Dissertations / Theses on the topic 'Obstetric emergencies'

This study explores the experiences of a group of midwives when caring for women who are having obstetric emergencies in labour. The study aimed to investigate the experiences of midwives to answer the research question 'What is the lived experience of caring for women during obstetric emergencies in labour, as perceived through the experiences of midwives?' The study utilised a descriptive phenomenological approach in which midwives were asked to recount their experiences during a non-directed interview. The data were analysed using a modified version of Colaizzi's (1978) framework. The study was conducted in two maternity units within National Health Service Trusts in the East of England. The participants comprised a convenience sample of eleven midwives with between six months and twenty-five years experience, all of whom had given care during obstetric emergencies in labour - in either acute or midwifery led units, or in the community setting. Four theme categories and twelve associated theme clusters were identified. The four theme categories were: learning to care; involvement; coping; and valuing and respecting. The study suggests that caring in obstetric emergencies is a demanding and, at times, exhausting reciprocal partnership between the midwife and the woman. The midwife-mother relationship is characterised by varying degrees of involvement. Caring is initiated in response to actual or perceived needs or wants, and is communicated through physical presence and an intense emotional connection. The woman and her family are valued and respected, which facilitates the connection. The ability to care and to cope in these difficult clinical situations is influenced by a number of factors, including the level of perceived support from colleagues and events in the midwife's' personal life. Caring is enhanced by an extended experiential knowledge base and can be ii ~~---------- extended beyond personally determined boundaries if either of these two factors is enhanced. The study offers insight into a previously unexplored aspect of midwifery practice, and has ramifications for both undergraduate preparation of student midwives, and the support and continuing professional development of qualified staff.

Study Setting: Two rural Indonesian districts served by the national midwife-in-the-village programme. Methods: Three critical incident audits of maternal mortality and severe morbidity: confidential enquiry, a verbal autopsy survey, and a participatory community-based review. Results: A range of inter-related factors contributed to poor quality and access. When delivery complications occurred, many women and families were un-informed, un-prepared, found care unavailable, unaffordable, and relied on traditional providers. Social health insurance was poorly promoted, inequitably distributed, complex, bureaucratic, and often led to lower quality care. Public midwives were scarce in remote areas and lacked incentives to provide care to the poor. Emergency transport was often unavailable and private transport incurred further expense. In facilities, there was reluctance to admit poor women, and ill-equipped, under-staffed wards for those accepted. Referrals between hospitals were also common. Examining adverse events from user and provider perspectives yielded multi-level causal explanations. These were used to develop a conceptual model relating structural arrangements (such as decentralisation, commodified care and reductions in public funding) to constrained service provision and adverse health consequences. Conclusions and recommendations: A policy shift towards healthcare as a public good may provide a route to reduce available maternal ill-health. Engaging with those who require and provide critical care in routine assessments can inform more robust health planning, and promote inclusion and participation in health.

This study examines global incentives to reduce maternal mortality, namely the fifth Millenium Developmnet Goal to reduce maternal mortality with 75% by 2015. More specifically it examines maternal mortality and obstetric care in situations of emergency. When exposed to extreme situations the risks of negative pregnancy- and delivey outcomes are increased. Data was collected from seconday sources and from interviews with health staff with experiences from humanitarian work in the field. The findings were analyzed using a theoretical framework explaining maternal mortality be referring to both direct and indirect causes. The two theoretical models used in the study are similar and reminds of each other when explaining maternal mortality. One is based on the assumption that an obstetric complication has occurred and differnt delays in recieving care is the main cause maternal mortality, whilst the other theory is more in depth and elaborates the underlying causes. The first theory is used a base tto analyze the data after which the other theory is applied in order to introdue a deeper dimension to the analysis. The findings suggest that direct causes accounts for 80 per cent of all maternal deaths, homorrhage being the largest, including in disasters. Further causes are infections, unsafe abortions, eclampsia and obstructed labor. Also, underlying socail factors such as gender inequality indirectly has a negative impact on maternal mortality. Moreover, findings suggest that obstetric care is prioritized in disaster relief response.

Aims: This study investigated perceived changes in knowledge and confidence to manage specific obstetric emergency situations following completion of an Advanced Life Support in Obstetrics (ALSO) course in Australia. Methodology: A prospective repeated measures survey design was employed using three questionnaires. From a sampling frame of all course attendees from May to September 2010 throughout Australia (N = 242), 68% (n = 165) completed pre- and immediate post-course questionnaires, and 61% (n = 101) completed a six-week post-course questionnaire. Descriptive statistics were reported as median and interquartile range. Statistical data were analysed using a Friedman two way repeated measures analysis of variance and the Wilcoxon signed rank test. All p levels lower than .05 were considered significant. Results: There was a significant overall improvement in perceived knowledge and confidence of the recommended management of all 17 emergency situations immediately post-course (p < .001) and at six weeks post-course (p < .001) when compared to pre-course levels. However, a significant decrease in knowledge and confidence for many emergency situations from immediately post-course to six weeks post-course (p < .05) was also observed. The midwives believed the interprofessional aspects of the course had increased their ability to learn (p = .014) and practise new skills (p < .001), work as a team member (p = .002) and communicate effectively with different professional colleagues (p = .008), whereas the doctors experienced no significant changes in their beliefs regarding these variables. The midwives also significantly increased their confidence in all four aspects of interprofessional interaction measured at six weeks following the course (p < .001), whereas the doctors only perceived a significant increase in confidence that their clinical decisions were respected by the midwives with whom they worked (p = .016). Conclusions: These results indicate that completion of the ALSO course in Australia has a positive effect on the knowledge and confidence of doctors and midwives to manage obstetric emergencies. There was also evidence that the course influenced midwives‟ confidence when working and communicating within an interprofessional team.

Obstetric emergencies account for the majority of causes of maternal death. The major causes of death in obstetric emergencies include bleeding, pregnancy induced hypertension, cord prolapse, shoulder dystocia, poor progress, placenta abruptio, placenta praevia and amniotic fluid embolism. A qualitative, descriptive phenomelogical research design was used to explore and describe the lived experiences of the advanced midwives regarding the management of obstetric emergencies in the MOUs of Gauteng province, South Africa. Semi-structured individual interviews were used to collect data from thirteen (13) advanced midwives who were purposively selected and had been working in the MOUs for two years and more after obtaining their qualifications. The seven Collaizi’s procedural steps were utilized for data analysis. Measures to ensure the trustworthiness of the study was adhered to. The findings revealed that, advanced midwives experiences psychosocial stress because of unconducive working environment and higher expectations from the patience and their families. They demonstrated professionalism even when the midwives showed lack of professionalism. In conclusion, unfavorable working conditions experienced by midwives had a negative impact in the management of pregnant women during obstetric emergencies. Management should support advanced midwives with necessary resources that will enable them to perform their duties effectively.<br>Dissertation (MNurs)--University of Pretoria, 2021.<br>Nursing Science<br>MNurs<br>Restricted

Malgré de nombreuses initiatives entreprises par le gouvernement au cours des dernières années, la mortalité maternelle demeure un véritable fléau au Cameroun. Pour cette raison, une recherche a été conduite pour déterminer l'ampleur de la mortalité maternelle dans les 7 maternités de troisième niveau du Cameroun, décrire les différentes étapes d'une intervention visant à améliorer le système de référence et la prise en charge des urgences obstétricales et évaluer son effet sur la mortalité maternelle.La recherche a été menée en trois phases. Une revue rétrospective des données agrégées de la période 2004 à 2006 a été réalisée incluant tous les accouchements, les complications obstétricales, les césariennes et les décès maternels. Ensuite une intervention de 33 mois a été mise en place dans 22 maternités périphériques ainsi que dans 3 maternités de troisième niveau où la mortalité maternelle était importante. L'évaluation de l'intervention a été faite à travers la méthode quasi expérimentale combinant l'étude avant-Après à l'étude ici-Ailleurs. Deux ans après l'intervention, les décès maternels enregistrés dans les 3 maternités cibles avaient diminué de plus de la moitié (P=0,000001). Le taux de létalité des complications obstétricales observé dans les mêmes maternités est passé de 2,2 à 0,7% (P=0,000001). Par ailleurs, le nombre de décès observés chez les femmes référées avait diminué et le taux de létalité était inférieur à 1%. Les résultats de la recherche mettent en évidence les conséquences du renforcement des compétences des prestataires, de l'amélioration du système de référence et de la qualité des soins sur la mortalité maternelle<br>Despite numerous initiatives undertaken by health authorities in the past years, maternal mortality remains a major public health issue in Cameroon. Against this background, research was conducted (i) to determine the maternal mortality patterns in 7 tertiary maternity centers in Cameroon, (ii) to document various stages of an intervention for improving referral system and the management of obstetric emergencies and (ii) evaluate the effect of these measures on maternal mortality and propose future actions. The research was conducted in three phases. A retrospective review of the aggregate data for the period 2004-2006 was performed including all births, obstetric complications, caesarean sections and maternal deaths. Then 33 months intervention has been set up in 22 peripheral maternities and in three tertiary maternity centers where maternal mortality was very high. The evaluation of the intervention was made using the quasi-Experimental design. This method combined the pre- and post- intervention study as well as the study of the maternities where there was intervention compared to the control group. Two years after the intervention, maternal deaths recorded in the target tertiary maternity centers decreased by more than half (P = 0.000001). The case fatality rate decreased from 2.2 to 0.7% in the same group (P = 0.000001). Moreover, the number of deaths among referred women decreased significantly and the case fatality rate was less than 1%. The research findings highlight the impact of capacity building providers, improvement of the referral system and quality of care on maternal mortality

Made available in DSpace on 2016-06-07T17:12:07Z (GMT). No. of bitstreams: 0 Previous issue date: 2015-02-25. Added 1 bitstream(s) on 2016-06-07T17:16:41Z : No. of bitstreams: 1 000864271.pdf: 1326989 bytes, checksum: eff2c8c90bf34c410902d700c1e35884 (MD5)<br>O objetivo geral do presente estudo foi analisar os chamados da população obstétrica usuária do SAMU 192 de Botucatu no ano de 2012 com relação à sua pertinência, considerando a paridade das mulheres. Trata-se de estudo observacional e analítico, realizado com população de mulheres no ciclo gravídico/puerperal e com profissionais da rede básica de saúde do município de Botucatu-SP. Os dados foram coletados a partir das fichas de atendimento do Serviço e chamados pertinentes foram todos os que resultaram em encaminhamento ao hospital e quando classificados nas cores vermelha, laranja e amarela, segundo critério de risco proposto pelo Ministério da Saúde. Quanto aos profissionais, a amostra foi composta por 67 pessoas, entre médicos, enfermeiros, auxiliares/técnicos de enfermagem e agentes comunitários de saúde. Nas análises estatísticas foram utilizados o teste qui-quadrado, Kruskal-Wallis e exato de Fisher, sendo que em todos os casos considerou-se p crítico <0,05. As análises foram feitas com o software SPSS v15.0. Este estudo foi aprovado por Comitê de Ética em Pesquisa da Faculdade de Medicina de Botucatu - UNESP. Para ambos os critérios de classificação utilizados, a prevalência de demanda não pertinente foi baixa. Não houve diferença estatisticamente significativa na demanda não pertinente segundo a paridade. Quando se consideram as diferentes categorias profissionais que atuam na atenção básica, não houve diferença entre elas, quando se investigou se primíparas devem ser prioritárias para o SAMU, quando comparadas às multíparas. O escore de conhecimento sobre a pertinência da demanda ao SAMU obtido pelos profissionais variou entre 7 e 8 e pode ser considerado elevado. A excelente condição da mulher no atendimento, as queixas brandas e o registro de achados leves pelos profissionais sugerem que o encaminhamento ao serviço de referência pode estar sendo superestimado, indicando falta de...<br>The general objective of the present study was to analyze the calls from the obstetric users of SAMU 192 in Botucatu, in 2012, as regards their pertinence and taking the women's parity into consideration. The present analytic and observational study included a population of women in the pregnancy-puerperium cycle as well as professionals of the primary healthcare network in the city of Botucatu, SP, Brazil. Data were collected from records of the Service and pertinent calls were all those resulting in referrals to hospitals and classified as red, orange and yellow according to the risk criteria proposed by the Brazilian Ministry of Health. As regards the involved professionals, the study sample comprised 67 peoples including physicians, nurses, nursing assistants/technicians and community healthcare agents. The chi-square, Kruskal-Wallis and exact Fisher's tests were utilized in the statistical analyses, and the critic p value was set at <0.05. The analyses were performed with the SPSS v15.0 software. The present study was approved by the Committee for Ethics in Research of Faculdade de Medicina de Botucatu - UNESP. A low prevalence of non pertinent demand was observed as both classification criteria were considered. No statistically significant difference was observed in relation to the non pertinent demand as the women's parity was considered. As the different professional categories involved in primary healthcare activities were considered, no difference was observed in the degree of priority given by SAMU to primiparae and multiparae. The scoring of the professionals' knowledge about demand pertinence ranged between 7 and 8 and may be considered high. The excellent health conditions of the women at their admission, their mild complaints and the reporting of mild findings by the professionals suggest that the index of referrals to the reference center might be overestimated, indicating lack of integration between primary ...

Este trabajo de investigación se llevó a cabo en el Instituto Materno Perinatal (Ex-Hospital Maternidad de Lima), con el objetivo de conocer la incidencia de la histerectomía durante la gestación (Histerectomía Obstétrica) y los factores asociados a la misma, para lo cual se recurrió a la revisión del total de casos de este procedimiento (136 pacientes) ocurridos en los dos últimos años, entre enero de 1999 a diciembre del 2000. En este lapso se registraron 43,559 partos de los cuales 14,004 (32.15%) fueron por cesárea y hubieron 3,229 admisiones por abortos. La edad promedio de las pacientes fue de 30.7 +/- 6.86 años (rango de 17 a 45 años), con una paridad promedio de 3.51 +/- 1.98 gestaciones (rango de 1 a 9). El 77.3% no tenía control prenatal, el 94.9% ingresaron por emergencia con edades gestacionales entre el 1er y 2do trimestre el 29.4% y el 3er trimestre y puérperas el 70.6%. La incidencia global fue de 3.12 histerectomías por cada 1000 partos y 12.39 histerectomías por cada 1000 abortos. Las principales indicaciones de Histerectomía Obstétrica fueron la sepsis (39.7%), seguido de la atonía uterina post-parto (28.7%), el acretismo (14%). Se practicó Histerectomía Abdominal Total en un 94.1%, el 17.6% fue cesárea histerectomía. La mortalidad alcanzó el 2.2% (3 casos) y el 91.2% fue dada de alta mejorada. Las complicaciones post-operatorias más frecuentes fueron la anemia (45.6%), CID (9.6%) y la infección de herida operatoria (8.1%). La histerectomía obstétrica es un procedimiento relativamente frecuente que se usa como un recurso para salvar la vida de la madre y su técnica requiere ser aprendida por todo especialista en gineco-obstetricia.<br>Tesis de segunda especialidad

El objetivo del presente trabajo fue establecer el porcentaje de errores de prescripción en recetas de pacientes hospitalizados del servicio gineco – obstetricia del Hospital de Emergencias Villa el Salvador abril - mayo del 2021. La metodología utilizada fue de tipo observacional, descriptivo y retrospectivo. Se reviso 1118 prescripciones médicas, de abril a mayo del 2021. Se confecciono una tabla en Microsoft Excel 2017 para la recopilación ,análisis y tabulación de los datos, obteniendo los siguientes resultados: según los datos del prescriptor se obtuvo número de colegiatura 98.03 %, firma del prescriptor 98.12 % y sello errores de prescripción 98.12%. En referencia a los indicadores relacionados a datos del paciente como genero se observó que existe 100 %. En relación a los datos del medicamento se observa que no existe error en cuanto a: Denominación Común Internacional, concentración, cantidad y forma farmacéutica. Pero si en dosis 71.82 %, frecuencia 71.92 % y duración del tratamiento 72.18 % . Con respecto a la legibilidad no existe errores de prescripción el 0% son prescritas con letras ilegibles. En conclusión, se identificó que el de 100% de las recetas analizadas no cumplen con los requisitos del manual de “buenas prácticas de prescripción”.

This thesis presents findings from a qualitative study of the emergence and early clinical translation of non-invasive prenatal diagnosis (NIPD) in the UK. Drawing from interviews with a range of experts and users I track the enrolment and translation of this new prenatal testing technology across a variety of clinical and social spaces. I show how encounters with NIPD prompt deep critical examination of the moral, social and political implications - not only of the technology - but of the established clinical practices (routine and specialised prenatal testing) and specific policy contexts (prenatal screening programmes) within which NIPD has begun to sediment. I explore how, as NIPD advances at a rapid pace and emerges within a culturally and politically complex context, the technology both aligns with and disrupts routine practices of prenatal screening and diagnosis. I show how, as the technology divides into two major strands - NIPD and NIPT - at an early stage of development, and before becoming naturalised/normalised within the clinic, scientists, clinicians and policy makers attempt to pin down, define and ‘fix’ the technology, drawing upon and engaging in substantive practices of division, categorisation and classification. I explore ambiguities present within such accounts, highlighting dissenting voices and moments of problematisation, and following this, I show how the ‘troubling’ of boundaries prompts much examination of ethical and social concerns. As a location within which interviewees explored more contentious issues, I show how abortion emerged as central to the discussion of NIPD. I proceed to show how institutionalised, professionalised bioethical debate dominates mainstream discourse, and I explain how a particular construction of the informed, individual choice-maker is mobilised in order to locate moral and political responsibility for testing in the hands of individuals, and to distance political/organisational structures from entanglement with problematic concerns. I explore how clinicians and patients respond to this positioning in multiple ways, both assimilating and questioning the mainstream discourse of ‘informed choice’. In conclusion, I highlight the broader (bio)political aspects of NIPD’s emergence and translation within prenatal screening and diagnosis.

Publicación a texto completo no autorizada por el autor<br>los estudiantes de la Escuela Académico Profesional de Obstetricia de la Universidad Nacional Mayor de San Marcos. Año 2012. Se aplicó como instrumento un cuestionario, con preguntas cerradas para evaluar el conocimiento y una escala tipo Likert para la evaluación de las actitudes. El diseño que se utilizó fue de tipo descriptivo y de corte transversal. Fueron evaluados 84 estudiantes, de los cuales, 56 (67%) alcanzaron un nivel de conocimiento medio sobre el Anticonceptivo Oral de Emergencia, 18 (21 %) obtuvieron un nivel de conocimiento bajo y 10 (12%) un conocimiento alto; en lo que respecta al nivel de actitud que tienen los estudiantes sobre el AOE, 50 (60%) tienen una actitud de indecisión, 22 (26%) una actitud de aceptación y 12 (14%) una actitud de rechazo. Se concluye que un porcentaje considerable (88%) de estudiantes obtuvo un nivel de conocimiento de medio a bajo respecto al Anticonceptivo Oral de Emergencia; y el nivel de actitud de los estudiantes va de Indecisión a aceptación de este método en un 86%.<br>Tesis

Objetivos: Determinar de que manera influye el nivel de conocimientos sobre las actitudes acerca de los métodos anticonceptivos hormonales de emergencia (AHE) que tienen las obstetrices de los hospitales Arzobispo Loayza, Daniel Alcides Carrión e Instituto Especializado Materno Perinatal. Métodos: El tipo y diseño de esta investigación es transversal, correlacional. La muestra fue obtenida mediante un muestreo aleatorio estratificado proporcional, obteniéndose un total de 110 obstetrices, y en cada estrato fue de: Hospital Arzobispo Loayza (n =13), Hospital Daniel Alcides Carrión (n =15) e Instituto Especializado Materno Perinatal (n =82). Se utilizó un cuestionario estructurado que comprendía tres secciones en las que se incluían los datos generales, actitudes y los conocimientos. Se realizaron análisis bivariados para los cuales se utilizaron las pruebas estadísticas Chi cuadrado, Coeficiente r de Pearson, Coeficiente de contingencia de Pawlick, de regresión lineal y ANAVA (Análisis de varianza).Para la determinación del tipo de actitud se utilizo el método MEPAC (Método Ponderado de Asignación de Pesos de Acumulación Central) y para la agrupación de los niveles de conocimiento se utilizó el método de “recorrido de las mitades”. Resultados: La relación entre la actitud y el conocimiento sobre la anticoncepción hormonal de emergencia es positiva con un r de Pearson de 0.22178. Del valor del coeficiente de regresión 0.50, podemos deducir que por cada puntaje de conocimiento hay una tendencia a que los puntajes obtenidos por las obstetrices reporten 0.5 puntos de incremento en los puntajes de actitudes Para someter a prueba las frecuencias observadas en el Cuadro obtenido, se sometieron al chi cuadrado. A partir de los datos se obtuvo un Ji² = 1.347 con cuatro grados de libertad (GL). Al cual le esta asociado una probabilidad p = 0.85335665, se concluyo aceptar la H0 (La actitud NO esta asociada al conocimiento).También se calculo el coeficiente de contingencia de Pawlik (CC), siendo este CC = 13.47%, el cual corresponde a variables pobremente asociadas. El tipo de actitud que predomina en estas instituciones es la positiva con un 83.64% en contraste la actitud negativa tiene un 13.64%, el nivel de conocimiento de las obstetrices acerca de los AHE es bajo con un porcentaje elevado en las tres instituciones de salud siendo este de un 81.82%. Conclusiones: Existe una relación significativa lineal positiva entre el conocimiento y la actitud mediante la vía paramétrica. No se encontró relación entre el conocimiento y la actitud mediante la vía no paramétrica. El nivel de conocimientos acerca de los AHE que tienen las obstetrices en los tres hospitales es bajo y la actitud que tienen hacia la AHE es positiva.<br>Tesis

Determina la percepción del uso de la telemedicina durante la emergencia sanitaria por la COVID-19 en profesionales de obstetricia de Lima Metropolitana, 2020. El estudio fue de enfoque cuantitativo, observacional, descriptivo y de corte transversal, desarrollado en 40 Obstetras que laboraban en Telemedicina. Se recolectó la información a través de la técnica encuesta de un instrumento válido y confiable de escala tipo Likert. Encuentra que el 80% de obstetras emplearon celulares para concretar las atenciones. 42,5% señalaron que las actividades programadas para los profesionales que participan en las diferentes áreas de atención no estaban alineadas y articuladas. Sobre la plataforma de telemedicina empleada para la atención de usuarios, 57,5% de obstetras sostuvieron que es de uso amigable. Además, 35% consideraron que la Telemedicina mantiene el acceso oportuno de la población a los servicios de salud y 45% obstetras indicaron que esta favorece al empoderamiento de los usuarios para el autocuidado de su salud. Concluye que en la percepción del uso de la telemedicina en los profesionales de obstetricia se encontró que 65% de obstetras tienen una percepción medianamente favorable seguido del 35% que tiene una percepción favorable, esto revela que se deben fortalecer los procesos de implementación de la telemedicina.

Publicación a texto completo no autorizada por el autor<br>Determina el nivel de conocimientos y prácticas acerca el anticonceptivo oral de emergencia en los internos rotantes en el área de Gineco-Obstetricia del Hospital Nacional Daniel Alcides Carrión. El presente estudio es cuantitativo; descriptivo de corte transversal. La población estuvo constituida por todos los internos rotantes del área Gineco-Obstetricia en los meses de enero y febrero 2012, siendo el total en este periodo 35 internos. El instrumento que se utilizó fue un formulario tipo cuestionario. En relación al nivel de conocimiento el anticonceptivo oral de emergencia de 35 (100%) de los internos, 10 (28%) tienen un conocimiento alto; 17 (49%) medio y 8 (23%) bajo. Respecto a las prácticas sobre el anticonceptivo oral de emergencia; de 35 (100%) internos, 14 (40%) manifiesta haber tomado alguna vez el anticonceptivo oral de emergencia. De los cuales 10 (71.4%) realiza una práctica inadecuada y 4 (28.6%) realiza un practica adecuada. Se concluye que los internos rotantes del área de Gineco-Obstetricia del Hospital Daniel Alcides Carrión, en su mayoría poseen un nivel de conocimiento medio (49%) sobre el anticonceptivo oral de emergencia, presentando mayor deficiencia en la característica de mecanismo de acción (37%). En cuanto a las prácticas, del 40% de los internos que utilizaron el anticonceptivo oral de emergencia, el 71% presentaron prácticas incorrectas, teniendo mayor dificultad en el manejo de los efectos secundarios (93%).

Introducción: La mortalidad materna sigue siendo un problema mundial durante el embarazo, parto y postparto, ante esto se requiere una formación profesional para el manejo de las principales emergencias obstétricas. Objetivo: Determinar el nivel de conocimientos sobre Hemorragia durante el Parto-Postparto y Trastornos Hipertensivos del Embarazo en Internos de Obstetricia del Instituto Nacional Materno Perinatal enero-junio 2015. Diseño: El estudio es observacional, descriptivo y prospectivo de corte transversal. Lugar: Instituto Nacional Materno Perinatal. Participantes: Se estudió a 62 Internos de Obstetricia que se encuentran realizando sus prácticas clínicas en el Instituto Nacional Materno Perinatal durante el año 2015. Intervenciones: Dado el tamaño de la población de internos de obstetricia se realizó una muestra censal. Para medir las variables de estudio se utilizó como instrumento un cuestionario con el cual fue evaluado cada interno de obstetricia. Para describir las variables cuantitativas se utilizó medidas de tendencia central y dispersión mientras que las variables cualitativas fueron expresadas con frecuencias absolutas y relativas. Principales Medidas: Se describió y determinó el nivel de conocimiento frente a las principales emergencias obstétricas: hemorragia durante el parto-postparto y trastornos hipertensivos del embarazo. Resultados: Los internos de obstetricia resultaron principalmente con un nivel medio en el conocimiento del diagnóstico (59,7%), manejo (69,4%) y medidas preventivas (54,8%) para la hemorragia durante el parto-postparto. De forma similar fueron los resultados del conocimiento en el diagnóstico y manejo de los trastornos hipertensos en el embarazo, donde se observó niveles medios de conocimiento en el 54,8 % y 66,1% respectivamente, sin embargo el 58,1% de los internos obtuvieron niveles altos de conocimiento para las medidas preventivas de los trastornos hipertensos en el embarazo, Conclusiones: Los internos de obstetricia del Instituto Nacional Materno Perinatal resultaron principalmente con niveles medios de conocimiento sobre la hemorragia durante el parto-postparto y los trastornos hipertensivos del embarazo.<br>Tesis

CAPES<br>As unidades hospitalares compõem grande parte do setor de serviços. Desta forma, esses locais são fortemente influenciados pela lógica de acumulação capitalista, pela tecnologia e pelas formas de organização do trabalho, em especial as organizações privadas. Com o movimento de reorganização produtiva e incorporação de tecnologias, são diversas as mudanças no processo de trabalho e, por conseguinte, nas atividades dos profissionais médicos. No decorrer da elaboração desse trabalho foram identificados elementos acerca da banalização do mal. Essa banalização e resignação dos profissionais frente a violência são desencadeadas pela adoção de estratégias coletivas de defesa. Sendo assim, esse trabalho tem por objetivo geral analisar como ocorre a racionalização das condições de trabalho por parte de ginecologistas obstetras e pediatras atuantes na urgência e emergência de hospitais públicos e privados de Curitiba e Região Metropolitana. Como procedimentos metodológicos, utilizou-se a abordagem de métodos mistos. A naturalização da violência, do sofrimento na qual os profissionais são submetidos, estão aliadas ao controle político-ideológico, controle burocrático, o imaginário construído acerca dos hospitais e as estratégias coletivas de defesa. Portanto, é possível compreender que as condições de trabalho de ginecologistas obstetras e pediatras na urgência e emergência são racionalizadas. Quando a injustiça social é naturalizada não são possíveis estratégias políticas de mudanças. Por isso, o primeiro passo é a tomada de consciência, é preciso desvelar a realidade, compreender os fenômenos em seu cerne e descartar superficialidades. É também necessário que as ações e as manifestações de indignação estejam aliadas a ações políticas com vistas a transformações.<br>Hospitals are a big part of the service sector. Thus, such institutions are highly influenced by the logic of the capitalist accumulation, technology and forms of labor organization, especially by private organizations. Starting with the restructuring process motion and incorporation of technologies, many changes in the working process occur, therefore, the activities of medical professionals as well. During the preparation of this research items regarding the banalization of evil were identified. This banalization and resignation of the professionals face to violence are caused by the adoption of collective defense strategies. Therefore, this research aims to analyze how the rationalization of working conditions by gynecologists obstetricians and pediatricians working in the emergency rooms of public and private hospitals in Curitiba and metropolitan region occurs. An approach of mixed methods was used as methodological procedures. The naturalization of violence, the suffering which professionals are submitted to, are combined with the political and ideological control, bureaucratic control, the imaginary built about hospitals and collective defense strategies. It is therefore possible to understand that labor conditions of gynecologists obstetricians and pediatricians in emergency rooms are rationalized. When social injustice is naturalized, political strategies for changes are not possible. For this reason, the first step is to gather awareness, there is a need to unveil the reality, to understand the phenomena at its core and discard superficialities. It is also necessary that the actions and expressions of indignation to come hand in hand with political actions in order to change to happen.

Publicación a texto completo no autorizada por el autor<br>El documento digital no refiere asesor<br>Determina los factores asociados al trauma obstétrico en recién nacidos atendidos en el Hospital Nacional Dos de Mayo durante el período de enero a diciembre del 2012. Estudio Observacional, de tipo analítico, prospectivo, transversal. Se estudió un total de 151 recién nacidos con trauma obstétrico (que representaron el grupo de estudio) y 199 recién nacidos sin trauma obstétrico (que representaron el grupo comparativo) que se atendieron en los servicios de pediatría que acuden al Hospital Nacional Dos entre Enero a Diciembre 2012. Se estimaron las frecuencias absolutas y relativas y medidas de tendencia central y de dispersión. Se utilizó la prueba Chi cuadrado y t-Student, toda interpretación estadística se realizó con un nivel de significancia del 95%. Con respecto al perfil sociodemográfico de las gestantes, la edad promedio es de 24.2 ± 6 años, siendo en la mayoría de 19-35 años (80.3%). El 72% de las participantes son convivientes y el 79.1% tienen un nivel educativo secundario. El 71.5% de las pacientes del grupo de estudio fueron “Nulíparas” comparado con el 47.7% de las pacientes del grupo comparativo, hallándose frecuencias relativas estadísticamente significativas (p<0.001). El 30.5% de las pacientes del primer grupo y el 36.7% de las pacientes del segundo grupo fueron consideradas con “Sobrepeso”, encontrándose diferencias significativas (p=0.005), la duración del parto fue “Adecuado” en el grupo de estudio y el grupo comparativo (78.8% y el 97% respectivamente), siendo las frecuencias relativas estadísticamente diferentes (p<0.001). En el 8.6% del grupo de estudio se realizaron maniobras externas a diferencia del grupo comparativo, que sólo se realizaron maniobras externas en el 0.5%, por lo existe diferencia significativa en ambos grupos (p=<0.001). El sexo masculino fue predominante en el grupo de estudio en un 57.6% comparado con el 46.2% de recién nacidos del grupo comparativo, siendo estadísticamente significativas ambas frecuencias relativas (p=0.035). La puntuación de Apgar durante el 1er minuto menor o igual a 7 en el grupo de RN con trauma obstétrico fue 14.6% comparado con el 2% de los RN sin trauma Obstétrico, observándose que los porcentajes son muy significativos (p<0.001). La puntuación de Apgar durante los 5 primeros minutos menor o igual a 7 fue 2.6% en los recién nacidos con trauma obstétrico mientras que no se evidenció ningún caso en el grupo de recién nacidos sin trauma obstétrico, aunque se observa diferencia significativa en ambas variables (p=0.021). Los Factores maternos fueron la edad materna avanzada, la cesárea anterior, evidenciándose que existen diferencias significativas entre ambas variables (p=0.007). Los Factores fetales asociados al trauma obstétrico fueron circular de cordón, presentación compuesta y fetos macrosómicos, aunque no existe relación entre ambas frecuencias relativas (p=0.123). La ruptura prematura de membranas, la atención de parto inminente y la acentuación del parto fueron factores de parto asociados significativamente a la presencia o ausencia de trauma obstétrico (p=0.011). Los tipos de trauma fetale más frecuentes en el estudio fueron: Caput sucedaneum (44.1%), cefalohematoma (30.4%) y fractura de clavícula (8.7%). Los principales factores asociados al trauma obstétrico en recién nacidos atendidos en el HNDM fueron la edad materna avanzada (p=0.007), la presencia de RPM (p=0.011), la paridad (p<0.001), la duración del parto (p<0.001) y las maniobras externas (p<0.001).<br>Trabajo académico

Publicación a texto completo no autorizada por el autor<br>El documento digital no refiere asesor<br>Compara las dos dosis bajas de ropivacaína conjuntamente con fentanilo 25 mg por vía intradural en pacientes sometidas a cesárea de emergencia del departamento de obstetricia en el Hospital de Supe Laura Esther Rodríguez Dulanto 2013. La investigación tiene diseño es no experimental, prospectivo, es de tipo descriptivo, observacional, comparativo. La muestra estuvo construido por 50 pacientes ASA I/II programadas para cesárea electiva. Las pacientes fueron distribuidos en dos grupos: 25 pacientes del grupo ROP 0,75%: ropivacaína 0,75% 1 mL con fentanilo 25 gr y 25 pacientes del grupo ROP 1%: ropivacaína 1% 1 mL con fentanilo 25gr. La edad media de los pacientes con ROP 1% es de 23.2 años mientras que la edad de los pacientes con ROP 0.75% la edad media es 25.4 años, no se encontró diferencia significativas P<0.05. Los resultados muestran que el peso medio en pacientes con ROP 1% es de 75.8Kg mientras que le peso medio de los pacientes con ROP 0.75% es de 74.5Kg no se encontró diferencias significativas P<0.05. Los pacientes con ROP 1% el 88% presento ASA I y del total de pacientes con ROP 0.75% el 72% presentaron ASA I. Se encontró diferencias significativas latencia para alcanzar T-6 entre los pacientes ROP 1% y pacientes ROP 0.75%, encontrándose que los pacientes con ROP1% presentan menor tiempo medio latencia para alcanzar T-6 (min) (5,74 min8 en relación a los pacientes con ROP 0.75% con media en latencia para alcanzar T-6 (min) de 7.34 min. No se encontró diferencias significativas latencia nivel + alto (min) P>0,05. Se encontró diferencias significativas P<0.05 en la presión arterial media en los T0, T1, T2, observándose menor tiempo en los pacientes con ROP 1%. Existe una mayor incidencia de hipotensión (60%) en el grupo de ROP 1%, encontrándose relación estadística P<0,05, no se encontró incidencia de bradicardia. Los pacientes con ROP 1% presentan mayor cantidad (165ug) de efedrina estadísticamente significativo en relación a los pacientes con ROP 0.75%. No se necesitó dosis de atropina en los dos grupos de estudio. Existe diferencias significativas en el tiempo para regresión a T-10, P<0.05 observándose menor tiempo de tiempo para regresión a T-10 (142.6 min) para las pacientes con ROP 1% en relación a las pacientes con ROP 0.75%. Existe diferencias significativas en el tiempo para regresión a T-10, P<0.05 Observándose menor tiempo de tiempo para regresión a T-10 (142.6 min) para las pacientes con ROP 1% en relación a las pacientes con ROP 0.75%. Los pacientes con ROP 1% el 84% tienen satisfacción excelente; el 92% consideran tener relajación excelente y el 68% no presentaron complicaciones. Concluye que el 10 mg al 1% de ropivacaína conjuntamente con fentanilo 25 mg por vía intradural puede producir un bloqueo más intenso que 7,5 mg al 0,75% ropivacaína conjuntamente con fentanilo 25 mg por vía intradural, pero manteniendo los beneficios que ofrece esta última dosis, como son: recuperación temprana de la función motora, baja incidencia de hipotensión y bajos requerimientos de efedrina.<br>Trabajo académico

Determina el perfil epidemiológico, indicaciones y complicaciones de las cesáreas de emergencia en el Hospital Nacional Daniel Alcides Carrión del Callao durante el año 2006. Realiza un estudio descriptivo retrospectivo, analítico y transversal Durante el año 2006 se atendieron un total de 6226 partos (100%) siendo 2149 (34,51%) cesáreas. La incidencia de cesáreas fue 34,51%, mientras las cesáreas de emergencia fueron 321, teniendo una incidencia de 5,15%. La edad promedio de las pacientes sometidas a cesáreas por emergencia fue 29,31 años, con un rango de 14 a 41 años. Las multíparas fueron el 35%, las primíparas 27,41% y 37,59% las nulíparas, siendo el promedio de paridad por gestante de 3. Las principales causas de cesárea por emergencias fueron el sufrimiento fetal agudo, seguida en importancia por la desproporción cefalopélvica y el DPP. Las complicaciones son escasas, siendo las infecciones el 6% de la población. Concluye que las cesáreas de emergencia fueron 321, teniendo una incidencia de 5,15%. Siendo la principal indicación el sufrimiento fetal agudo y la principal complicación las infecciones.<br>Trabajo académico

El documento digital no refiere asesor.<br>Determina las complicaciones maternas y neonatales que se asocian a la cesárea de emergencia, en pacientes del Hospital Nacional Docente Madre Niño San Bartolomé 2013. El estudio es observacional, diseño analítico, comparativo, retrospectivo y transversal. Se estudió a 240 pacientes que cumplieron los criterios de inclusión y exclusión de las cuales 120 fueron cesáreas de emergencia y 120 con cesárea electiva. Para la descripción de resultados se utilizó las frecuencias absolutas y porcentajes, mientras que para relacionar las variables se usó la prueba de chi-cuadrado. Las edades de las pacientes estuvieron comprendidas entre 19 a 41 años con una media de 28.5±6.2. Respecto al estado civil se observó principalmente conviviente (58,8%). Los distritos de procedencia más frecuente fueron: Lima cercado (20%) y San Martín de Porres (15,4%). En su mayoría tienen grado de instrucción secundaria (66,3%). En relación a los datos clínicos se observó que el 32,5% presentó sobrepeso y el 20,4% obesidad. También se observó que el 1,7% de las pacientes fueron hipotensas y el 8,3% hipertensas. La temperatura de las pacientes estuvo entre 36ºC a 37.4ºC y el 59,2% presentó anemia. De los datos obstétricos el 56,2% de las pacientes tiene de 1 a más hijos vivos. El periodo Intergenésico fue menor a 1 año (31,7%) y de más de 2 años (49.2%). También se observó la edad gestacional entre 37 a 41 semanas, mientras que el 38,3% presentó cesárea anterior y 14,6% RPM. En los datos del recién nacido se observó peso normal en el 53,3%, edad gestacional por Capurro de 39 semanas a más (71,3%). Respecto las principales indicaciones para realizar la cesárea se observó cesárea iterativa (36,7%), incompatibilidad céfalo pélvica (18,8%), fetos con alguna dificultad (15,4%), bloqueo tubárico bilateral (10,8%) y macrosomia fetal (10,4%). Entre las complicaciones maternas fueron: anemia leve o severa (58,8%), ITU (5,8%) y endometritis (5%). El tipo de cesárea por emergencia estuvo asociada significativamente a la endometritis (p<0.018) y a la estancia hospitalaria del recién nacido mayor a 3 días (p=0.002). Entre las complicaciones neonatales se observó el APGAR al 1º minuto <9 (71.3%) mientras que al 5º minuto (96.7%) los recién nacidos presentaron 9 puntos y el síndrome de dificultad respiratoria se presentó en 2 (0.8%) casos. El tiempo de hospitalización fue mayor a 3 días (17.5%). Se concluye que la endometritis y la estancia hospitalaria del recién nacido mayor a 3 días se asocian significativamente a la cesárea de emergencia, en pacientes del Hospital Nacional Madre Niño San Bartolomé 2013.<br>Trabajo académico

Publicación a texto completo no autorizada por el autor<br>Establece la percepción de la calidad en la atención de emergencia obstétrica del Hospital San Juan de Lurigancho durante el periodo julio a diciembre 2017. Estudio de diseño cuantitativo, descriptivo, transversal. La medición de la satisfacción del usuario se realiza mediante el modelo de medición de la calidad percibida del servicio - encuesta SERVPERF modificada, el cual mide la satisfacción del usuario, para este estudio se evalúa la satisfacción de acuerdo a sus percepciones. La muestra está constituida por 169 personas (gestantes y puérperas). La percepción de la calidad de la atención en la emergencia obstétrica del Hospital San Juan de Lurigancho es de satisfacción en un 66.5%; la percepción de la calidad por dimensiones son de satisfacción para la fiabilidad 59.5%, la capacidad de respuesta 49%, la seguridad 67%, la empatía 78.2% y los aspectos tangibles un 77.8%; los atributos con más porcentajes de usuarios satisfechos son la atención según la gravedad del caso, la atención rápida en caja o admisión de emergencia, la resolución del problema de salud por el cual acude, el interés que muestra el personal por resolver cualquier inquietud del paciente y que la emergencia cuente con los equipos necesarios y disponibles.<br>Tesis

INTRODUCCION: La preeclampsia complica el 3 al 5% de todos los embarazos y es causa importante de mortalidad materna. La preeclampsia de inicio tardío representa el 80% de todos los casos de preeclampsia y presenta algunos factores de riesgo modificables como el sobrepeso y la obesidad. OBJETIVO: Determinar si el sobrepeso y la obesidad pregestacional es factor de riesgo asociado a preeclampsia de inicio tardío en las gestantes atendidas en el servicio de emergencia del Hospital Nacional Daniel Alcides Carrión Durante el periodo Julio 2014 a Julio 2015. METODOS: Estudio Observacional Analítico - Casos y Controles. El tamaño muestral calculado fue de 200 casos y 200 controles, relación caso control de 1:1. Se empleó una ficha de recolección de datos para el recojo de las variables planteadas en el presente estudio. El análisis de la información incluyó análisis descriptivo, análisis Bivariado de la (variable dependiente e independiente). RESULTADOS: El sobrepeso y la obesidad pregestacional se muestra como factor de riesgo asociado a preeclampsia de inicio tardío p=0,000 (OR= 7,4; IC 95% 4,7 – 11,6), además el no tener antecedente de enfermedad hipertensiva del embarazo está asociado a menos riesgo de presentar preeclampsia de inicio tardío p=0,000 (OR=0.192; IC95% 0.115 – 0.320). El resto de variables intervinientes no muestra asociación. CONCLUSIONES: El sobrepeso y obesidad pregestacional son factores de riesgo asociados a preeclampsia de inicio tardío.

The role of midwife has been an integral part of the culture of childbirth in Queensland throughout its history, but it is a role that has been modified and reshaped over time. This thesis explores the factors that underpinned a crucial aspect of that modification and reshaping. Specifically, the thesis examines the factors that contributed to the statutory regulation of midwives that began in 1912 and argues that it was that event that etched the development of midwifery practice for the remainder of the twentieth century. In 1859, when Queensland seceded from New South Wales, childbirth was very much a private event that took place predominantly in the home attended by a woman who acted as midwife. In the fifty-threeyears that followed, childbirth became a medical event that was the subject of scrutiny by the medical profession and the state. The thesis argues that, the year 1912 marks the point at which the practice of midwifery by midwives in Queensland began a transition from lay practice in the home to qualified status in the hospital. In 1912, through the combined efforts of the medical profession, senior nurses and the state, midwives in Queensland were brought under the jurisdiction of the Nurses' Registration Board as "midwifery nurses". The Nurses' Registration Board was established as part of the Health Act Amendment Act of 1911. The inclusion of midwives within a regulatory authority for nurses represented the beginning of the end of midwifery practice as a discrete occupational role and marked its redefinition as a nursing specialty. It was a redefinition that suited the three major stakeholders. The medical profession perceived lay midwives to be a disjointed and uncoordinated body of women whose practice contributed to needless loss of life in childbirth. Further, lay midwives inhibited the generalist medical practitioners' access to family practice. Trained nurses looked upon midwifery as an extension of nursing and one which offered them an area in which they might specialise in order to enhance their occupational status and career prospects. The state was keen to improve birth rates and to reduce infant mortality. It was prepared to accept that the regulation of midwives under the auspices of nursing was a reasonable and proper strategy and one that might assist it to meet its objectives. It was these separate, but complementary, agendas that prompted the medical profession and the state to debate the culture of childbirth, to examine the role of midwives within it, and to support the amalgamation of nursing and midwifery practice. This thesis argues that the medical profession was the most active and persistent protagonist in the moves to limit the scope of midwives and to claim midwifery practice as a medical specialty. Through a campaign to defame midwives and to reduce their credibility as birth attendants, the medical profession enlisted the help of senior nurses and the state in order to redefine midwifery practice as a nursing role and to cultivate the notion of the midwife as a subordinate to the medical practitioner. While this thesis contests the intervention of the medical profession in the reproductive lives of women and the occupational territory of midwives, it concedes that there was a need to initiate change. Drawing on evidence submitted at Inquests into deaths associated with childbirth, the thesis illuminates a childbirth culture that was characterised by anguish and suffering and it depicts the lay midwife as a further peril to an already hazardous event that helps to explain medical intervention in childbirth and, in part, to excuse it. The strategies developed by the medical profession and the state to bring about the occupational transition of midwives from lay to qualified were based upon a conceptual unity between the work of midwives and nurses. That conceptualisation was reinforced by a practical training schedule that deployed midwives within the institution of the lying-in hospital in order to receive the formal instruction that underpinned their entitlement to inclusion on the Register of Midwifery Nurses held by the Nurses' Registration Board. The structure that was put in place in Queensland in 1912 to control and monitor the practice of midwives was consistent with the policies of other Australian states at that time. It was an arrangement that gained acceptance and strength over time so that by the end of the twentieth century, throughout Australia, the practice of midwifery by midwives was, generally, consequent upon prior qualification as a Registered Nurse. In Queensland, in the opening years of the twenty-first century, the role of midwife remains tied to that of the nurse but the balance of power has shifted from the medical profession to the nursing profession. At this time, with the exception of a small number of midwives who have acquired their qualification in midwifery from an overseas country that recognises midwifery practice as a discipline independent of nursing, the vast majority of midwives practising in Queensland do so on the basis of their registration as a nurse. Methodology This thesis explores the factors that influenced the decision to regulate midwifery practice in Queensland in 1912 and the means by which that regulation was achieved. The historical approach underpins this research. The historical approach is an inductive process that is an appropriate method to employ for several reasons. First, it assists in identifying the origins of midwifery as a social role performed by women. Second, it presents a systematic way of analysing the evidence concerning the development of the midwifery role and the status of the midwife in society. Third, it highlights the political, social and economic influences which have impacted on midwifery in the past and which have had a bearing on subsequent midwifery practice in Queensland. Fourth, the historical approach exposes important chronological elements pertaining to the research question. Finally, it assists the exposure of themes in the sources that demonstrate the behaviour of key individuals and governing authorities and their connection to the transition of midwifery from lay to qualified. Consequently, through analysing the sources and collating the emerging evidence, a cogent account of interpretations of midwifery history in Queensland may be constructed. Data collection and analysis The data collection began with secondary source material in the formative stages of the research and this provided direction for the primary sources that were later accessed. The primary source material that is employed includes testimonies submitted at Inquests into maternal and neonatal deaths; parliamentary records; legislation, government gazettes, and medical journals. The data has been analysed through an inductive process and its presentation has combined exploration and narration to produce an accurate and plausible account. The story that unfolds is complex and confusing. Its primary focus lies in ascertaining why and how midwifery practice was regulated in Queensland. The thesis therefore explores the factors that influenced the decision to regulate midwifery practice in Queensland in 1912 and the means by which that regulation was achieved. Limitations of the study The limitations of the study relate to the documentary evidence and to the cultural group that form the basis of the study. It is acknowledged that historical accounts rely upon the integrity of the historian to select and interpret the data in a fair and plausible manner. In the case of this thesis, one of its limitations is that midwives did not speak for themselves but were, instead, spoken for by medical practitioners and parliamentarians. As a consequence, the coronial and magisterial testimonies that are employed constitute a limitation in that while they reveal the ways in which lay midwifery occurred, they relate only to those childbirth events that resulted in death. Thus, they may be said to represent the minority of cases involving the lay midwife rather than to offer a broader and perhaps more balanced picture. A second limitation is that the accounts are recorded by an official such as a member of the police or of the Coroner's Office and are sanctioned by the witness with a signature or, more often, a cross. It is therefore possible that the recorder has guided these accounts and that they are not the spontaneous evidence of the witness. Those witnesses and the culture they represent are drawn predominantly from non- Indigenous working class. Thus, a third limitation is that the principal ethnic group featured in this thesis has been women of European descent who were born in Queensland or other parts of Australia. This focus has originated from the data itself and has not been contrived. However, it does impose a restriction to the scope of the study.

The role of midwife has been an integral part of the culture of childbirth in Queensland throughout its history, but it is a role that has been modified and reshaped over time. This thesis explores the factors that underpinned a crucial aspect of that modification and reshaping. Specifically, the thesis examines the factors that contributed to the statutory regulation of midwives that began in 1912 and argues that it was that event that etched the development of midwifery practice for the remainder of the twentieth century. In 1859, when Queensland seceded from New South Wales, childbirth was very much a private event that took place predominantly in the home attended by a woman who acted as midwife. In the fifty-threeyears that followed, childbirth became a medical event that was the subject of scrutiny by the medical profession and the state. The thesis argues that, the year 1912 marks the point at which the practice of midwifery by midwives in Queensland began a transition from lay practice in the home to qualified status in the hospital. In 1912, through the combined efforts of the medical profession, senior nurses and the state, midwives in Queensland were brought under the jurisdiction of the Nurses' Registration Board as "midwifery nurses". The Nurses' Registration Board was established as part of the Health Act Amendment Act of 1911. The inclusion of midwives within a regulatory authority for nurses represented the beginning of the end of midwifery practice as a discrete occupational role and marked its redefinition as a nursing specialty. It was a redefinition that suited the three major stakeholders. The medical profession perceived lay midwives to be a disjointed and uncoordinated body of women whose practice contributed to needless loss of life in childbirth. Further, lay midwives inhibited the generalist medical practitioners' access to family practice. Trained nurses looked upon midwifery as an extension of nursing and one which offered them an area in which they might specialise in order to enhance their occupational status and career prospects. The state was keen to improve birth rates and to reduce infant mortality. It was prepared to accept that the regulation of midwives under the auspices of nursing was a reasonable and proper strategy and one that might assist it to meet its objectives. It was these separate, but complementary, agendas that prompted the medical profession and the state to debate the culture of childbirth, to examine the role of midwives within it, and to support the amalgamation of nursing and midwifery practice. This thesis argues that the medical profession was the most active and persistent protagonist in the moves to limit the scope of midwives and to claim midwifery practice as a medical specialty. Through a campaign to defame midwives and to reduce their credibility as birth attendants, the medical profession enlisted the help of senior nurses and the state in order to redefine midwifery practice as a nursing role and to cultivate the notion of the midwife as a subordinate to the medical practitioner. While this thesis contests the intervention of the medical profession in the reproductive lives of women and the occupational territory of midwives, it concedes that there was a need to initiate change. Drawing on evidence submitted at Inquests into deaths associated with childbirth, the thesis illuminates a childbirth culture that was characterised by anguish and suffering and it depicts the lay midwife as a further peril to an already hazardous event that helps to explain medical intervention in childbirth and, in part, to excuse it. The strategies developed by the medical profession and the state to bring about the occupational transition of midwives from lay to qualified were based upon a conceptual unity between the work of midwives and nurses. That conceptualisation was reinforced by a practical training schedule that deployed midwives within the institution of the lying-in hospital in order to receive the formal instruction that underpinned their entitlement to inclusion on the Register of Midwifery Nurses held by the Nurses' Registration Board. The structure that was put in place in Queensland in 1912 to control and monitor the practice of midwives was consistent with the policies of other Australian states at that time. It was an arrangement that gained acceptance and strength over time so that by the end of the twentieth century, throughout Australia, the practice of midwifery by midwives was, generally, consequent upon prior qualification as a Registered Nurse. In Queensland, in the opening years of the twenty-first century, the role of midwife remains tied to that of the nurse but the balance of power has shifted from the medical profession to the nursing profession. At this time, with the exception of a small number of midwives who have acquired their qualification in midwifery from an overseas country that recognises midwifery practice as a discipline independent of nursing, the vast majority of midwives practising in Queensland do so on the basis of their registration as a nurse. Methodology This thesis explores the factors that influenced the decision to regulate midwifery practice in Queensland in 1912 and the means by which that regulation was achieved. The historical approach underpins this research. The historical approach is an inductive process that is an appropriate method to employ for several reasons. First, it assists in identifying the origins of midwifery as a social role performed by women. Second, it presents a systematic way of analysing the evidence concerning the development of the midwifery role and the status of the midwife in society. Third, it highlights the political, social and economic influences which have impacted on midwifery in the past and which have had a bearing on subsequent midwifery practice in Queensland. Fourth, the historical approach exposes important chronological elements pertaining to the research question. Finally, it assists the exposure of themes in the sources that demonstrate the behaviour of key individuals and governing authorities and their connection to the transition of midwifery from lay to qualified. Consequently, through analysing the sources and collating the emerging evidence, a cogent account of interpretations of midwifery history in Queensland may be constructed. Data collection and analysis The data collection began with secondary source material in the formative stages of the research and this provided direction for the primary sources that were later accessed. The primary source material that is employed includes testimonies submitted at Inquests into maternal and neonatal deaths; parliamentary records; legislation, government gazettes, and medical journals. The data has been analysed through an inductive process and its presentation has combined exploration and narration to produce an accurate and plausible account. The story that unfolds is complex and confusing. Its primary focus lies in ascertaining why and how midwifery practice was regulated in Queensland. The thesis therefore explores the factors that influenced the decision to regulate midwifery practice in Queensland in 1912 and the means by which that regulation was achieved. Limitations of the study The limitations of the study relate to the documentary evidence and to the cultural group that form the basis of the study. It is acknowledged that historical accounts rely upon the integrity of the historian to select and interpret the data in a fair and plausible manner. In the case of this thesis, one of its limitations is that midwives did not speak for themselves but were, instead, spoken for by medical practitioners and parliamentarians. As a consequence, the coronial and magisterial testimonies that are employed constitute a limitation in that while they reveal the ways in which lay midwifery occurred, they relate only to those childbirth events that resulted in death. Thus, they may be said to represent the minority of cases involving the lay midwife rather than to offer a broader and perhaps more balanced picture. A second limitation is that the accounts are recorded by an official such as a member of the police or of the Coroner's Office and are sanctioned by the witness with a signature or, more often, a cross. It is therefore possible that the recorder has guided these accounts and that they are not the spontaneous evidence of the witness. Those witnesses and the culture they represent are drawn predominantly from non- Indigenous working class. Thus, a third limitation is that the principal ethnic group featured in this thesis has been women of European descent who were born in Queensland or other parts of Australia. This focus has originated from the data itself and has not been contrived. However, it does impose a restriction to the scope of the study.

The contribution of Emergency Obstetric Care (EmOC) in reducing maternal mortality in Ethiopia is very minimal as evidenced by poor provision and low utilization of EmOC. Client centred EmOC provision improves the provision and utilization of EmOC; leading to the treatment of the majority of obstetric complications which are the main causes of maternal mortality. This study describes clients’ views and perspectives concerning the quality of EmOC provision in Ethiopian public health facilities. An explorative and descriptive phenomenological qualitative study design was used in the study in order to explore and describe the lived experiences of clients with EmOC services. Key informant interviews with women who had direct obstetric complications and received EmOC at three public health facilities in Addis Ababa generated rich data on their lived experiences. Content analysis was used to analyze the data as it complies with the phenomenological data analysis and Atlas ti version 6.2 qualitative data analysis software was employed. The findings revealed that quality EmOC is a welcoming, life-saving timely care given in a clean environment with humility, respect, equal treatment and encouragement. It is care that is safe for the client, technically sound, responsive and meets clients’ needs and expectations. Accessibility of life saving care at all time and collaborative and coordinated care created good experiences for the clients. The causes of clients’ disappointment with the provision of EmOC were higher expectations from female providers, underestimation by providers, non responsive providers, and ethical misconduct by providers such as mocking, insulting, yelling, advantage taking providers, undelivered promises by providers, expectation with place of delivery, expectation with newborn care and a limited number of health workers attending delivery. Discrimination, high cost of care and asking client to buy drugs and supplies and referrals from centres, are some of the barriers on r the use of EmOC at public health facilities. The provision of EmOC is constrained by overloaded staffs, shortage of space to accommodate clients and inadequate number of beds. In conclusion, clients have expectations and experiences of provision of EmOC that influence their future decision to seek care. Finally, a client centred guideline for the provision of client centred EmOC provision was developed.<br>Health Studies<br>D. Litt. et Phil. (Health Studies)

Maternal and newborn health is one of the main indicators of a good health system. The study wished to develop a strategy to improve the referral system for maternal and newborn care. To identify issues for improvement, the researcher explored the appropriateness of referrals, referral pathways and challenges, and provider costs for maternal and newborn care at health centres and hospitals levels. The researcher selected a sequential explanatory mixed method research design. Two primary hospitals and six health centres were purposively selected for participation. The first phase collected quantitative data by reviewing the health facilities’ medical records for services provided and health service costing, respectively. Data collection covered one Ethiopian fiscal year (8 July 2017 to 7 July 2018). Based on the existing human resource arrangement and care needs, the health service costing found that a single midwife at health centre level spent half of the expected time for delivery care. The cost estimates of various types of care delivery care indicated that delivery care at health centre and hospital levels cost $27.5 to $30.2, and $34.7 to $37.8, respectively. The primary hospitals incurred four times the cost for newborn intensive care units and Caesarean sections compared to normal delivery care. In the second phase, the researcher collected qualitative data from 26 purposively selected key informants in interviews. The findings indicated that the selected hospitals and health centres had a referral system, but several factors impeded its effective implementation. Knowledge of referral pathways determined the referral practices at the lower level of the system. The number of inappropriate referrals to primary hospitals indicated a need to mobilize and educate the community on the services available and protocols of care. In general, most referrals could have been managed at health centre level. Emergency medical transportation is a critical component of the referral system; delays in transportation determine the outcome of care at hospital level. Ambulance management was generally poor, lacked a tracking system, and was negatively affected by confusion and lack of coordination between facilities. The available ambulances were not well equipped or well-staffed for emergency management. Moreover, there were frequent breakdowns due to limited budget for maintenance and running costs. The quality of maternal care depends on the quality of the labour monitoring. However, partograph utilization was not consistently practised. Admitted cases were not properly monitored because of the high caseload and limited supervision support. In many cases, healthcare professionals tended to “treat charts” rather than promote evidencebased practice while providing care. The quality of practice was challenged by insecurity in the working environment but strengthened by good teamwork and available consultation support. The implementation of the existing referral system depended on the people involved; the use of performance indicators; follow up by management, and an accountability framework. The findings of the two phases of the study and review of other countries’ experiences on the identified problems, led to the development of draft strategy and then a consultation with relevant experts produced the final strategy. The strategy includes interventions to improve the practices at the sending and receiving facilities as well as suggestions to improve the communication, transportation and overall governance system. Then, taking into consideration all the phases of the study, the researcher makes recommendations for practice and further research.<br>Health Studies<br>D. Litt. et Phil. (Healht Studies)