Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research.

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

Work-related post-traumatic stress symptoms in obstetricians and gynaecologists: findings from INDIGO, a mixed-methods study with a cross-sectional survey and in-depth interviews.

OBJECTIVES: To explore obstetricians' and gynaecologists' experiences of work-related traumatic events, to measure the prevalence and predictors of post-traumatic stress disorder (PTSD), any impacts on personal and professional lives, and any support needs. DESIGN: Mixed methods: cross-sectional survey and in-depth interviews. SAMPLE AND SETTING: Fellows, members and trainees of the Royal College of Obstetricians and Gynaecologists (RCOG). METHODS: A survey was sent to 6300 fellows, members and trainees of RCOG. 1095 people responded. Then 43 in-depth interviews with trauma-exposed participants were completed and analysed by template analysis. MAIN OUTCOME MEASURES: Exposure to traumatic work-related events and PTSD, personal and professional impacts, and whether there was any need for support. Interviews explored the impact of trauma, what helped or hindered psychological recovery, and any assistance wanted. RESULTS: Two-thirds reported exposure to traumatic work-related events. Of these, 18% of both consultants and trainees reported clinically significant PTSD symptoms. Staff of black or minority ethnicity were at increased risk of PTSD. Clinically significant PTSD symptoms were associated with lower job satisfaction, emotional exhaustion and depersonalisation. Organisational impacts included sick leave, and 'seriously considering leaving the profession'. 91% wanted a system of care. The culture in obstetrics and gynaecology was identified as a barrier to trauma support. A strategy to manage the impact of work-place trauma is proposed. CONCLUSIONS: Exposure to work-related trauma is a feature of the experience of obstetricians and gynaecologists. Some will suffer PTSD with high personal, professional and organisational impacts. A system of care is needed. TWEETABLE ABSTRACT: 18% of obstetrics and gynaecology doctors experience post-traumatic stress disorder after traumatic events at work.

Identifying fear of childbirth in a UK population: qualitative examination of the clarity and acceptability of existing measurement tools in a small UK sample.

BACKGROUND: Fear of childbirth is related to but not synonymous with general anxiety, and represents a superior predictor for maternal and infant outcomes. There is a need to improve the identification and provision of support for women experiencing high fear of childbirth. However it is uncertain as to whether existing measurement tools have appropriate content validity (i.e. cover the relevant domains within the construct), practical utility, and whether they are acceptable for use with a UK population. This study aimed to (1) identify the utility and acceptability of existing measures of fear of childbirth (FOC) with a small UK sample and (2) map the content of existing measures to the key concepts of fear of childbirth established by previous research. METHODS: Ten pregnant women; five with high and five with low fear of childbirth participated in a cognitive interview covering four most commonly used measures of fear of childbirth: 1. The Wijma Delivery Expectancy Questionnaire (WDEQ A), 2. The Oxford Worries about Labour Scale (OWLS), 3. The Slade-Pais Expectations of Childbirth Scale - fear subscale (SPECS) and 4. The Fear of Birth scale (FOBS). Each measure was also reviewed by participants for ease and clarity of understanding and acceptability. The measures were then reviewed against the key domains identified in the fear of childbirth literature to ascertain the adequacy of content validity of each measure. Interviews were analysed using thematic analysis for each scale item. RESULTS: All measures except the FOBS, included items that either women did not understand or, if where there was understanding the meanings were inconsistent across women. All measures demonstrated limited acceptability and content validity for the specific construct of FOC. Therefore, none of the measurement tools currently used within the UK met criteria for understanding, acceptability and content validity for measurement of FOC. CONCLUSIONS: Findings emphasise a need to develop a specific fear of childbirth tool with good clarity which demonstrates appropriate content validity, and that is acceptable in presentation and length for pregnant women in a UK population.

Establishing a valid construct of fear of childbirth: findings from in-depth interviews with women and midwives.

BACKGROUND: Fear of childbirth (FOC) can have a negative impact on a woman's psychological wellbeing during pregnancy and her experience of birth. It has also been associated with adverse obstetric outcomes and postpartum mental health difficulties. However the FOC construct is itself poorly defined. This study aimed to systematically identify the key elements of FOC as reported by women themselves. METHODS: Semi-structured interviews with pregnant women (n = 10) who reported to be fearful of childbirth and telephone interviews with consultant midwives (n = 13) who regularly work with women who are fearful of childbirth were conducted. Interviews were analysed using thematic analysis for each group independently to provide two sources of information. Findings were reviewed in conjunction with a third source, a recently published meta-synthesis of existing literature of women's own accounts of FOC. The key elements of FOC were determined via presence in two out of the three sources at least one of which was from women themselves, i.e. the reports of the women interviewed or the meta-synthesis. RESULTS: Seven themes were identified by the women and the consultant midwives: Fear of not knowing and not being able to plan for the unpredictable, Fear of harm or stress to the baby, Fear of inability to cope with the pain, Fear of harm to self in labour and postnatally, Fear of being 'done to', Fear of not having a voice in decision making and Fear of being abandoned and alone. One further theme was generated by the women and supported by the reports included the meta-synthesis: Fear about my body's ability to give birth. Two further themes were generated by the consultant midwives and were present also in the meta-synthesis: Fear of internal loss of control and Terrified of birth and not knowing why. CONCLUSIONS: Ten key elements in women's FOC were identified. These can now be used to inform development of measurement tools with verified content validity to identify women experiencing FOC, to support timely access to support during pregnancy.

Skilful prediction of Sahel summer rainfall on inter-annual and multi-year timescales.

Summer rainfall in the Sahel region of Africa exhibits one of the largest signals of climatic variability and with a population reliant on agricultural productivity, the Sahel is particularly vulnerable to major droughts such as occurred in the 1970s and 1980s. Rainfall levels have subsequently recovered, but future projections remain uncertain. Here we show that Sahel rainfall is skilfully predicted on inter-annual and multi-year (that is, >5 years) timescales and use these predictions to better understand the driving mechanisms. Moisture budget analysis indicates that on multi-year timescales, a warmer north Atlantic and Mediterranean enhance Sahel rainfall through increased meridional convergence of low-level, externally sourced moisture. In contrast, year-to-year rainfall levels are largely determined by the recycling rate of local moisture, regulated by planetary circulation patterns associated with the El Niño-Southern Oscillation. Our findings aid improved understanding and forecasting of Sahel drought, paramount for successful adaptation strategies in a changing climate.

Signs of neuropathic pain depend on signals from injured nerve fibers in a rat model.

The present study was undertaken to determine the role of injured fibers in the development of neuropathic pain using our earlier established rat model. Our model was produced by placing tight ligatures to the L5 or both the L5 and L6 spinal nerves on one side in the rat. These rats showed long-lasting behavioral signs of mechanical allodynia and heat hyperalgesia. Using the uniqueness of our model, 3 specific questions are being asked concerning the initiation and maintenance of behavioral signs for neuropathic pain. The results of behavioral tests performed after various surgical manipulations suggest that: (1) peripheral nerve injury itself is the critical factor for the development of behavioral signs of neuropathic pain; (2) signs of neuropathic pain appear only when injury occurs at a part of the peripheral nerve distal to the dorsal root ganglion; and (3) signals (either electrical or chemical) entering the spinal cord from the injured fibers or the dorsal root ganglion cells play a critical role for both initiation and maintenance of the neuropathic pain state.

Evidence for invasion of regenerated ventral root afferents into the spinal cord of the rat subjected to sciatic neurectomy during the neonatal period.

Sectioning the sciatic nerve of experimental animals at the neonatal stage triggers growth of afferent fibers in the ventral root. The present study examined the possibility that the regenerating fiber terminals grow into the spinal cord. The sciatic nerve on one side was cut in neonatal rats. After the rats were fully grown, either an electrophysiological or a histochemical study was performed. The results of electrophysiological experiments showed that stimulation of certain loci in the L5 spinal cord evoked antidromic potentials in the L5 ventral root with a long latency. Various evidence suggests that the long latency potentials are due to activation of C fibers. These C-fiber potentials were on average bigger and were elicited from more numerous loci on the side ipsilateral to the sciatic nerve lesion than on the contralateral side. Furthermore, stimulation of the spinal cord of unoperated normal rats rarely evoked such potentials. For the histochemical study, horseradish peroxidase (HRP) was injected into the L5 spinal cord after cutting the L4-L6 dorsal roots. A lot more cells in the L5 dorsal root ganglion (DRG) on the side ipsilateral to the sciatic nerve lesion were labeled with HRP transported retrogradely through the L5 ventral root than on the contralateral side. Control experiments showed that few DRG cells are labeled with HRP in normal unoperated rats. The combined results of the electrophysiological and histochemical studies suggest invasion of ventral root afferents into the spinal cord, given enough postoperative time. It is not known whether or not these terminals make functional synaptic contacts in the spinal cord.

Neonatal sciatic nerve lesion triggers the sprouting of fibers in the contralateral ventral root of the rat.

We explored the possibility that unilateral neurectomy of the sciatic nerve of the rat at the neonatal stage triggers sprouting of afferent fibers in the contralateral ventral root. 3 months after neonatal sciatic neurectomy, the numbers of both myelinated and unmyelinated fibers in the L5 and L3 ventral roots were counted on electron micrographic montages. Age-matched littermates were used as unoperated controls. To identify regenerating axons, electron microscopic immunohistochemistry was done on the ventral roots using antibody against growth-associated phosphoprotein (GAP-43). Neonatal sciatic neurectomy resulted in: (1) about a three-fold increase in the number of unmyelinated fibers in the contralateral L5 ventral root as compared with the unoperated control; (2) about a 25-fold increase in the number of unmyelinated fibers in the ipsilateral L5 ventral root as compared with the control; (3) approximately 25% of the unmyelinated fibers in the contralateral L5 ventral root expressing GAP-43; and (4) no significant change in the number of unmyelinated fibers in the L3 ventral root of either side as compared with the control. The data suggest that a neonatal sciatic neurectomy of the rat triggers sprouting of unmyelinated afferent fibers in the ventral root of the contralateral as well as the ipsilateral side. The sprouting is restricted, however, to spinal segments which receive inputs from the sciatic nerve.

Thickened pituitary stalk with central diabetes insipidus: report of three cases.

Diabetes insipidus of central origin usually results from lesions in the hypothalamic neurohypophyseal system. Lymphocytic infundibuloneurohypophysitis is an uncommon cause. Cases of lymphocytic infundibuloneurohypophysitis with thickening of the pituitary stalk and enlargement of the neurohypophysis with no hyperintense signal in the posterior pituitary have been reported. Reported cases presenting with isolated thickening of the pituitary stalk are very rare. We report three such cases, one in a nulliparous woman and the other two in men. Magnetic resonance (MR) imaging in these patients revealed isolated thickening of the pituitary stalk, loss of the hyperintense signal of the posterior pituitary, and an adenohypophysis of normal size. All cases had abnormal nodular infundibular enlargement. One male patient had hypogonadism; the other patients showed no sign of adenohypophyseal deficiency on stimulation test. Serial follow-up MR imaging revealed that all three patients had persistent thickening of the pituitary stalk. Diabetes insipidus was controlled by the administration of desmopressin acetate in all patients.