Psychological aspects of caesarean section

This chapter gives an overview of research relating to psychological aspects of caesarean section. It focuses on four main questions: *What are the psychological effects of caesarean section on the mother, her partner and her relationship with her infant? *What factors (obstetric, psychological, attitudinal, and health care-related) make women more vulnerable to adverse psychological outcomes after a caesarean section? *What are women distressed about when they have had a caesarean section? *How can post-caesarean psychological distress be prevented or managed?A methodological critique of existing studies on psychological aspects of caesarean section is also given. In conclusion, recommendations for practice and for future research are made.

Towards a conceptual framework for evaluating primary care research networks

We describe a conceptual framework that we have developed for evaluating primary care research networks. The framework includes objectives, process indicators, and outcome indicators. We propose the framework as a provisional model that we hope will promote further research and debate.

Nurse management of patients with minor illnesses in general practice: multicentre, randomised controlled trial

OBJECTIVE

To assess the acceptability and safety of a minor illness service led by practice nurses in general practice.

DESIGN

Multicentre, randomised controlled trial.

SETTING

5 general practices in south east London and Kent representing semi-rural, suburban, and urban settings.

PARTICIPANTS

1815 patients requesting and offered same day appointments by receptionists.

INTERVENTION

Patients were assigned to treatment by either a specially trained nurse or a general practitioner. Patients seen by a nurse were referred to a general practitioner when appropriate.

MAIN OUTCOME MEASURES

The general satisfaction of the patients as measured by the consultation satisfaction questionnaire. Other outcome measures included the length of the consultation, number of prescriptions written, rates of referral to general practitioners, patient's reported health status, patient's anticipated behaviour in seeking health care in future, and number of patients who returned to the surgery, visits to accident and emergency, and out of hours calls to doctors.

RESULTS

Patients were very satisfied with both nurses and doctors, but they were significantly more satisfied with their consultations with nurses (mean (SD) score of satisfaction 78.6 (16. 0) of 100 points for nurses v 76.4 (17.8) for doctors; 95% confidence interval for difference between means -4.07 to -0.38). Consultations with nurses took about 10 minutes compared with about 8 minutes for consultations with doctors. Nurses and doctors wrote prescriptions for a similar proportion of patients (nurses 481/736 (65.4%) v doctors 518/816 (63.5%)). 577/790 (73%) patients seen by nurses were managed without any input from doctors.

CONCLUSION

Practice nurses seem to offer an effective service for patients with minor illnesses who request same day appointments.

An economic evaluation comparing two schedules of antenatal visits

OBJECTIVES

To conduct an economic evaluation comparing a traditional antenatal visiting schedule (traditional care) with a reduced schedule of visits (new style care) for women at low risk of complications.

METHODS

Economic evaluation using the results of a randomised controlled trial, the Antenatal Care Project. This took place between 1993 and 1994 in antenatal clinics in South East London and involved 2794 women at low risk of complications.

RESULTS

The estimated baseline costs to the UK National Health Service (NHS) for the traditional schedule were 544 Pounds per woman, of which 251 Pounds occurred antenatally, with a range of 327-1203 Pounds per woman. The estimated baseline costs to the NHS for the reduced visit schedule was 563 Pounds per woman, of which 225 Pounds occurred antenatally, with a range of 274-1741 Pounds per woman. Savings from new style care that arose antenatally were offset by the greater numbers of babies in this group who required special or intensive care. Sensitivity analyses based on possible variations in unit costs and resource use and modelled postnatal stay showed considerable variation and substantial overlap in costs.

CONCLUSIONS

Patterns of antenatal care involving fewer routine visits for women at low risk of complications are unlikely to result in savings to the Health Service. In addition, women who had the reduced schedule of care reported greater dissatisfaction with their care and poorer psychosocial outcomes which argues against reducing numbers of antenatal visits.

Caregiver stress: a failed negotiation? A qualitative study in South West France

The purpose of this work is to analyze the various negotiations involved in setting up and developing a caregiving relationship with a disabled elderly person, to understand the processes inducing caregiver stress. Within the conceptual framework defined by the paradigm of negotiation, this study uses the theoretical contributions of the parallelist theory and the theory of the gift. It is based on a qualitative inquiry including fifty-four caregivers conducted in Toulouse (South West France). The analysis focuses on two undersystems of the caregiver's relationships: 1) the caregiver/cared-for's relationship, which is characterized by the establishment and maintenance of a "tacit contract" and 2) the relationships with other eligible caregivers, which are marked by the "designation" of the principal caregiver. This analysis shows that a failure in the negotiation process can induce a designation and/or a weak tacit contract-the result of which is the caregiver's expression of stress. This expression is closely linked to the caregiver's perception of a negative balance in his/her exchanges with the partners. This study should help break away from the one-way arrow model currently dominating the field of caregiver stress research.

Do the psychosocial and behavioral changes that accompany motherhood influence the impact of pregnancy on long-term weight gain?

The aim of the present study was to assess whether the psychosocial and behavioral changes that occur during and after pregnancy influence long-term weight gain. The study examined 74 mothers enrolled in the Antenatal Care (ANC) Project (a randomized controlled trial of antenatal care based in South London), all of whom had volunteered to take part in a subsequent follow-up study. Data on body weight at the beginning of pregnancy; lifestyle and behavior during pregnancy; antenatal care and obstetric history; together with measures of postnatal depression and parenting stress following pregnancy were taken from the existing ANC Project database. Additional measurements of height and weight together with information on a variety of lifestyle changes and psychosocial characteristics, were gathered during semi-structured interviews at each mother's home, two and a half years after their children had been born. The results show that pregnancy-related weight gains are not simply the result of retaining weight that is gained during pregnancy, but that they also originate from gaining additional weight in the postpartum period. Mothers who felt they ate more after their children were born, had significantly greater long-term weight gains (2.78 (1.42) kg) than those who felt that they had not increased their food intake (-1.15 (0.76) kg; t = 2.49, p = 0.016). Similarly, mothers who felt they had greater access to food postpartum, had significantly greater long-term weight gains (1.70 (0.87) kg) than those who felt they did not have greater access to food (-1.37 (1.13) kg; t = 2.18, p = 0.032). There was some evidence that the lifestyle changes which accompany pregnancy and motherhood increase some women's vulnerability to eating disorder psychopathology. Mothers who felt they did less exercise after pregnancy than they did before, were also at greater risk of long-term weight gain (p = 0.028), as were mothers with low numbers of supportive individuals (p = 0.033). Neither the stress of parenting nor maternal depression were significantly associated with an increased risk of long-term weight gain (p > 0.05).

Does reducing the frequency of routine antenatal visits have long term effects? Follow up of participants in a randomised controlled trial

1117 low risk women, who had been randomly allocated to either the traditional schedule of 13 antenatal visits or a reduced schedule of six to seven visits, were followed up 2.7 years after their delivery. Follow up was by means of a postal questionnaire (assessing the mother-child relationship, maternal psychological wellbeing, health service use, health-related behaviour and health beliefs), and patient record data on the frequency of contacts in general practice. There was no evidence of differences between the two groups for any of the outcomes examined. Offering a reduced schedule of routine antenatal visits to low risk women does not appear to have any long term effects.

Relative importance of heritable characteristics and lifestyle in the development of maternal obesity

STUDY OBJECTIVE

To assess the relative importance of heritable characteristics and lifestyle in the development of "maternal obesity" after pregnancy.

SETTING

South east London, in the homes of mothers who had delivered their babies at either Guy's, Lewisham or St Thomas's hospitals.

PARTICIPANTS

Seventy four mothers of low antenatal risk who had been enrolled in the Antenatal Care (ANC) Project (a previous trial of antenatal care) during the first trimester of pregnancy, and who had subsequently been followed up 2.5 years after delivery.

DESIGN

Information on parental obesity, psychosocial and sociodemographic factors as well as lifestyle, was gathered during a semi-structured interview at each mother's home. Additional anthropometric and psychosocial data were taken from the existing ANC Project database. These data were used to assess the relative importance of heritable characteristics and lifestyle on changes in maternal body weight from the beginning of pregnancy to the follow up interview.

MAIN RESULTS

After adjusting for the effects of potential confounders and known risk factors for maternal obesity, women who selected larger silhouettes to represent their biological mothers were significantly more likely to have higher long term weight gains than those who selected thinner maternal silhouettes (r = 0.083, p = 0.004). Women who were less satisfied with their bodies postpartum had significantly greater long term weight gains than those women who displayed no increase in dissatisfaction with their bodies after pregnancy (r = 0.067, p = 0.010).

CONCLUSIONS

A heritable predisposition to gain weight together with changing attitudes to body size, both had an independent role in the development of maternal body weight after pregnancy. Differences in each woman's heritable predisposition to gain weight and any changes in body image that occur after pregnancy might explain why some women gain weight in association with pregnancy.

Prolonged intermittent high intensity exercise impairs neuromuscular performance of the knee flexors

This study investigated the effect of prolonged intermittent high intensity exercise upon the isokinetic leg strength and electromechanical delay of the knee flexors. Seven male collegiate soccer players were exposed to: (i) a prolonged intermittent high intensity exercise task (PIHIET) which required subjects to complete a single-leg pedalling task, with the preferred limb, (75 rpm for all constant-load portions of the task) consisting of 48 x 1.8 minute cycles of exercise, and (ii) a control task consisting of no exercise. Pre-, mid- and post-PIHIET gravity corrected indices of knee flexion angle-specific torque (0.44 rad knee flexion (AST); 0 rad=full knee extension; [1.05 rad x s(-1)]) were made for both intervention and control limbs. Electromechanical delay (EMD) of the m. biceps femoris during supine knee flexion movements was evaluated in the preferred leg on both intervention and control days. Repeated measures ANOVAs revealed significant condition (intervention; control) by time (pre; mid; post) interactions for both knee flexor AST (F[2,12]=4.8; p < 0.03) and EMD (F[2,12]=4.1; p < 0.05). AST was observed to decrease by 16% and EMD increase by 30% pre to post intervention. These observations suggest an impairment of neuromuscular control and the ability to maintain force generation in the knee flexors, near the extremes of the range of motion during prolonged intermittent high-intensity exercise activities. Changes of this magnitude may pose a threat to the integrity of the knee joint.

A transglutaminase-related antigen associates with keratin filaments in some mouse epidermal cells

A mouse monoclonal IgG, G82, directed against guinea pig liver transglutaminase recognizes a transglutaminase-related antigen that is associated with the keratin intermediate filament network in some primary mouse keratinocytes. The association can be seen at the resolution of individual keratin tonofibrils following fixation and staining for double-label indirect immunofluorescence. Western blots indicate that G82 reacts with two proteins of 95 kDa and 280 kDa, respectively, in extracts of these cells. The 95-kDa band is also recognized by a polyclonal antibody against purified guinea pig liver transglutaminase, and the 280-kDa protein seems to correspond to a similar protein that was shown to be recognized by G92.1.2 in the intermediate filament fraction of primary mouse fibroblasts. The transglutaminase-related antigen was shown by confocal microscopy to co-localize only with nonbasal cell specific keratin intermediate filaments.

Ross procedure in congenital patients: results and left ventricular function

METHODS

From April 1990 to August 1995, 121 patients (median age 42 years) underwent aortic valve replacement with allografts (69 patients) or autografts (52 patients). In this latter group, 24 Ross procedures have been performed in congenital patients since November 1991 (median age 10 years, range five months to 27 years): aortic incompetence (n = 17), isolated aortic stenosis (n = 5), small stenotic prosthesis (n = 2). Transthoracic echocardiography was obtained preoperatively in all patients and serially after surgery with the aim of measuring aortic and pulmonary annuli and evaluate gradients and incompetence and to study the left ventricular function. Intraoperative transoesophageal echocardiography was routinely used. Complete root replacement was performed in all patients.

RESULTS

One patient died in the early postoperative period (4%). There was no late death. All survivors remained in NYHA class I and were free of complications and medications. No gradient nor any significant aortic incompetence could be demonstrated. In 17 patients with predominant aortic incompetence before surgery, the left ventricular function was followed prospectively, end-diastolic left ventricular dimensions diminished drastically from 2 +/- 3.4 S.D. above normal to -0.63 +/- 2.4 S.D. at one week postoperatively (day 10) to reach a normal value one to three months after surgery. Left ventricular mass remained abnormal at day 10 (from 4.7 +/- 3.3 S.D. to 5.3 +/- 3.8 S.D.) and diminished more progressively to reach a normal value (0.14 +/- 1.4 S.D.) at three months. This resulted in a significant decrease of end-systolic wall stress (-3.6 +/- 2.1 S.D.) and in a hyperdynamic function in the immediate postoperative days except in two patients. These two patients were characterized preoperatively by more severely dilated left ventricle (end diastolic dimension 5.3 +/- 0.03 versus 1.6 +/- 3 S.D.) with decreased left ventricular wall thickness (1.19 +/- 0.7 versus 3.44 +/- 1.9 S.D.), decreased ratio between end diastolic wall thickness and end diastolic dimension (0.14 +/- 0.06 versus 0.2 +/- 0.06) and a decreased velocity of shortening. Unlike the other 15 patients, the left ventricular function did not recover completely at mid term follow-up in those two patients.

CONCLUSION

The Ross operation is a safe procedure and allows us to suppress completely the abnormal loading conditions of the left ventricle, resulting in a complete recovery of left ventricular function in most patients.

Women's satisfaction with traditional and reduced antenatal visit schedules

OBJECTIVE

to ascertain: (i) which demographic, obstetric, maternity care, practical and attitudinal variables, and which variables relating to social support and life problems predict satisfaction with traditional antenatal visit schedules; and (ii) which of these variables predict satisfaction with reduced antenatal visit schedules.

DESIGN

a secondary analysis of data from the Antenatal Care Project (a randomised controlled trial comparing two schedules of routine antenatal visits).

SETTING

three hospitals and their community sites in south-east London.

PARTICIPANTS

1882 pregnant women, that is all those who took part in the Antenatal Care Project, on whom maternity record data were available, and who returned their antenatal questionnaire.

INTERVENTION

participants were randomly allocated to follow either the traditional schedule of 13 routine antenatal visits, or a reduced schedule of seven visits for nulliparous women and six visits for multiparous women.

MEASUREMENTS

a questionnaire developed specifically for the Antenatal Care Project. Also some data extracted from women's maternity records.

FINDINGS

women satisfied with reduced schedules were more likely to live in rented accommodation, and to have a caregiver who both listened and encourage them to ask questions than women not satisfied with reduced schedules. Women satisfied with the reduced schedules were less likely to be depressed in pregnancy than those not satisfied with reduced schedules. Women satisfied with the traditional schedule were more likely to have their general practitioner involved in their antenatal care, and to receive social support from relatives than those not satisfied with the traditional schedule. Initial preferences and expectations were also associated with satisfaction.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

(i) groups most likely to be satisfied with traditional or reduced antenatal visit schedules cannot be easily identified. It is therefore necessary to talk to women individually, and tailor care to their particular preferences; (ii) social support for depressed women needs to be safeguarded if reduced schedules are to be introduced; (iii) improving the psychosocial quality of antenatal care may be a good strategy for making reduced visit schedules more acceptable to pregnant women.

A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project

OBJECTIVE

To compare the clinical and psychological effectiveness of the traditional British antenatal visit schedule (traditional care) with a reduced schedule of visits (new style care) for low risk women, together with maternal and professional satisfaction with care.

DESIGN

Randomised controlled trial.

SETTING

Places in south east London providing antenatal care for women receiving shared care and planning to deliver in one of three hospitals or at home.

SUBJECT

2794 women at low risk fulfilling the trial's inclusion criteria between June 1993 and July 1994.

MAIN OUTCOME MEASURES

Measures of fetal and maternal morbidity, health service use, psychosocial outcomes, and maternal and professional satisfaction.

RESULTS

Pregnant women allocated to new style care had fewer day admissions (0.8 v 1.0; P=0.002) and ultrasound scans (1.6 v 1.7; P=0.003) and were less often suspected of carrying fetuses that were small for gestational age (odds ratio 0.73; 95% confidence interval 0.54 to 0.99). They also had some poorer psychosocial outcomes; for example, they were more worried about fetal wellbeing antenatally and coping with the baby postnatally, and they had more negative attitudes to their babies, both in pregnancy and postnatally. These women were also more dissatisfied with the number of visits they received (odds ratio 2.50; 2.00 to 3.11).

CONCLUSIONS

Patterns of antenatal care involving fewer routine visits for women at low risk may lead to reduced psychosocial effectiveness and dissatisfaction with frequency of visits. The number of antenatal day admissions and ultrasound scans performed may also be reduced. For the variables reported, the visit schedules studied are similar in their clinical effectiveness. Uncertainty remains as to the clinical effectiveness of reduced visit schedules for rare pregnancy problems.