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It is prudent to advise patients to allow this flexion-creep to reverse itself before performing activities that require lumbar stability fungus za kucha purchase diflucan 150mg otc. When viscoelastic tissue is loaded and then subsequently unloaded fungus between breasts diflucan 400mg cheap, the amount of stress is lower for a given amount of strain fungus between breasts order diflucan 200 mg free shipping. This phenomenon is a consequence of the tissue’s viscosity antifungal kit discount diflucan on line, and is called hysteresis. The area between the loading and unloading curves (shaded area, see ﬁgure) is a measure of hysteresis, and represents the energy absorbed by the tissue, which is usually lost in the form of heat (although it could cause tissue damage). Repeated loadings, as well as acute and chronic stretching, increase a tendon’s compliance and decrease the amount of hysteresis. These changes increase the energy returned during the stretch-shortening cycle (improving performance), and can decrease the risk of injury. These changes show that stretching has beneﬁcial effects other than just improving the range of motion of a joint. The amount of force or tension that a muscle can produce varies with the length of the muscle at the time of contraction. When the ﬁbers shorten beyond resting length, the force production decreases slowly at ﬁrst, and then rapidly. This relationship can be used to help explain why surgically lengthened muscles are weak postoperatively (see ﬁgure). Discuss some factors that affect the biomechanical properties of tendons and ligaments. There are morphological, biomechanical, metabolic, and histologic differences between types of cartilage in the joints of the lower extremities. Those differences, in part, are the reason why osteoarthritis is more prominent in the knee and hip joints than in the ankle joint. With boundary lubrication, a layer of fluid prevents direct contact between two surfaces, decreasing friction. With fluid ﬁlm lubrication, the fluid between two surfaces separates the contact surfaces and distributes the loading between them. Increased fluid pressure creating a wedge, separating two surfaces (hydrodynamic). Increased fluid pressure deforming the articular surface, creating greater contact area (elastohydrodynamic). Increased pressure on the articular cartilage, forcing fluid out onto the surface (weep) 38. Friction is a force, parallel to the contact surface, that opposes motion between two objects. The magnitude of the friction force will depend upon the material characteristics of the two contacting surfaces, and will be lower if there is relative motion between the two surfaces. A certain amount of friction between the ground and our shoes is necessary for efﬁcient movement and to prevent slipping, but it also wears the soles of our shoes. High friction forces between the ground and the shoe increase the risk of ankle and knee injuries in sports where there is a lot of sudden turning or stopping, while repetitive friction forces to the skin can cause blisters. An obvious example would be the difference in change in volume response to resistive exercise by a muscle and a tendon. A tendon adapts to change slower than muscle because it has fewer cells (in this case, tenocytes) that are capable of facilitating adaptation. Evidence on the rate of adaptation of ligaments, cartilage, and intervertebral disks is scarce, but it is believed that they develop more slowly than muscle. It is important to realize, during rehabilitation, that a muscle will regain its strength before the other tissues of the musculoskeletal system, and therefore muscle strength alone is not a good indicator of the rehabilitation process. What happens to the strength of an intramedullary rod when its diameter is increased? How long does it take for strength to return to normal levels after the removal of a screw? One should be able to assume that the strength of the ﬁxation is determined by the pull-out strength of the lag screw, or approximately a 40% increase in strength over plating alone. Why do we use the terms varus with talipes varus, varum with genu varum, and vara with coxa vara? Varus and valgus are adjectives and should be used only in connection with the noun they describe. Talipes is a form of the masculine noun talus, thus talipes varus (foot inverted and pointed, as in a clubfoot); genu is a neutral noun, thus genu varum or valgus (bowlegged or knock-kneed); and coxa is feminine, thus coxa vara (any decrease in the femoral neck shaft angle <120 to 135 degrees). The inflammatory response is characterized by a cascade of biochemical reactions and represents the body’s initial reaction to injury, whether caused by trauma, surgery, or metabolic or infectious disease. The principal signs of the inflammatory response are erythema (rubor), swelling (tumor), elevated tissue temperature (calor), and pain (dolor). Local vasodilation, fluid leakage into the extracellular and extravascular spaces, and impaired lymphatic drainage are responsible for the erythema, swelling, and increased tissue temperature. The proliferative phase may begin early in the inflammatory phase but is thought to be most extensive approximately 21 days after injury. The matrix formation/remodeling phase begins 3 weeks after injury and may last for up to 2 years, although in many cases the majority of remodeling has occurred by 2 months. Because the time frames for these three phases overlap considerably, the accepted delineations should be used as general guidelines only. Soft Tissue Injury and Repair 25 Cerny K: Kinesiology versus biomechanics: a perspective, Phys Ther 64:1809, 1984. Kubo K, Kanehisa H, Fukunaga T: Effects of resistance and stretching training programmes on the viscoelastic properties of human tendon structures in vivo, J Physiol 538:219-226, 2002. The fourth cardinal sign of inflammation— pain—is the result of mechanical distention and pressure of the soft tissues and chemical irritation of pain-sensitive nerve receptors. The acute inflammatory phase begins immediately after injury and lasts 24 to 48 hours, although some aspects may continue for up to 3 weeks. Describe the basic vascular and cellular activities associated with the inflammatory reaction and the primary function of each activity. Blood vessels at the site of the injury initially undergo vasoconstriction, which is mediated by norepinephrine and usually lasts from a few seconds to a few minutes. If serotonin is released by mast cells in the area of injury, a secondary prolonged vasoconstriction occurs to slow blood loss in the affected region. Additional cellular activities after soft tissue injury include margination of leukocytes, which adhere to the vessel wall, and chemotaxis (movement of white blood cells through the extravascular space toward the site of injury), which begins the process of phagocytosis and removes the cellular debris caused by the injury. Both histamine and serotonin are released from granules of mast cells in the area of the injury. Histamine results in elevated vascular permeability, whereas serotonin is a potent vasoconstrictor. Kinins, notably bradykinin, also cause a marked increase in vascular permeability, much as histamine does. Pro-inflammatory prostaglandins are believed to sensitize pain receptors, attract leukocytes to the inflamed area, and increase vascular permeability by antagonizing vasocon striction. Which cell type is especially prominent in the proliferative and matrix formation phases of connective tissue healing? It is responsible for synthesizing and secreting most of the ﬁbers and ground substance of connective tissue. Soft tissue injury signals the ﬁbroblast to multiply rapidly and mobilizes free connective tissue cells to the injured area. The matrix provides the strength and support of the soft tissue and also serves as the means for diffusion of tissue fluid and nutrients between capillaries and cells. Healing after soft tissue injury is affected by the availability of a number of factors, including blood supply, proteins, minerals, and amino acids. Enzymes and hormones also play a role in tissue healing, as do mechanical stress and infection. Steroids suppress the mitotic activity of ﬁbroblasts, which results in diminished deposition of collagen ﬁbers and reduction in tensile strength. Anti biotic medicines inhibit protein synthesis and may adversely affect wound healing and scar formation. Disease processes such as diabetes mellitus signiﬁcantly retard wound healing because small-vessel disease inhibits normal collagen synthesis. Collagen biosynthesis is especially sensitive to the availability of proper nutrients. Glucosamine is the precursor for compounds important to connective tissue health, such as chondroitin sulfate and hyaluronic acid, and increases proteoglycan production.

The sonographic features of difuse fatty liver are: bright liver antifungal internal medications generic 50 mg diflucan with visa, with greater echogenicity than the kidney decreased portal vein wall visualization poor penetration of the posterior liver and hepatomegaly (Fig fungus or lichen cheap 200mg diflucan amex. Frequent locations include the region of the porta hepatis antifungal otic purchase cheap diflucan on-line, near the falciform ligament fungus gnats wiki buy diflucan 200 mg without prescription, the dorsal 152 lef lobe and the caudate lobe. The hepatic vessels are usually normal and not displaced in these areas on colour or power Doppler images. Note the undulating hepatopetal fow signal Vascular diseases Portal hypertension Sonography can be useful for defning the presence of ascites, hepatosplenomegaly and collateral circulation; the cause of jaundice; and the patency of hepatic vascular channels. With the development of a porto-systemic shunt, however, the calibre of the veins may decrease. The superior mesenteric and splenic veins are more strongly infuenced by respiration and the patient’s position. The main sites of porto-systemic shunt are the gastro-oesophageal junction, for the gastric and para-oesophageal varix; 153 the fssure of the ligamentum teres, for the recanalized umbilical vein; the splenic and lef renal hilum, for spleno-renal and gastro-renal shunts; and the mesentery for mesenteric varix. The mean portal venous fow velocity is approximately 15–18 cm/s but varies with respiration and cardiac pulsation. In advanced portal hypertension, the fow becomes biphasic and fnally hepatofugal (Fig. Note the biphasic hepatofugal fow signal Portal vein thrombosis Portal vein thrombosis develops secondary to slow fow, hypercoagulable states, infammation or invasion by a malignancy such as hepatocellular carcinoma, metastatic liver disease, pancreatic carcinoma or primary hepatic vascular leiomyosarcoma of the portal vein. Slow fow is usually secondary to portal hypertension, with shunting of mesenteric and splenic fow away from the liver. In sonography, portal fow is absent, and the vessel may be flled with a hypoechoic thrombus. As an acute thrombus can be hypoechoic or anechoic and may be overlooked, colour Doppler examination is necessary. Doppler sonography is also useful for distinguishing benign from malignant portal vein thrombi in patients with cirrhosis. The following sonographic fndings suggest malignant thrombi: expansion of involved portal vein a periportal tumour connected to the thrombi and a pulsatile fow signal within the thrombi (Fig. Hepatic venous obstruction and Budd-Chiari syndrome As the hepatic veins have thin walls and no adventitia, the walls are less echogenic than those of the portal vein. Normal individuals show two prominent antegrade (hepatofugal) waves and one prominent retrograde (hepatopetal) wave; thus, the hepatic veins have a triphasic wave. The larger of the two antegrade waves occurs during systole and is due to atrial relaxation, whereas the other occurs during diastole afer opening of the tricuspid valve. In some cases, it may indicate anatomical obstruction between the right atrium and hepatic veins, such as a tumour or Budd-Chiari syndrome. Hepatic venous obstruction can be due to obstruction of the suprahepatic portion of the inferior vena cava, thrombosis of the main hepatic veins themselves or obstruction at the level of small hepatic venules. Budd-Chiari syndrome generally involves the frst two conditions, while hepatic veno-occlusive disease involves the last. The sonographic fndings in Budd-Chiari syndrome include evidence of hepatic vein occlusion and abnormal intrahepatic collaterals. The fndings in hepatic vein occlusion include partial or complete disappearance of the hepatic veins, stenosis, dilatation, thick wall echoes, abnormal course, extrahepatic anastomoses and thrombosis. In Budd-Chiari syndrome, Doppler sonography may show abnormal blood-fow patterns in the hepatic veins and inferior vena cava. The fow in the inferior vena cava, the hepatic veins or both changes from phasic to absent, reversed, turbulent or continuous. The portal blood fow may also be afected, characteristically being either slowed or reversed. Colour Doppler imaging can reveal hepatic venous occlusion, hepatic-systemic collaterals, hepatic vein–portal vein collaterals and anomalous or accessory hepatic veins of increased calibre. Hepatic veno-occlusive disease Hepatic veno-occlusive disease is defned as progressive occlusion of the small hepatic venules. Patients with this disease are clinically indistinguishable from those with Budd Chiari syndrome. Doppler sonography shows normal calibre, patency and phasic fow in the main hepatic veins and inferior vena cava. Simple cysts are anechoic, with a well demarcated, thin wall and posterior acoustic enhancement (Fig. In adult polycystic liver disease, the cysts are small (< 2–3 cm) and occur throughout the hepatic parenchyma. Sonographically, peribiliary cysts can be seen as discrete, clustered cysts or as tubular structures with thin septa, paralleling the bile ducts and portal veins (Fig. A simple cyst in the right lobe of the liver, showing a well demarcated, thin-walled, anechoic lesion (long arrow) with posterior acoustic enhancement (short arrows) Fig. Bright echogenic foci in the liver with distal ring-down artefacts are characteristic (Fig. Multiple echogenic foci with posterior ring-down artefacts (arrows) are seen in the right lobe of the liver Haemangioma Haemangiomas are benign congenital tumours consisting of large, blood-flled cystic spaces. Teir sonographic appearance is characteristic: most are less than 3 cm, homogeneous and hyperechoic with acoustic enhancement (Fig. Another typical feature is a heterogeneous central area containing hypoechoic portions with a thin or thick echogenic border (Fig. It is commoner in women than men, particularly among women of childbearing age, and is typically a well circumscribed, usually solitary mass with a central scar. On sonography, focal nodular hyperplasia is well defned and hyperechogenic or isoechogenic relative to the liver (Fig. It ofen manifests as a subtle liver mass that is difcult to diferentiate from the adjacent normal liver. Doppler features of focal nodular hyperplasia are highly indicative, in that well developed peripheral and central blood vessels are seen (Fig. The characteristic fnding on colour Doppler is intra-tumoral blood vessels within the central scar, with either a linear or a stellate confguration. Patients may present with right upper-quadrant pain secondary to rupture, with bleeding into the tumour. Hepatic adenomas have also been reported in association with glycogen storage or von Gierke disease. Because hepatic adenoma has a propensity to haemorrhage and there is a risk for malignant degeneration, surgical resection is recommended. The sonographic appearance of hepatic adenoma is non-specifc, and the echogenicity is variable (Fig. In haemorrhage, a fuid component may be evident within or around the mass, and free intraperitoneal blood may be seen. Biliary cystadenoma and biliary cystadenocarcinoma Biliary cystadenoma is a rare cystic neoplasm occurring primarily in middle-aged women. Although it is usually benign, it tends to recur afer subtotal excision and can develop into a malignant cystadenocarcinoma. The most striking feature of the gross pathology of a biliary cystadenoma or cystadenocarcinoma is its multiloculated 158 Fig. In patients with biliary cystadenoma, the most common sonographic f nd i ng is a sept ated mu lt i loc u la r c y st w it h no g ros s nodu le s or sof-t is sue ma s s (Fig. Although cystadenoma usually cannot be diferentiated from cystadenocarcinoma by imaging criteria, the presence of solid nodular masses or coarse calcifcations along the wall or septa in a multilocular cystic mass indicates a likely diagnosis of biliary cystadenocarcinoma (Fig. Increasing echogenicity is related to the presence of haemorrhage, fbrosis and necrosis, echogenic lesions being found in about one 159 Fig. The mosaic pattern is due to the presence of multiple compartments of diferent histological origin in a tumour. It is typically large, solitary and slow growing, ofen with calcifcation and a central fbrosis scar resembling focal nodular hyperplasia. Metastases Metastatic disease is the commonest form of neoplastic involvement of the liver. It is most common in association with colon cancer, with decreasing frequency in gastric, pancreatic, breast and lung cancers. Knowledge of a prior or concomitant malignancy and features of disseminated malignancy at the time of sonography are helpful for correct interpretation of sonographically detected liver masses. They may present as a single liver lesion, but do so more commonly as multiple focal masses. Although there are no absolutely confrmatory features of metastatic disease on sonography, the presence of multiple solid nodules of diferent sizes and the presence of a hypoechoic halo surrounding a liver mass are indicative of metastasis (Fig.

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The tail is usually afected frst fungus killing rattlesnakes purchase diflucan cheap online, followed by the body and then the head fungus gnats mycetophilidae order 100 mg diflucan with amex, though in some cases the head may be most severely afected fungus festival buy cheap diflucan 50mg line. This has to be assessed subjectively antifungal kidney buy discount diflucan 200mg on-line, on the basis of the number and diameter of vessels seen compared with those seen with the same equipment and settings in normal subjects (Fig. The size, echo pattern and vascularity of the epididymal tail is, however, variable in normal subjects, and the ultrasound signs of mild epididymitis are ofen equivocal. It follows that a normal ultrasound scan does not exclude a diagnosis of epididymo-orchitis. Tere are hypoechoic and sometimes also hyperechoic foci, and there is ofen a small reactive echogenic hydrocele (Fig. If the testis is involved, it is usually larger than the one on other side, ofen with hypoechoic bands radiating from the hilum, representing oedema around the septae and the enlarged blood vessels than run alongside them (Fig. The normal intratesticular arteries spiral, so that only small lengths are seen in a single ultrasound plane. The spermatic cord may be involved in the infammatory process, with thickening and hyperaemia. In a very few severe cases, swelling of the cord within the inguinal canal (funiculitis) causes ischaemia of the testis, with reduced or absent blood fow on Doppler study. In addition to hypoechoic areas, there are hyperechoic foci, probably due to haemorrhage. The spermatic cord is swollen and contains prominent vessels Such cases are so uncommon that they may be discounted in the interpretation of the scan. Tere may be cellulitis of the scrotal wall, with thickening and hyperechoic areas, but this is more easily assessed clinically. The main complications of epididymo-orchitis are abscess formation and focal orchitis: Abscesses usually occur in the epididymis and may discharge through the scrotal wall. On ultrasound they are seen to have a thick wall and fuid contents of variable echogenicity (Fig. In some cases, there are mass-like lesions within the testis, which may be indistinguishable from tumour (Fig. The diagnosis may be suggested by the presence of orchitis, but it should be remembered that orchitis and testicular tumours can coexist. Indeed, there is some evidence that testicular tumours may predispose to orchitis by obstructing the tubules. Areas of focal orchitis become less prominent with treatment and either resolve completely or leave a scar. In this situation, serum tumour markers should also be measured: elevated levels indicate a tumour, though normal levels do not exclude tumour. Focal orchitis may sometimes progress to testicular abscess Tuberculous epididymo-orchitis Tuberculous epididymo-orchitis is a chronic condition, ofen presenting as a mass with little pain. Ultrasound appearance Scans of early cases show epididymal swelling similar to that in bacterial epididy mitis, sometimes also with areas of calcifcation (Fig. There are echodense foci of calcifcation 359 Ofen, because there is no pain, patients present late, by which time there is severe enlargement of the epididymis with hyperechoic and hypoechoic areas. The ultrasound appearance, therefore, is ofen of a single inhomogeneous mass in which it is difcult to distin guish the testis from the epididymis (Fig. It is sometimes impossible to distinguish tuberculous epididymo orchitis from a tumour. The epididymis and testis are fused into a single infammatory mass a b Schistosomiasis (bilharzia) Schistosoma haematobium ofen afects the urinary tract and the epididymis, causing mild epididymitis. Ultrasound appearance The characteristic feature on ultrasound scans is multiple, hyperechoic rounded foci, about 1–1. Late changes of epididymo-orchitis The majority of cases of epididymo-orchitis return to normal afer antibiotic treatment. Ultrasound appearance The echo texture of the hard areas is usually very similar to the surrounding epididymis, which makes them difcult to see ultrasonically (Fig. With this technique the 360 hard area, usually in the epididymal tail, may be seen to move diferently from the surrounding epididymis. Focal orchitis may leave hyperechoic or hypoechoic scars or hypoechoic infarcts (Fig. There are hyperechoic ova throughout the testis, as well as small hypoechoic foci representing granulomas a b Fig. Three months after an episode of severe epididymitis, there is residual enlargement of the testicular tail. The spermatic artery is essentially the only artery that supplies blood to the testis, which quickly becomes ischaemic and afer 6–24 h becomes infarcted. It initially becomes ischaemic, but collateral vessels quickly enlarge so that the tissues survive. This can only occur when the attachment of the testis and epididymis to the scrotal wall, the pedicle, is abnormally narrow. Neonatal torsion, however, has a diferent presentation from childhood and adolescent torsion. Adolescent and adult torsion As noted earlier, if adequate equipment and expertise are not immediately available, it is better to rely on clinical fndings and perform a surgical exploration if torsion is suspected. Torsion produces changes in the grey-scale appearance of the testis and epididymis, but it is the Doppler study that confrms or excludes the diagnosis. Ultrasound appearance On the grey-scale image, the testis is swollen and initially mildly heterogeneous with hypoechoic areas. If the torsion has been present for more than 24 h, there is ofen a hypoechoic band around the periphery of the testis. This is because the testis does have some collateral blood supply, although it is insufcient to prevent infarction (Fig. It is worth searching for this feature as it is totally diagnostic; however, it is not visible in all cases. Used with contrast-specifc sofware they give a perfusion image in which the testis is shown to be non-perfused. However, the appropriate sofware is expensive and the technique is not in general use. Vessels are clearly seen around the testis but there is a marked reduction in the intratesticular vessels Fig. The testis is seen to be non-perfused, except for a small area at the hilum (arrows) a b Testis Testis Incomplete torsion The term ‘incomplete torsion’ describes a twist of the cord of 360° or less. The venous return is, however, occluded so that testicular infarction still occurs. Ultrasound appearance The diference from complete torsion is that a signifcant number of vessels may be seen, particularly at the testicular hilum. As stated previously, some vessels may also be seen in complete torsion so that the distinction on Doppler study may not be clear. In a signifcant number of cases, the testis will subsequently re-twist and eventually complete torsion will occur. Ultrasound appearance The grey-scale fndings seen in early torsion may be present but are not diagnostic. Clinical examination of the testis may reveal a narrow testicular hilum (bell-clapper deformity). Anteroposterior inversion of the testis ofen accompanies a narrow hilum and may be detected clinically. Torsion can occur as a result of this anomaly Narrow hilum Neonatal torsion this is discussed in Volume 2 of this manual. Henoch–Schönlein purpura Henoch–Schönlein purpura may cause testicular vasculitis, producing acute scrotal pain identical to that of torsion. Ultrasound appearance The characteristic appearance is of a very stranded hydrocele. This gives the appear ance of branching echogenic lines crossing the hydrocele fuid. As the strands attach to the tunica albuginea, they cause the testicular surface to appear ragged. There is a characteristic very stranded hydrocele causing a ragged-looking testicular surface Focal testicular infarcts Testicular infarcts occur in hypercoagulability states, including sickle-cell disease, but may also be idiopathic. Ultrasound appearance A wedge-shaped or angular hypoechoic area is typical of an infarct (Fig. However, some tumours, particularly small ones, are also hypovascular and no blood vessels may be seen within them on a Doppler scan.

The participants were cataloged into five groups by delivery methods fungi journals order diflucan 50mg without a prescription, including: spontaneous vaginal delivery without injuries (N=184) fungus gnats and mold buy generic diflucan on line, spontaneous vaginal delivery with episiotomy or perineal laceration (N=182) antifungal medicine oral purchase diflucan 50 mg on line, operative vaginal delivery (N=180) antifungal shampoo for jock itch buy diflucan with mastercard, elective caesarean section (N=182), and emergency caesarean section (N=184). The authors reported that the overall sexual function, sexual satisfaction, and quality of life among women with elective caesarean section and their husbands were better than the other groups (Safarinejad, Kolahi, & Hosseini, 2009). McDonald and Brown (2013) carried out a prospective pregnancy cohort study of 1507 nulliparous women recruited in early pregnancy (≤ 24 weeks) in Australia and found that in contrast with the women who underwent spontaneous vaginal delivery, women who underwent caesarean section had decreased likelihoods of resuming 13 vaginal sex by 6 weeks postpartum, regardless of the timing of caesarean section (before or after commencing labor). There are no studies controlling for attitudes and beliefs held by pregnant women regarding the impact on sexuality and the quality of the relationship of a woman with her partner by delivery methods. This gap will be addressed by developing an appropriate instrument for obtaining data on attitudes and beliefs regarding childbirth delivery options and sexuality. The Theory of Planned Behavior Humenick (2007) suggested that a theoretical framework could assist the childbirth educator to organize maternal realities into sets of meaningful and related concepts and thus further the effort to increase expectant pregnant women’s understanding, problem solving, and decision making regarding their unique maternal realities. It is designed to predict behaviors not entirely under volitional control by including measures of perceived behavioral control, such as self-efficacy. In this study, perceived behavioral control was specifically defined in terms of childbirth self efficacy. The rationale for this decision is based on Ajzen (2002) who stated that there is a need to incorporate self-efficacy within perceived behavioral control construct, and on the recommendation by Fishbein (2008) to treat self-efficacy as a form of perceived behavioral control in an integrative model of behavioral prediction that attempts to account for health promotion decision-making among health professionals and patients. Ajzen began research in this area in the late 1960s, when the attitude concept was under attack by contemporary social psychologists. Numerous studies had observed little, if any, correspondence between verbal expressions of attitude and overt (observable) behavior. The individual’s behavioral intention is comprised of the motivational components— attitude towards the behavior, subjective norms, and perceived behavioral control—that affect a behavior. Intention is, in turn, determined by the person’s attitude toward the specific behavior, subjective norms (beliefs about how significant others feel about the behavior), and perceived behavioral control (sense of personal control) about being able to engage in the behavior (Spring, 2008). In other words, intention is an indication of an individual’s readiness to perform a given behavior. For example, pregnant women may tend to eat healthy food because they think healthy food is good for themselves and their fetuses, even if they desire to eat unhealthy food during their pregnancies. Subjective norms focus on the individual’s beliefs regarding what significant others think about the behaviors. For instance, a mother-in-law plays an important role during a woman’s pregnancy in Taiwan, so her judgments or values are likely to influence the pregnant woman’s choice of delivery options. Perceived behavioral control is the individual’s beliefs about whether a specific behavior is easy or difficult for her to perform. For example, if a pregnant woman believes she has the capability of breastfeeding, she is more likely to prepare herself to breastfeed during her pregnancy (Conner & Sparks, 1996). First, perceived behavioral control, attitude toward the behavior, and subjective norms are determinants of the individual’s intention. Second, holding intention constant, the probability that a behavior will be executed increases with increasing perceived behavioral control. Third, perceived behavioral control will influence 16 behavior directly to the degree that perceived behavioral control reflects actual control: availability of requisite opportunities and resources, such as time, money, and health status. Hence, positive attitudes, perceived social acquiescence, and perceived ease of behavioral performance can influence intention to engage in a particular behavior or choose a particular option (Ajzen, 1991; Armitage & Conner, 1999). In addition, the perceived behavioral control construct accounted for significant amounts of variance in intention and behavior, independent of attitude towards the behavior and subjective norms (Armitage & Conner, 2001). Perceived Self-efficacy in Health Promotion the concept of perceived self-efficacy in the framework of cognitive behavior modification was proposed by the psychologist Albert Bandura at Stanford University in 1977 (Bandura, 1977). Perceived self-efficacy is defined as an individual’s evaluation of their own capabilities to organize and execute sequences of action required to attain specific achievements or goals (Bandura, 1986). Those with greater perceived self-efficacy are more likely to initiate behavior change compared to those who possess lower perceived self-efficacy. Perceived capabilities could be considered a predominant factor in determining whether individuals construe the specific behavior change as being within their volitional control. Outcome expectancy is an individual’s belief that a specific outcome is a consequence of a particular behavior. Efficacy expectancy is an individual’s perception that she possesses adequate capabilities to successfully or regularly execute a series of behaviors to attain the anticipated outcome. Perceived self-efficacy is dynamic and developed in response to information from four principal sources: performance attainment, vicarious experiences of observing the performances 18 of others, verbal persuasion and allied social support that one possesses certain capabilities, and physiological states from which people partly judge their capability, such as strength, and vulnerability to dysfunction (Bandura, 1986). Performance attainment is the most significant influence on individuals’ perceived self efficacy. Individuals’ repeated successes will reinforce their positive self-perception, while repeated failures will reinforce their negative self-perception. For individuals who possess strong self-efficacy, occasional failures are unlikely to have much effect on their evaluations of their own capabilities. In addition to performance attainment, individuals also evaluate their self efficacy through vicarious experiences. If they witness other similar individuals performing successfully, their own self-efficacy improves. Verbal persuasion has been widely applied to strengthen individuals’ beliefs that they have the capabilities to reach a specific level of performance. Individuals who are persuaded that they possess the capabilities are more inclined to make an effort to successfully execute specific activities than those who are not persuaded. Finally, physiological states influence individuals to have differential judgments of their capabilities to perform a given task. If individuals sense fear, fatigue, or pain, they usually perceive physical inefficacy, which undermines their performance (Bandura, 1986). Greater perceived self-efficacy is responsible, in part, for better health status, higher achievement, and greater social integration. When individuals are aware of the importance of precautions, they are inclined to modify their behavior. Before forming a behavior intention, deliberating detailed action plans, and performing regular health behaviors, individuals develop beliefs regarding their capabilities to engage in behavior modification (Schwarzer & Fuchs, 1996). In childbirth, self-efficacy was first used as a core concept by Manning and Wright (Manning & Wright, 1983). Manning and Wright (1983) stated that self-efficacy expectancies predicted persistence in pain control without medication better than other predictors in self efficacy theory. However, there is only one dissertation abstract (Samuels, 1987) in psychology regarding self-efficacy in childbirth that could be found after Manning and Wright’s work. The roots of the childbirth self-efficacy concept in the nursing literature can be traced back to Lowe’s work (Lowe, 1991), which depicted maternal confidence during childbirth in the context of self efficacy theory. After the term “childbirth self-efficacy” was introduced by Lowe in nursing (Lowe, 1991, 1993), a series of instrument development studies (Cunqueiro, Comeche, & Docampo, 2009; Drummond & Rickwood, 1997; Gao, Ip, & Sun, 2011; Ip, Chan, & Chien, 2005; Ip, Chung, & Tang, 2008; Khorsandi et al. In Chinese nursing research, the role regarding perceived self-efficacy in maternal-child care has been studied since 2005 by childbirth educators and researchers (Ip et al. For example, perceived self-efficacy was measured in a randomized controlled trial to assess the effect of individual counseling regarding diet and physical activity on weight retention among Taiwanese pregnant women. The results demonstrated that those from pregnancy to six months postpartum and those from birth to six months postpartum, have better self-efficacy scores for health behaviors and the subscales of nutrition and physical activity than the comparison group (Huang, Yeh, & Tsai, 2011). Moreover, a non-randomized controlled experimental study evaluated a prenatal yoga program provided to Taiwanese primigravidas in the third trimester of pregnancy with the aim of decreasing the pregnancy discomforts and increasing childbirth self efficacy. The study showed that women who participated in the prenatal yoga program reported significantly fewer pregnancy discomforts than the control group at 38-40 weeks of gestation, along with higher outcome and self-efficacy expectancies during the active stage of labor and the second stage of labor compared with the control group (Sun et al. Furthermore, childbirth self-efficacy has been identified as a significant indicant of pregnant women’s ability to cope with labor, and it influences their motivation for spontaneous vaginal delivery and the favorable perception of maternal experiences in Mainland China (Gao et al. Given the evidence relating childbirth self-efficacy to labor and delivery behaviors, I believe that this construct is a valid choice for operationalizing perceived behavior control with proposed application of the theory of planned behavior. Research Design this study used a multiphase mixed method design (qualitative and quantitative). Participants and Setting Participants were Taiwanese pregnant women recruited from the prenatal clinic in a large urban hospital in northern Taiwan, a 1000-bed medical center with an annual birth rate of around 2000. Inclusion criteria for all phases of this study were the following: (1) first-time pregnancy (primigravida), (2) age ≥ 20 years, (3) singleton pregnancy, (4) ability to listen, speak, read and write in Chinese, (5) Taiwanese nationality, and (6) voluntary agreement to participate. The exclusion criteria were as follows: (1) women who have major obstetric or medical pregnancy complications, and (2) women who cannot read and write in Chinese. This estimated sample size is consistent with recommendations made by Comrey and Lee (1992) for conducting factor analysis (100= poor, 200 = fair, 300 = good, 500 = very good, 1,000 or more = excellent).