupted relationships' and 'strength of purpose: a way to succeed as a mother'., Conclusions: It is evident that a small percentage of women experience a traumatic birth. Although some women who experience a traumatic birth do not necessarily have physical or psychological adverse outcomes, others identify a significant personal impact. Healthcare professionals must recognize women's need to be involved in decision-making and to be fully informed about all aspects of their labour and birth to increase their sense of control., (© 2010 Blackwell Publishing Ltd.)

Background: Nine percent of new mothers in the United States who participated in the Listening to Mothers II Postpartum Survey screened positive for meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for posttraumatic stress disorder after childbirth. Women who have had a traumatic birth experience report fewer subsequent children and a longer length of time before their second baby. Childbirth-related posttraumatic stress disorder impacts couples' physical relationship, communication, conflict, emotions, and bonding with their children., Objective: The purpose of this study was to describe the meaning of women's experiences of a subsequent childbirth after a previous traumatic birth., Methods: Phenomenology was the research design used. An international sample of 35 women participated in this Internet study. Women were asked, "Please describe in as much detail as you can remember your subsequent pregnancy, labor, and delivery following your previous traumatic birth." Colaizzi's phenomenological data analysis approach was used to analyze the stories of the 35 women., Results: Data analysis yielded four themes: (a) riding the turbulent wave of panic during pregnancy; (b) strategizing: attempts to reclaim their body and complete the journey to motherhood; (c) bringing reverence to the birthing process and empowering women; and (d) still elusive: the longed-for healing birth experience., Discussion: Subsequent childbirth after a previous birth trauma has the potential to either heal or retraumatize women. During pregnancy, women need permission and encouragement to grieve their prior traumatic births to help remove the burden of their invisible pain.

Background and Significance: Women's perceptions of childbirth are defined within sociocultural context. Listening to the voices of women is essential to increase nurses' sensitivity to the needs of childbearing women and help nurses provide culturally competent healthcare., Purpose: The purpose of this qualitative descriptive study was to identify Australian women's perceptions of giving birth., Method: Seventeen Australian women who had given birth in the past 12 months participated in audiotaped interviews. Trustworthiness of the findings was ensured. Themes were generated on the basis of rich narrative data., Results: Themes included focusing on the moment of birth, being empowered by giving birth, defining the spiritual dimension of giving birth, having a diminished or traumatic birth, feeling concern for the child, coming to know the child, and receiving care: nurses making a difference., Implications for Clinical Practice: Results confirm the findings of other studies suggesting that provision of educational resources and individualized nursing care creates a climate of confidence in childbearing women.

Purpose: To describe unplanned cesarean birth as experienced by African American women., Method: Descriptive phenomenology was used with interviews from seven women who experienced unplanned cesarean birth. Interviews of each woman's birth experience were transcribed and analyzed using Colaizzi's descriptive, phenomenological method., Results: The findings were clustered into five themes: preparing for childbirth, mistrust, feeling rushed, being fearful, and sacrificing., Clinical Implications: The results from this study contribute to the understanding of psychosocial stressors that are associated with childbirth complicated by unplanned cesarean birth. This study lends evidence to our practice by providing information about how important anticipatory guidance is for expectant women because the possibility of cesarean birth in today's environment is not remote. Discussions about unplanned cesarean births should also be a part of this anticipatory guidance.

Birth trauma can affect infants in adverse ways. The results of birth trauma can include feeding problems, bonding issues and emotional health. There are many ways that midwives and parents can prevent such trauma as well as help infants and children heal from birth trauma.

Background: Little is known about the impact of life-threatening obstetric complications ('near miss') on women's mental health in low- and middle-income countries., Aims: To examine the relationships between near miss and postpartum psychological distress in the Republic of Benin., Method: One-year prospective cohort using epidemiological and ethnographic techniques in a population of women delivering at health facilities., Results: In total 694 women contributed to the study. Except when associated with perinatal death, near-miss events were not associated with greater risk of psychological distress in the 12 months postpartum compared with uncomplicated childbirth. Much of the direct effect of near miss with perinatal death on increased risk of psychological distress was shown to be mediated through wider consequences of traumatic childbirth., Conclusions: A live baby protects near-miss women from increased vulnerability by giving a positive element in their lives that helps them cope and reduces their risk of psychological distress. Near-miss women with perinatal death should be targeted early postpartum to prevent or treat the development of depressive symptoms.

Purpose: This study documented new case and estimated annual case prevalence, and relationships among women's negative birth perceptions, provider disaffirmation, perinatal trauma symptoms, and depression at 6-7 months postpartum., Design and Methods: An exploratory investigation of 71 White women (20.8% of the total population) was conducted. CONCLUSIONS. New case prevalence of negative birth perceptions (9.6:100), perinatal trauma symptoms (10.2:100), disaffirmation (8.6:100), and depression (15.7:100) are greater than other prominent high burden diseases. Variables were significantly correlated., Practice Implications: Findings reinforce the need for psychiatric liaison advanced practice nurses caring for childbearing women, including roles for detection/screening, educating professionals in communication, legislative/advocacy for funding, and further research.

Introduction: Magnetic resonance imaging (MRI) studies have demonstrated that patients with schizophrenia have thinner brain cortices compared with healthy control subjects. Neurodevelopment is vulnerable to obstetric complications (OCs) such as hypoxia and birth trauma, factors that are also related to increased risk of developing schizophrenia. With the hypothesis that OCs might explain the thinner cortices found in schizophrenia, we studied patients with schizophrenia and healthy controls subjects for association between number and severity of OCs and variation in cortical thickness., Methods: MRI scans of 54 adults with schizophrenia or schizoaffective disorder and 54 healthy controls were acquired at Karolinska Institutet, Stockholm, Sweden. Measures of brain cortical thickness were obtained using automated computer processing (FreeSurfer). OCs were assessed from obstetric records and scored blindly according to the McNeil-Sjöström scale. At numerous cortical locations, putative effects of OCs on cortical thickness variation were tested for each trimester, for labour, for composite OC scores, severe OC scores, and hypoxia scores among patients and controls separately., Results: Number and severity of OCs varied among both patient and control subjects but were not associated with cortical thickness in either of the groups. Patients demonstrated thinner brain cortices but there were no significant differences in number and severity of OC scores across groups., Conclusion: In the present study, number and severity of obstetric complications were not associated with brain cortical thickness, in patients with schizophrenia or in healthy control subjects. The thinner brain cortices found in patients with schizophrenia were not explained by a history of OCs.

Objective: The purpose of this study was to investigate pregnant women's intentions for opting for caesarean section (CS), their experiences regarding previous births and their expectations for subsequent delivery. Our objectives were to identify medical and psychological predictors pertaining to the decision for CS on demand., Design: The cross-sectional survey was conducted at two study centres over a three-month period including German speaking women at any time of pregnancy and consisted of an anonymous structured questionnaire. Logistic regression was computed to investigate the predictive value of medical variables, birth experience and birth anxiety on the demand for CS., Results: Nineteen of 201 participants preferred to deliver by CS on demand and 15 felt uncertain about their decision. How the preceding delivery had been experienced was significantly better in the vaginal delivery (VD)-group (women not considering CS on demand) than in the CS-group (good experience in 81.7% and 52.0% respectively, p = 0.007). A negative previous birth experience and a preceding CS were predictors for the wish to deliver by CS., Conclusions: As negative birth experience predicts the wish for a CS, specific supportive care during first pregnancy could play a pivotal role in making this decision.

Unlabelled: Prenatal cocaine exposure (PCE) may be associated with alterations in children's developing emotional arousal and regulation systems., Objective: We examined emotional responses to a frustrating task and subsequent behavior problems in 225 2 1/2 year olds (129 Prenatally Cocaine and Other Drug Exposed [PCE], 30 Non Cocaine but other drug Exposed [NCE], 66 Non Drug Exposed [NDE])., Method: Children's behaviors in a frustrating toy wait task at age 2 1/2 were coded for emotional arousal and regulation behaviors., Results: Findings indicated a trend for PCE toddlers to show greater agitated emotional arousal than NCE and NDE toddlers. Further, PCE boys made more references to their caregivers in the task than NDE boys. Higher agitated arousal at age 2 1/2 years was related to greater decreases in externalizing behaviors through age 5 1/2 years., Conclusion: Findings suggest a link between cocaine exposure and emotional arousal and regulation and highlight the need to understand complex relations between emotion and risk for later psychopathology in exposed youth.

Patient-initiated elective cesarean delivery is emerging as an urgent issue for practitioners, hospitals, and policy makers and for pregnant women. This exploratory qualitative study looks at the birth stories and cultural knowledge that women use to inform the decision about an elective cesarean without medical indication. Data collection consisted of exploratory qualitative in-depth interviews with 17 primiparous women in British Columbia, Canada. Interviews revealed the influence of socially circulated birth stories and cultural narratives on their attitudes towards mode of delivery. Participants included in their decision making process both medical information and informal birth stories that were technologically inclined and confirmed their preference for cesarean delivery. Results indicate that women who participated in this study drew heavily from social and cultural knowledge in forming their decision to give birth by patient-initiated elective cesarean delivery. Although the numbers of women who request a cesarean delivery for social reasons is still small, the persuasive influence on parturient women of positive cesarean stories and negative vaginal stories must be considered. Care providers and childbirth educators need to become familiar with the social influences impacting women's decisions for mode of delivery so that truly informed choice discussions can be undertaken.

Objectives: To examine the associations between fear of childbirth and emergency caesarean section and between fear of childbirth and dystocia or protracted labour and fetal distress., Design: Prospective cohort study., Setting: Danish National Birth Cohort., Population: A total of 25 297 healthy nulliparous women in spontaneous labour with a single fetus in cephalic presentation at term following an uncomplicated pregnancy., Methods: Data were collected during 1997-2003 from computer-assisted telephone interviews twice in pregnancy linked with national health registers., Main Outcome Measures: Risk for emergency caesarean section of women who feared childbirth; risk for dystocia/protracted labour or fetal distress of women who feared childbirth., Results: Fear of childbirth in early (16 weeks, 6 +/- 29 days) and late (31 weeks, 4 +/- 21 days) pregnancy was associated with emergency caesarean section: OR, 1.23 (1.05-1.47) and 1.32 (1.13-1.55), respectively. When fear of childbirth was expressed at both interviews, the OR was 1.43 (1.13-1.80). Women who feared childbirth had an increased risk for dystocia or protracted labour (OR, 1.33; 1.15-1.54), but not for fetal distress (OR, 0.94; 0.72-1.23)., Conclusions: Fear of childbirth during pregnancy was associated with dystocia and emergency caesarean section but not with fetal distress.

Aim and Objective: To test the effectiveness of an efficacy-enhancing educational intervention to promote women's self-efficacy for childbirth and coping ability in reducing anxiety and pain during labour., Background: The evidence of the effective application of the self-efficacy theory in health-promoting interventions has been well established. Little effort has been made by health professionals to integrate self-efficacy theory into childbirth care., Design: Randomised controlled trial., Methods: An efficacy-enhancing educational intervention based on Bandura's self-efficacy theory was evaluated. The eligible Chinese first-time pregnant women were randomly assigned to either an experimental group (n = 60) or a control group (n = 73). The experimental group received two 90-minute sessions of the educational programme in between the 33rd-35th weeks of pregnancy. Follow-up assessments on outcome measures were conducted within 48 hours after delivery. The short form of the Chinese Childbirth Self-Efficacy Inventory was used to measure maternal self-efficacy prior to labour. Evaluation of pain and anxiety during the three stages of labour and performance of coping behaviour during labour were measured by the Visual Analogue Scale and Childbirth Coping Behaviour Scale respectively., Results: The experimental group was significantly more likely than the control group to demonstrate higher levels of self-efficacy for childbirth (p < 0.0001), lower perceived anxiety (p < 0.001, early stage and p = 0.02, middle stage) and pain (p < 0.01, early stage and p = 0.01, middle stage) and greater performance of coping behaviour during labour (p < 0.01)., Conclusions: The educational intervention based on Bandura's self-efficacy theory is effective in promoting pregnant women's self-efficacy for childbirth and reducing their perceived pain and anxiety in the first two stages of labour., Relevance to Clinical Practice: Relief of pain and anxiety is an important issue for both women and childbirth health professionals. The efficacy-enhancing educational intervention should be further developed and integrated into childbirth educational interventions for promoting women's coping ability during childbirth.

Unplanned, adverse events during labor or delivery may generate a negative response during the early postpartum period, resulting in disruption of usual functioning and mood. High levels of maternal depressive symptoms are associated with parenting, infant attachment, behavioral problems and cognition (Beck 2002). The purpose of this study was to examine the relationship of adverse events in labor or delivery and depressive symptoms, functional status and infant care at 2-weeks postpartum. The secondary aim was to explore the role of social support as a possible moderator in the relationship between adverse birth events and maternal outcomes. A secondary analysis of data (n = 123) was performed using data collected in a prospective, observational study examining the effects of antidepressant use during pregnancy. Adverse events did not significantly predict depressive symptoms (odds ratio = 1.34, p = .536), functional status (R(2) change = .001, p = .66), or infant care (R(2) change = .004, p = .48) at 2-weeks postpartum when controlling for depression during pregnancy, antidepressant use at delivery, education level, age, and parity. Social support had significant effects on depressive symptoms (p = .02), functional status (p = .014), and infant care (p < .001) but did not moderate the effect of adverse events when predicting depressive symptoms (odds ratio = 1.01, p = .045), functional status (R(2) change = .009, p = .056) and infant care (R(2) change < .001, p = .92). Adverse events did not predict maternal outcomes at 2-weeks postpartum. Social support was related to depressive symptoms, functional status and infant care, but did not moderate the effects of adverse events.

Background: An improvement in maternal health conditions can only be achieved when a reduction in the number of deaths is accompanied by a reduction in the frequency of severe complications of pregnancy. The objective of this study was to investigate women's experiences related to the burden of severe maternal morbidity., Methods: This qualitative study is based on narratives of women who survived severe complications of pregnancy and who were admitted to the intensive care unit of a public university hospital in the city of Campinas, Brazil. A sample of 30 women was recruited between April 2007 and January 2008. Before hospital discharge, eligible women who agreed to participate responded to a semidirected interview. The interviews were recorded and the transcripts received a thematic analysis., Results: Two major themes were identified, one more closely related to the experience of a critical illness and the other to the experience of care. A complex set of reactions was found in the women who survived, indicating the occurrence of acute stress-related disorders., Conclusions: On the basis of narratives of women who almost died during pregnancy and childbirth, we reported on an acute stress disorder that may be associated with the occurrence of severe maternal complications, which we named, the "maternal near-miss syndrome." The implementation of integrated care that encompasses the physical, psychological, social, and spiritual aspects of women's health may help to alleviate the burden that maternal complications impose on millions of women around the world.

Objective: The objective of this study is to gain insight into the nature of obstetric fistulae in Africa through patient perspectives., Study Design: At l'Hôpital Saint Jean de Dieu in Tanguieta, Benin, 37 fistula patients underwent structured interviews about fistula cause, obstacles to medical care, prevention, and reintegration by 2 physicians via interpreters., Results: The majority of participants (43%) thought their fistulae were a result of trauma from the operative delivery. Lack of financial resources (49%) was the most commonly reported obstacle to care, and prenatal care (38%) was most frequently reported as an intervention that may prevent obstetric fistulae. The majority (49%) of the participants requested no further reintegration assistance aside from surgery., Conclusion: Accessible emergency obstetric care is necessary to decrease the burden of obstetric fistulae in Africa. This may be accomplished through increased and improved health care facilities and education of providers and patients.

Objective: to describe the development and application of a brief counselling intervention for women who have experienced a traumatic birth., Intervention: the birthing trauma counselling model reflecting women's need to establish a therapeutic connection with a midwife, talk about their birth experience and have their feelings validated. Gaps in understanding of events need explanation and explicit connections made between the event and subsequent emotions and behaviours. Developing a rational understanding of birthing events and how labour may have been managed differently assists women to revise their assumptions about maternity care and gain a sense of control. Fostering social support, reinforcing positive approaches to coping and exploring solutions to restoring self-confidence and reducing anxiety may help re-establish psychological equilibrium., Discussion and Conclusion: the counselling intervention is consistent with trauma theory and draws on cognitive behavioural therapy principles. Midwives are well placed to provide counselling support to women experiencing birth-related distress. Further testing of the intervention in the clinical setting with a large sample is required.

Background: Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. The objectives of this study were to assess women's awareness of danger signs of obstetric complications and to identify associated factors in a rural district in Tanzania., Methods: A total of 1118 women who had been pregnant in the past two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi-square test was used to determine associations between categorical variables and multivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs., Results: More than 98% of the women attended antenatal care at least once. Half of the women knew at least one obstetric danger sign. The percentage of women who knew at least one danger sign during pregnancy was 26%, during delivery 23% and after delivery 40%. Few women knew three or more danger signs. According to multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8-19) in comparison with no education at all. The likelihood to have more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took place at a health institution and whether the mother was informed of having a risks/complications during antenatal care., Conclusion: Women had low awareness of danger signs of obstetric complications. We recommend the following in order to increase awareness of danger signs of obstetrical complications: to improve quality of counseling and involving other family members in antenatal and postnatal care, to use radio messages and educational sessions targeting the whole community and to intensify provision of formal education as emphasized in the second millennium development goal.

Obstetric fistula is a devastating complication of obstructed labor that affects more than two million women in developing countries, with at least 75,000 new cases every year. Prolonged pressure of the infant's skull against the tissues of the birth canal leads to ischemia and tissue death. The woman is left with a hole between her vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) or both, and has uncontrollable leakage of urine or feces or both. It is widely reported in scientific publications and the media that women with obstetric fistula suffer devastating social consequences, but these claims are rarely supported with evidence. Therefore, the true prevalence and nature of the social implications of obstetric fistula are unknown. An integrative review was undertaken to determine the current state of the science on social implications of obstetric fistula in sub-Saharan Africa.

Introduction: An increasing number of women give birth by caesarean section (CS) in Denmark, some without any medical reasons for this procedure. This is called maternal request sectio (MRS). To analyse the development of MRS over a five-year period and investigate how parity, former birth complications, the weight of the child and the mother's living area and age are related to MRS., Material and Methods: Retrospective registry analysis of births during the period 1 January 2002 to 31 December 2006. MRS was identified by the surgical code KZYM00., Results: 5,165 MRSs were recorded during the study period. Among nulliparous (P0) women there was an increase in MRS from 3.2% of all elective CS in 2002 to 19.4% in 2006. The largest share, 24.1%, was found in the age group 35+. Among multiparous (P1+) women there was an increase from 5.5% to 31.2%, and the largest share, 35.8%, was in the age group 15-24. MRS was most frequent in the Capital Region. Women who had experienced CS, third degree perineal tear, or perinatal death in their first delivery, had a 3.8, 1.3 and 2.0 times increased risk of MRS in their next delivery. The weight of the child had no influence on MRS., Conclusion: MRS has increased over the past five years, and now amounts to 1.3% of all births for P0 women and 3.6% for P1+ women. Previous birth complications and the age and living area of the mother are associated with MRS. Better knowledge of the reasons why some women choose MRS would provide professionals with better tools to support these women.

Objectives: To examine the impact of antenatal psychosocial stressors, including maternal common mental disorders (CMD), upon low birth weight, stillbirth and neonatal mortality, and other perinatal outcomes in rural Ethiopia., Methods: A population-based sample of 1065 pregnant women was assessed for symptoms of antenatal CMD (Self-Reporting Questionnaire-20: SRQ-20), stressful life events during pregnancy (List of Threatening Experiences: LTE) and worry about the forthcoming delivery. In a sub-sample of 654 women from six rural sub-districts, neonatal birth weight was measured on 521 (79.7%) singleton babies within 48 h of delivery. Information about other perinatal outcomes was obtained shortly after birth from the mother's verbal report and via the Demographic Surveillance System., Results: After adjusting for potential confounders, none of the psychosocial stressors were associated with lower mean birth weight, stillbirth or neonatal mortality. Increasing levels of antenatal CMD symptoms were associated both with prolonged labour (>24 h) (SRQ 1-5: RR 1.4; 95% CI 1.0-1.9, SRQ >or= 6: RR 1.6; 95% CI 1.0-2.6) and delaying initiation of breast-feeding more than eight hours (SRQ 1-5: RR 1.4; 95% CI 0.8 to 2.4, SRQ >or= 6: RR 2.8; 95% CI 1.3-6.1). Worry about delivery was also associated with labour longer than 24 h (RR 1.5; 95% CI 1.0-2.1)., Conclusions: This study provides preliminary evidence of important public health consequences of poor maternal mental health in low-income countries but does not replicate the strong association with low birth weight found in South Asia.

Purpose: To describe the essence of women's unexpected birthing experiences., Methods: Descriptive phenomenology using interviews with 10 women who had birthing experiences that were not what they had expected, including (1) an instrumentally assisted vaginal delivery either by forceps and/or by a vacuum extractor, (2) a third- or fourth-degree tear, (3) birth by an emergency cesarean birth, or (4) women who perceived that their delivery was incongruent with their expectations. Interviews of each woman's birth experience were transcribed using Colaizzi's method of analysis., Results: The findings reflected the absence of three critical elements-caring, connection, and control-that the women believed were missing from their birthing experiences. The lack of caring was demonstrated by the statement: "They were there to take care of your baby and not you and that's the end of it." The lack of connection was demonstrated by the statement "I just didn't have a nurse who was really there." The lack of control was demonstrated by this statement: "You're not in control of the experience.", Clinical Implications: Perinatal nurses have an opportunity to influence a caring environment in which women feel connected to their nurse and in control of their labor and birth. Tailoring nursing care to meet the needs of each mother, especially women who are experiencing things they had not expected in labor or during birth, may be the key ingredient to ensure optimal birthing experiences.

Background: This study aimed to examine the association among past traumatic events, high-risk pregnancy, delivery complications, and postpartum posttraumatic stress (PTS) symptoms., Methods: The final convenience sample consisted of 1071 Jewish women at midpregnancy. Data were gathered at three time points (during pregnancy and 1 month and 6 months after childbirth) through self-report questionnaires., Results: There was a higher percentage of high-risk pregnancy among those who reported a history of traumatic events. Although the total score of PTS symptoms did not correspond with high-risk pregnancy, the intrusion and avoidance subscales did. Furthermore, a history of traumatic events as well as prenatal PTS symptoms, prenatal depression, and the subjective pain and distress during delivery accounted for postpartum PTS symptoms. Prenatal depression was found to account for delivery complications., Conclusions: Findings indicate that a history of trauma should be considered a risk factor for high-risk pregnancy and for postpartum PTS symptoms.

Objective: The main aim of this study was to explore whether specific groups of patients with first episode non-affective psychosis could be identified on a psychopathological basis and, then, whether such identified groups could be validated by exploring their correlation with a variety of neurodevelopmental markers., Method: Eighty-seven patients with a first episode of non-affective psychotic disorder were consecutively recruited. We assessed psychopathology and neurological soft signs using the PANSS and the Neurological Evaluation Scale, respectively. We collected information on obstetric complications, premorbid adjustment and family history., Results: All PANSS symptoms were analysed using principal component analysis and four factors were obtained (negative, disorganization, positive and paranoid). Subsequently, the four factors were subjected to a cluster analysis where three groups emerged: "paranoid" (n=40), "low score" (n=29) and "negative" (n=18) subtype. After adjusting by sex and age, we found that the "negative group" had poorer social premorbid adjustment, worse verbal fluency and higher prevalence of both obstetric complications and neurological soft signs, when compared with the "low score" group. Similarly, the "negative group" showed significantly poorer social premorbid adjustment and higher number of neurological soft signs than the "paranoid group"., Conclusions: Our results support that, among non-affective first onset psychotic patients, those with predominant negative symptoms are more likely to correlate with higher presence of neurodevelopmental markers.

Aim: This paper is a report of a study to explore women's experiences of becoming a mother after prolonged labour., Background: The negativity associated with a complicated labour such as prolonged labour can lead to a struggle to become a healthy mother and could restrict the process of becoming a mother., Methods: Interviews were conducted in 2004 with 10 mothers who had been through a prolonged labour with assisted vaginal or caesarean delivery 1-3 months previously. Thematic content analysis was used., Findings: Three themes were formulated, describing women's experiences as fumbling in the dark, struggling for motherhood and achieving confidence in being a mother. The difficulties and suffering involved in becoming a mother after a prolonged labour were interpreted to be like 'fumbling in the dark'. Women experienced bodily fatigue, accompanied by feelings of illness and detachment from the child. Having the child when in this condition entailed a struggle to become a mother. In spite of these experiences and the desire to achieve confidence in being a mother, the reassurance of these women regarding their capacity for motherhood was crucial: it was central to their happiness as mothers, encouraged interaction and relationship with the child, and contributed to their adaptation to motherhood., Conclusion: Women experiencing prolonged labour may be comparable with the experience of and recovery from illness, which could contribute to difficulties transitioning to motherhood and limit a woman's ability to be emotionally available for the child.

Although much effort has gone into promoting early skin-to-skin contact and parental involvement at vaginal birth, caesarean birth remains entrenched in surgical and resuscitative rituals, which delay parental contact, impair maternal satisfaction and reduce breastfeeding. We describe a 'natural' approach that mimics the situation at vaginal birth by allowing (i) the parents to watch the birth of their child as active participants (ii) slow delivery with physiological autoresuscitation and (iii) the baby to be transferred directly onto the mother's chest for early skin-to-skin. Studies are required into methods of reforming caesarean section, the most common operation worldwide.

Background: Caesarean section rates have increased in Norway, as in the rest of the western world since the beginning of the 1970s, and further explanations are needed to understand this development. The study aimed to examine whether demographic or psychological burdens differed among women who feared childbirth, according to whether or not they requested caesarean section., Material and Methods: In the period 2000-02, 164 pregnant women who feared childbirth were referred for counselling with two midwives (specialized in mental health) at the antenatal clinic at the University Hospital of North Norway. Data were retrieved from counselling sessions, referral letters, antenatal and intrapartum care records. The group that wished to have caesarean sections (n = 86) was compared with the one that did not (n = 78)., Results: 80% of the women had previously experienced anxiety and/or depression, 32% had eating disturbances and 72% reported having been abused. In the group requesting caesarean section the women had more severe fear of childbirth, previous traumatic birth experiences, previous anxiety and depression, lack of confidence in the professional staff and fewer had been treated for their psychological problems. At the onset of labour, 86% who initially requested a caesarean delivery were prepared for a vaginal birth. The overall caesarean rate for both groups was 32%., Interpretation: The women who feared childbirth generally had a larger burden of psychosocial and psychiatric problems than others, and those who requested a caesarean delivery had most. Charting and processing these burdens is presumably of significance for the birth outcome.

Background: Little research has been conducted to date on women's postnatal emotional well-being and satisfaction with the care received in the Netherlands. The aim of this study was to investigate Dutch women's views of their birth experience 3 years after the event., Methods: A questionnaire was mailed to all women who had given birth in 2001 and who had at least one prenatal, perinatal, or postnatal visit to the participating midwifery practice. Women who had a subsequent birth after the index birth in 2001 were not excluded. We specifically asked respondents to reflect on the birth that occurred in 2001. Women were asked to say how they felt now looking back on their labor and birth, with five response options from "very happy" to "very unhappy.", Results: We received 1,309 postnatal questionnaires (response rate 44%). The sample was fairly representative with respect to the mode of delivery, place of birth, and obstetric interventions compared with the total Dutch population of pregnant women; however, the sample was not representative for ethnicity and initial caregiver. Three years after delivery, most women looked back positively on their birth experience, but more than 16 percent looked back negatively. More than 1 in 5 primiparas looked back negatively compared with 1 in 9 multiparas. Adjusted odds ratios (OR) for looking back negatively 3 years later included having had an assisted vaginal delivery or unplanned cesarean delivery (OR 2.6, 95% CI 1.59-4.14), no home birth (OR 1.4, 95% CI 1.04-1.93), referral during labor (OR 2.4, 95% CI 1.48-3.77), not having had a choice in pain relief (OR 2.9, 95% CI 1.91-4.45), not being satisfied in coping with pain (OR 4.9, 95% CI 2.55-9.40), a negative description of the caregivers (OR 2.9, 95% CI 1.85-4.40), or having had fear for the baby's life or her own life (OR 2.3, 95% CI 1.47-3.48)., Conclusions: A substantial proportion of Dutch women looked back negatively on their birth experience 3 years postpartum. Further research needs to be undertaken to understand women's expectations and experiences of birth within the Dutch maternity system and an examination of maternity care changes designed to reduce or modify controllable factors that are associated with negative recall.

Background: A woman's childbirth experience has an influence on her future preferred mode of delivery. This study aimed to identify determinants for women who changed from preferring a planned vaginal birth to an elective cesarean section after their first childbirth., Methods: This prospective longitudinal observational study involved two units that provide obstetric care in Hong Kong. A mail survey was sent to 259 women 6 months after their first childbirth. These women had participated in a longitudinal cohort study that examined their preference for elective cesarean section in the antenatal period of their first pregnancies. Univariate and multivariate analyses were performed to identify determinants for women who changed from preferring vaginal birth to elective cesarean section., Results: Twenty-four percent (23.8%, 95% CI 18.4-29.3) of women changed from preferring vaginal birth to elective cesarean section after their first childbirth. Determinants found to be positively associated with this change included actual delivery by elective cesarean section (OR 106.3, 95% CI 14.7-767.4) intrauterine growth restriction (OR 19.5, 95% CI 1.1-353.6), actual delivery by emergency cesarean section (OR 8.4, 95% CI 3.4-20.6), higher family income (OR 3.2, 95% CI 1.1-8.8), use of epidural analgesia (OR 2.6, 95% CI 1.0-6.8), and higher trait anxiety score (OR 1.1, 95% CI 1.0-1.3). The most important reason for women who changed from preferring vaginal birth to elective cesarean section was fear of vaginal birth (24.4%)., Conclusions: A significant proportion of women changed their preferred mode of delivery after their first childbirth. Apart from reducing the number of cesarean sections in nulliparous women, prompt provision of education to women who had complications and investigations into fear factors during vaginal birth might help in reducing women's wish to change to elective cesarean section.

Objective: Recent studies have hypothesized that perinatal complications might increase the risk of developing eating disorders. However, it is unclear which pathways might link obstetric complications and eating disorders. The present study aimed at exploring the relationship between obstetric complications and temperament in eating disordered subjects., Methods: The sample was selected among subjects who took part in a prevalence study carried out on a representative sample of the general population and from among people with anorexia and bulimia nervosa referred to an outpatient specialist unit. Subjects who were born in the two obstetric wards of Padua Hospital between 1971 and 1979 and who completed the Tridimensional Personality Questionnaire were included. A blind analysis of the obstetric records of the whole sample was performed. The final sample was composed of 66 anorexia nervosa, 44 bulimia nervosa, and 257 control subjects., Results: Among the different groups of obstetric complications, only the group that included preterm birth and other signs of neonatal immaturity or dysmaturity displayed a significant relationship with harm avoidance. The use of a mediation path analytic model revealed a significant, but incomplete, mediation effect of harm avoidance in explaining the link between neonatal dysmaturity and the development of eating disorders. Maternal weight gain during pregnancy seemed to have a protective effect on harm avoidance., Conclusions: The presence of signs of neonatal dysmaturity at birth seems to influence the development of high levels of harm avoidance in eating disorders.

Objective: To explore women's preferences for, and trade-offs between, key attributes of intrapartum care models., Design: Mixed-methods study using discrete choice experiments (DCEs) and focus groups., Setting: The North of Scotland., Population: Women from the catchment areas of eight rural maternity units in the North of Scotland., Methods: Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery., Main Outcome Measures: Preferences for attributes of intrapartum care., Results: Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances., Conclusions: In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.

Objectives: To summarize the social, economic, emotional, and psychological consequences incurred by women with obstetric fistula; present the results of a meta-analysis for 2 major consequences, divorce/separation and perinatal loss; and report on improvements in health and self-esteem and on the possibility of social reintegration following successful fistula repair., Methods: We conducted a review of the literature published between 1985 and 2005 on fistula in developing countries. We then performed a meta-analysis for 2 of the major consequences of having a fistula, divorce/separation and perinatal child loss., Results: Studies suggest that surgical treatment usually closes the fistula and improves the physical and mental health of affected women., Conclusion: With additional social support and counseling, women may be able to successfully reintegrate socially following fistula repair.

Objective: To investigate the prevalence, aetiology and outcomes of caesarean section refusal in pregnant women., Design: A prospective controlled study., Setting: University of Nigeria Teaching Hospital and Aghaeze Hospital, Enugu, Nigeria., Population: A total of 62 Nigerian women who declined elective caesarean section., Method: Interviewer-administered questionnaires at the time of caesarean section refusal and postdelivery. The delivery outcomes of the subjects were compared with that of a matched control group of women who accepted caesarean section., Main Outcome Measures: Prevalence, maternal reasons for caesarean section refusal and the resultant maternal and perinatal mortality., Results: The prevalence of caesarean section refusal was 11.6% of all caesarean deliveries. Maternal reasons for refusing caesarean section include fear of death, economic reasons, desire to experience vaginal delivery and inadequate counselling. Outcomes were significantly worse among women who refused elective caesarean section than in the controls with a maternal mortality of 15% (versus 2%, P = 0.008) and a perinatal mortality of 34% (versus 5%, P < 0.001)., Conclusion: There is a high prevalence of caesarean section refusal in south-eastern Nigeria. Women declining caesareans have very poor maternal and perinatal outcomes and need extra support.

Objective: To examine obstetrical complications as a risk factor for developing bipolar disorder (BPD). We hypothesized that children with a bipolar parent would be at greater risk for obstetrical complications than demographically matched children of healthy adults. Additionally, within this "at-risk" (AR) sample, we hypothesized that obstetrical complications would be associated with the development of psychiatric disorders., Methods: The Washington University in St. Louis Kiddie-Schedule for Affective Disorders and Schizophrenia (WASH-U KSADS) was administered to children (AR) who had at least one parent with BPD (N=36) and children of healthy parents (HC) (N=27), by raters who were blind to diagnostic category. To assess obstetrical risk history, the Rochester Research Obstetrical Scale (ROS) was administered to parents of AR and HC children., Results: Children at familial risk for BPD had greater total (p=0.02) and prenatal (p=0.006) obstetrical complication scores than children of healthy parents. However, obstetrical complications were not associated with the development of affective, anxiety, or disruptive behavioral disorders within the at-risk group., Conclusion: Our data suggest that compared with children of families without BPD, children of parents with BPD may be at greater risk for obstetrical complications, particularly those that occur during the prenatal period; however, at this early follow-up period factors other than obstetrical complications appear to contribute to the differences in rates of psychiatric disorders between these groups.

Pathological fear of childbirth known as "tokophobia" affects about 6-10% pregnancies and is of concern mainly because of remarkable sequele regarding women's morbidity, the neurobehavioral development of their children, and cesarean section on maternal request (CSMR). Fear of labor is a multidimensional problem involving a number of biological, psychological and social background factors and may be divided into primary and secondary tokophobia and tokophobia as a symptom of depression. Fear of childbirth is closely related to the fear of labor pain. It appears that women who experience fear, suffer from more pain due to alterations in the mechanisms of pregnancy induced analgesia. Despite no relevant connection between tokophobia and request for effective analgesia for labor pain relief, neuraxial techniques should always be available, especially to women with increased levels of negative emotions. However, epidural analgesia itself may increase fear level at the end and after labor and delivery. The mainstay of tokphobia treatment constitutes psychotherapeutic methods, which decrease negative labor experience; their impact on CSMR is controversial. There is a strong need for multidisciplinary approach to tokophobia due to its complexity and obstetric, anesthesiological, psychological and psychiatric implications.

Background: Previous research shows that 1 to 6 percent of women will develop symptoms of posttraumatic stress disorder after childbirth. The objective of this study was to examine thoughts and emotions during birth, cognitive processing after birth, and memories of birth that might be important in the development of postnatal posttraumatic stress symptoms., Methods: In a qualitative study, women with posttraumatic stress symptoms (n= 25) and without (n = 25) were matched for obstetric events to examine the nonmedical aspects of birth that made it traumatic. Women were interviewed 3 months after birth., Results: The following themes emerged for all women: thoughts during birth included mental coping strategies, wanting labor to end, poor understanding of what was going on, and mental defeat. More negative than positive emotions were described during birth, primarily feeling scared, frightened, and upset. Postnatal cognitive processing included retrospective appraisal of birth, such as taking a fatalistic view and focusing on the present, for example, concentrating on the baby. Memories of birth included not remembering parts of the birth and forgetting how bad it was. Women with posttraumatic stress symptoms reported more panic, anger, thoughts of death, mental defeat, and dissociation during birth; after birth, they reported fewer strategies that focused on the present, more painful memories, intrusive memories, and rumination, than women without symptoms., Conclusions: The results provide a useful first step toward identifying aspects of birth and postnatal processing that might determine whether women develop postnatal posttraumatic stress symptoms. Further research is needed to broaden knowledge of posttraumatic stress disorder before drawing definite conclusions.

Background: Non-progressive labour is the most common complication in nulliparas and is primarily treated by augmentation. Augmented labour is often terminated by instrumental delivery. Little qualitative research has addressed experiences of non-progressive and augmented deliveries. The aim of this study was to gain a deeper understanding of the experience of non-progressive and augmented labour among nulliparas and their experience of the care they received., Methods: A qualitative study was conducted using individual interviews. Data was collected and analysed according to the Grounded Theory method. The participants were a purposive sample of ten women. The interviews were conducted 4-15 weeks after delivery., Results: The women had contrasting experiences during the birth process. During labour there was a conflict between the expectation of having a natural delivery and actually having a medical delivery. The women experienced a feeling of separation between mind and body. Interacting with the midwife had a major influence on feelings of losing and regaining control. Reconciliation between the contrasting feelings during labour was achieved. The core category was named Dialectical Birth Process and comprised three categories: Balancing natural and medical delivery, Interacting, Losing and regaining control., Conclusion: A dialectical process was identified in these women's experiences of non-progressive labour. The process is susceptible to interaction with the midwife; especially her support to the woman's feeling of being in control. Midwives should secure that the woman's recognition of the fact that the labour is non-progressive and augmentation is required is handled with respect for the dialectical process. Augmentation of labour should be managed as close to the course of natural labour and delivery as possible.

Objective: to determine risk factors for the occurrence of severe perineal trauma (third and fourth degree tears) during childbirth., Design: a prospective cohort study was conducted using the hospital's computerised obstetric information system. Additional data were gathered on women who sustained severe perineal trauma. Descriptive statistics and logistic regression were used to assess risk factors for severe perineal trauma. Midwives were asked to comment on possible reasons for severe perineal trauma. Written responses made by midwives were analysed using content analysis. Discussion groups with midwives were held to further explore their experiences., Setting: Royal Prince Alfred Hospital, Sydney, Australia., Participants: all women having vaginal births (n=6595) in a 2-year period between 1 April 1998 and 31 March 2000, in both the birth centre and the labour ward., Measurements and Findings: 2% of women (n=134) experienced severe perineal trauma. One hundred and twenty-two women had third-degree tears and 12 had fourth-degree tears. Primiparity, instrumental delivery, Asian ethnicity and heavier babies were associated with an elevated risk of severe perineal trauma. Midwives identified several factors they believed contributed to severe perineal trauma. These were lack of effective communication with the woman during the birth, different birth positions, delivery technique, ethnicity and obstetric influences., Key Conclusions: findings support current knowledge that primiparity, instrumental birth, heavier babies and being of Asian ethnicity are associated with increased rates of severe trauma. Specific attention needs to be paid to the strong association found between being of Asian ethnicity and experiencing severe perineal trauma., Implications for Practice: further identification and validation of the concerns expressed by midwives to reduce severe perineal trauma is warranted so that preventative strategies can be used and researched.

Objective: To establish whether women's preference for elective caesarean section (ELCS) changes as gestation advances., Design: A prospective longitudinal observational study., Setting: Two units providing obstetric care in Hong Kong, one public and one private., Sample: Five hundred and one nulliparous Chinese pregnant women attending their routine fetal anomaly scan in either unit., Methods: Consented subjects had two interviews using a structured questionnaire at 18-22 weeks and 35-37 weeks of gestation, respectively. Multivariate analysis was performed to identify determinants for preferring ELCS at the two gestational ages., Main Outcome Measure: The preferences for the mode of delivery at the two gestational ages., Results: The prevalence of maternal preference for ELCS in the study cohort was 17.2% (95% CI 13.9-20.5) and 12.7% (95% CI 9.6-15.8) at mid-trimester and at term, respectively. Significantly more women who preferred ELCS at mid-trimester changed to a trial of vaginal delivery (VD) at term than vice versa (42.0 versus 3.8%). The partner's preference for ELCS was a significant determinant for women preferring ELCS throughout the antenatal period. Among the women booked in the public sector, more women who preferred ELCS at term changed to deliver in private hospitals than those who preferred VD (46.2 versus 9.7%)., Conclusions: Many women changed from preferring ELCS to preferring VD as their pregnancy approached term. The partner's preference was a significant determinant for the women's choice. If a decrease in the proportion of women preferring ELCS is desired, the intervention programme should target the women and their partners who hold such a preference at 20 weeks.

Unlabelled: Sleep disturbance is a typical complaint during pregnancy, particularly in the third trimester. Previous studies of this phenomenon have not measured sleep in the last days of pregnancy as women transition into labor. Poor sleep can have potentially adverse effects on labor and delivery., Objective: The purpose of this study was to evaluate the amount of sleep obtained in the 5 days preceding childbirth, and the relationship between sleep in this time frame and both pain and fatigue during early labor., Methods: Thirty-five nulliparous women were recruited from childbirth preparation classes. Sleep was measured with wrist actigraphy continuously until hospital admission for delivery. Participants completed self-report measures of pain and fatigue in early labor prior to hospital admission., Result and Discussion: Most women experienced spontaneous labor onset during the night. Sleep quality deteriorated progressively over the last 5 days of pregnancy, and was the lowest on the night before hospital admission. This was the case even when labor was induced (40%)., Conclusion: There was a significant relationship between the amount of sleep the night before hospitalization and pain perception in women with spontaneous labor onset. Results from this study can be used to advise women in late pregnancy about expected sleep patterns and measures to optimize sleep and rest.

Purpose of Review: The purpose of the review was to evaluate recent studies in the field of psychosomatic obstetrics and gynecology for new directions in research., Recent Findings: Psychosomatic obstetrics and gynecology covers a wide canvas, and the present review shows extensive research in some areas and large gaps in others. There have been significant developments in the field of pregnancy-related psychiatric morbidity, particularly anxiety states and posttraumatic stress disorder; however, there is a need for better and more specific measurement and screening methods. Among gynecological conditions there have been advances in research on chronic pelvic pain and gynecological cancers, but most other gynecological conditions have been neglected. What is encouraging is the increasing amount of research from the developing world and the focus on common reproductive conditions based on community studies. In addition, in light of the recent findings and concerns related to hormone replacement therapy, research on mood disorders related to menopause is increasing, with refinement in measurements, definitions, and treatment methods., Summary: While studies on prevalence and risk factors abound, what is missing are well conducted intervention studies. The next phase of research should focus on preventive and intervention studies that are easily adaptable the world over.