| 1. |
- Asplin, Nina
(författare)
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Women's experiences and reactions when a fetal malformation is detected by ultrasound examination
- 2013
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Second trimester ultrasound examination among pregnant women in Sweden is almost universal. The detection of a fetal malformation on ultrasound puts health care providers and pregnant women in a difficult and precarious situation. What information and how it is communicated is crucial to women’s decision-making about continuing or terminating at pregnancy. The main aim of this thesis was to describe and analyze women’s experiences and reactions following the detection of a fetal malformation on an ultrasound scan. Methods: Two semi-structured in-depth interviews were performed, with women informed of a fetal malformation following an ultrasound scan. A total of 27 women took part in the first round of interviews: women continuing their pregnancy were interviewed, either in gestational week 30 or three weeks after the diagnosis; those terminating their pregnancy were interviewed two to four weeks after termination (Paper I). A second interview with 11 women who terminated their pregnancy was conducted six months after termination (Paper III). Two questionnaires were also administered. The first, answered by 99 women (Paper II) and comprising 22 study- specific questions along with emotional well-being and socio-demographics variables and medical and obstetric history, was conducted at the same time as the first stage of interviews. The other questionnaire, answered by 56 women incorporated common self- report instruments and was performed three times: first in gestational week 30, and then two respectively six months postpartum (Paper IV). Qualitative data were analyzed through content analysis, and quantitative data were analyzed through descriptive statistics. Results: The timing, duration, and manner of women’s initial counseling and ongoing support were shown to be important in the interaction between women and caregivers. Positive interactions improved the women’s ability to understand the information and fostered feelings of trust and safety, which in turn reduced their anxiety. Most of the women who expected a baby with an abnormality expressed their need for information on several occasions to help them make this difficult decision. They also wished for information from different specialists and continuity of care. These needs were even stronger in women who chose to terminate their pregnancy. We found women continuing their pregnancy to be at high risk of depressive symptoms, major worries, and high anxiety levels, both in mid-pregnancy, and at two months and one year postpartum. Despite these findings, the results of the maternal-fetal attachment scale for women who continued their pregnancy with a fetus diagnosed with a malformation indicated a high level of attachment. Conclusions and Clinical Implications: Effective communication, empathy and compassion, and consistent follow-up routines are important to ensure good treatment and care of this group of women. Taking these results into account may improve caregivers’ ability to counsel these vulnerable patients and to ensure that their needs are properly met.
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| 2. |
- Niklasson, Boel
(författare)
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Pain relief following cesarean section : short and long term perspectives
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundPostoperative pain treatment in women undergoing cesarean section (CS) needs to be effective to enable fast and smooth recovery without adverse outcomes and to improve breastfeeding and bonding between mother and child. It is also important that pain treatment should have minimal impact on the newborn.The overall aimThe overall aim of this thesis was to investigate how to improve pain management in women undergoing cesarean section.Specific aims were:* To investigate if a single injection of bupivacaine with adrenaline close to the fascia could decrease opiate consumption and pain in patients undergoing CS in spinal anesthesia and whether the same treatment influences the need for opiates in women operated in general anesthesia (paper 1 and 3).* To study the overall incidence and risk factors for persistent pain after CS and to characterize the persistent pain, regarding intensity, body location and impact on daily life (paper 2).* To clarify whether oral oxycodone (OXY) can provide equal/better and safe postoperative pain relief after CS compared to intravenous morphine followed by oral codeine (IVM) (paper 4).* To study pharmacokinetic aspects of postoperative OXY treatment of mothers after CS and to investigate possible drug exposure through breast milk, including the effects on the newborn (paper 5).Methods and results:Study I: Two hundred and sixty women undergoing CS were randomized to receive injection ofeither 40 ml bupivacaine (2.5 mg/ml) with adrenaline (5 μg/ml) (n=130) or 40 ml saline solution (0.9%) (n=130), close to the fascia before closure of the wound. Morphine consumption, pain assessment by Numerical Rating Scale (NRS) and time to mobilization were recorded. Morphine requirements were significantly less for up to 12 h postoperatively and mean and maximum pain intensity lower during the first 6 h in the group receiving local anesthesia (p ≤0.05).Study II: A prospective follow up study of the women participating in study I. A questionnaire consisting of the Brief Pain Inventory (BPI) was posted to all women at 3, 6 and 12 months after surgery. Women rated pain intensity as well as interference with factors related to general function and quality of life. Women reported pain in one or more locations, in the CS surgical site as well as in other parts of the body. At 3 months 40% had pain and at 6 and 12 months 27% and 21%, still had pain. CS on maternal request i.e. psychological indication as well as a first CS were significant (p ≤0.05) risk factors for persistent pain at 3 months. Severe postoperative pain in the immediate postoperative period (0-48 h) or undergoing a first CS were significant independent risk factors for the development of persistent pain up to 6 months after CS. Parameters related to quality of life such as sleeping difficulties were significantly impaired in women with persistent pain.Study III: A retrospective study (2008-2014) was conducted at the Karolinska University Hospital, Huddinge where medical records of women who underwent CS in general anesthesia were reviewed. After applying exclusion criteria 250 medical records remained. Information 3 about women receiving local anesthesia in the surgical wound, 20 or 40 ml bupivacaine/adrenaline (36 and 42 women in each group), were collected and data from women receiving no local treatment were identified and served as controls (n=172). A significantly lower morphine consumption during the 6 first postoperative hours was seen in patients receiving 40 ml local anesthetics when compared with controls (p ≤0.05) but no difference was seen for the 20 ml group or between treatment groups.Study IV: Eighty women scheduled for elective CS were recruited and randomized to receive extended release tablets and short acting OXY (n=40) or IVM (n=40). All patients received a multimodal therapy with ibuprofen and paracetamol and the opiates were administered as needed. Outcome measures were safety parameters for mother and child, opioid requirements, pain intensity by NRS, time to mobilization and time consumption to administer drugs. To evaluate safety for the newborns Apgar scores, acid base status in the umbilical cord, weight development and the Neurological Adaptive Capacity Score were used. A significantly lower postoperative pain intensity measured by NRS was observed 0-6 hours and 25-48 hours in the OXY group (p ≤0.05). Opioid consumption was significantly less in the OXY than in the IVM group 0-5 days postoperatively. Total time to administer analgesics was significantly shorter in the OXY group. There was a significant difference in common opiate related adverse effects between the two groups (3 women in the OXY group compared to 15 in the IVM/codeine group). No negative effects in the newborns related to opioid treatment were observed in either of the two groups.Study V: The material was obtained in study IV. Maternal blood and breastmilk were sampled at 24 and 48 hours and neonatal blood was collected at 48 hours postpartum. All samples were analyzed for OXY and the metabolites noroxycodone, oxymorphone and noroxymorphone. Detectable plasma levels of OXY and its metabolites were found in all women and even if there were small quantities of breastmilk detectable levels were found also here. In most cases there were low or non-detectable levels of OXY in the plasma of the neonates.Conclusions: A single injection of bupivacaine with adrenaline in the surgical wound decreases the need for rescue morphine postoperatively and was demonstrated to be a safe and effective pain management in women undergoing CS both in spinal and general anesthesia. Standardized postoperative treatment with oral OXY after CS was shown to be time effective and to give a better pain control, with lower opioid intake than a protocol using IVM/codeine, both as components of a multimodal analgesic regime. Our clinical data and the pharmacokinetic analyses support the view that OXY treatment is safe for mothers and neonates. As severe postoperative pain is a risk factor for long term pain the initial pain relief is crucial and we found that experiences related to quality of life were significantly impaired in women with persistent pain. We suggest that our findings can be of clinical importance, not least in women who have their CS performed in general anesthesia.
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| 3. |
- Wallin Lundell, Inger, 1958-
(författare)
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Induced Abortions and Posttraumatic Stress - Is there any relation? : A Swedish multi-centre study
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Induced abortion is a common medical intervention. Whether psychological sequelae might follow induced abortion has long been a subject of concern among researchers, and there is lack of knowledge about the relationship between posttraumatic disorder (PTSD) and induced abortion. Aims: To study and compare PTSD, posttraumatic stress symptoms (PTSS) and anxiety- and depressive symptoms among women seeking abortion, allowing for demographic variables. Further aims were to assess risk factors and to assess PTSD and PTSS following induced abortion in relation to experienced care at the clinic. Methods: This was a multi-centre cohort study targeting women who requested an induced abortion at the outpatient clinics of the gynaecology and obstetrics departments of six public hospitals in Sweden. All women who requested an induced abortion before the end of gestational week 12 were approached for participation. PTSD, PTSS, anxiety- and depressive symptoms, personality traits and women’s perceptions of abortion care were measured by means of questionnaires. Measurements were made at the first visit before the abortion as well as three- and six-months thereafter. Data collection was performed from September 2009 to January 2011. Results: 1,514 women filled out the questionnaire before the abortion. Abortion-seeking women did not suffer from PTSD to a greater extent than the general Swedish female population. Few women (51/720) developed PTSD or PTSS after the abortion, 11 did so due to trauma experience related to the abortion. Women at risk of posttraumatic stress were more likely to be young, having anxiety- or depressive symptoms and personality traits related to neuroticism. Furthermore, women with PTSD or PTSS were more likely to perceive certain aspects of the abortion care as deficient. Conclusions: The vast majority of women coped well with the induced abortion. Few developed posttraumatic stress post abortion. The majority did so because of trauma experiences unrelated to the induced abortion. Young women and women with mental distress are vulnerable groups that need to be paid attention to in abortion care. These women are at risk for negative experiences of the abortion care, and may be at risk of PTSD or PTSS post abortion
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| 4. |
- Georgsson Öhman, Susanne
(författare)
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Women's Experiences of Fetal Screening for Down's Syndrome by Means of an Early Ultrasound Examination
- 2005
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The general aim of this thesis was to explore women's reactions to and experiences of fetal screening for Down's syndrome PS) by means of an ultrasound examination, including measurement of fetal nuchal translucency (NT). The effect of this screening on maternal worry about the baby's health was investigated, as well as reactions to a false positive test and interpretation of information about riskAlso, an instrument measuring worry during pregnancy, the Cambridge Worry Scale, was translated into Swedish and tested on a sample of pregnant women.A sub-sample of 2026 women was drawn from a larger randomised controlled trial including 39,572 women, which investigated medical outcomes of the new fetal screening policy. Of these women, 1030 were randomly allocated to the intervention group, and 996 to routine care. No statistically significant differences were found between the two groups regarding major worry about something being wrong with the baby, general anxiety and depressive symptoms m midpregnancy and two months postpartum.Twenty-four women who had received information about an increased risk according to NT were interviewed during pregnancy and after birth. Twenty of these women had false positive tests, and for 16 the risk was higher than expected considering their age. These women expressed major worry, and many said they chose to reject their pregnancy, to take "time out", while waiting for the results of fetal karyotyping. Two months after the birth, most of these women seemed to have overcome the stressful situation.In the intervention group of the above trial 796 women had a risk score for DS recorded in a clinical database. Of these women 620 said they had received information about the risk score, and 64 percent stated the figure almost correctly. The actual risk was associated with women's perception of the risk. Worry about the baby's health and depressive symptoms did not differ statistically between women who were at high risk (1:250 or higher) and at low risk. However, women who perceived that the risk was high were more worried about the baby's health and also seemed to have more depressive symptoms in mid-pregnancy compared with those who perceived the risk to be low. No differences were observed at two months after birth.The translated version of the Cambridge Worry Scale was tested on 200 Swedish pregnant women in Stockholm. The three main sources of worry were about the baby's health, giving birth and miscarriage. The internal- consistency reliability was 0.81 (Cronbach's alpha). Three items were added to the original scale to capture women's worry about the maternity services.In conclusion, the intervention with an early ultrasound examination including risk assessment for DS by measuring the NT did not affect maternal worry about the baby's health, general anxiety or depressive symptoms 'm mid-pregnancy or two months after birth. However, a false positive test could cause strong reactions of anxiety and rejection of the pregnancy for some weeks. Many had problems to recall and interpret a given risk score. An actual high risk score was not associated with major worry about the baby's health or depressive symptoms, whereas a woman's perception of being at high risk had such an association. The Swedish version of the Cambridge Worry Scale was considered to be useful and well suited for its purpose.
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| 5. |
- Wätterbjörk, Inger, 1955-
(författare)
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Couples' experiences of an extended information visit about prenatal screening : decision making and satisfaction
- 2014
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The overall aim of this thesis was to describe pregnant women's and partners' views and experiences on early prenatal screening with the combined test, with special focus on the two-step information model.Interviews were performed with 15 couples who had taken part in the extended information visit about prenatal screening, describing their perceptions of the information model (I) and ten couples or women of those, for a follow-up interview exploring their decision-making process (II). Seven couples, who had not taken part in the extended information visit, were interviewed describing their views and experiences about prenatal screening (III). A questionnaire was answered by 295 women and by 223 partners about their satisfaction about the decision whether or not to participate in the combined test, and their assessment of whether or not this choice had been difficult (IV).The results showed that different opinions were expressed about the offer of the extended information visit. The separate visit was welcomed by most couples (I). The decision-making process regarding whether to take part in the test or not was described by most couples as a fairly straightforward decision, while for others it was a more complex process that required a great deal of consideration (II). An apprehension of the test, by some of those who had refrained the extended information visit, was that it was an expression of society's involvement in decisions that belong to the expectant parents (III). Ninety-three percent of both women and partners considered the decision about participating in the combined tests as uncomplicated, and well over 90%, of both women and partners were satisfied with their decision (IV).The conclusions in this thesis, are that the decision whether or not to participate in the combined test is multidimensional and influenced by different views. The two-step information model helped the pregnant woman and the partner to make a decision in a fairly straightforward process or a more complex process with mixed feelings.
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