The puritan periods and age of classicism Essay Example

The puritan periods and age of classicism Essay Former presidents and officers of the ABACAS, (mention their names), my fellow alumni from different batches , guests, ladies and gentlemen, a pleasant evening .. Were gathered here tonight as usual to annually celebrate this reunion of great significance, our BACH grand alumni global reunion. Binnacle Catholic High School, BACH, rings a bell in our hearts, it brings us back to wonderful memories as cost say that high school days are the best, perfect, exciting days of our lives. BACH was our very foundation where we got educated and trained, Many years have gone by since we all graduated from BACH, we lost touch, we became distant, there has been transition in our lives since then. We had varied lives: we faced challenges , experienced heartbreaks ,reaped rewards. _our Journey may not be easy But we all made it here tonight , thankful for the role BACH has played in our development. Our alma mater gave us a special sense of belonging. Our directors, school heads and teachers, whether still living or not, touched our lives and gave us gifts which we carry to the end of our lives. Let us be thankful again for this gathering , rekindle high school memories, renew our friendships, and continue to support our alma mater in our own way, for this Is the legacy that the founders of our school and the great director , the late FRR. Leo Benzene left us to fulfill. We will write a custom essay sample on The puritan periods and age of classicism specifically for you for only $16.38 $13.9/page Order now We will write a custom essay sample on The puritan periods and age of classicism specifically for you FOR ONLY $16.38 $13.9/page Hire Writer We will write a custom essay sample on The puritan periods and age of classicism specifically for you FOR ONLY $16.38 $13.9/page Hire Writer I wont keep you long with a lengthy speech because we need to spend more time to enjoy this occasion. Let us get reacquainted and share our stories Let us stay forever young so that our horizon still looms ahead, beckoning tomorrows of fulfillment and greater Joy and most of all , we shall meet again next year, and In the ensuing years to come.

Galapagos essays

Galapagos essays A. After I read Galapagos, I thought it was a good story. It was a little different from other novels I have read in that the author, Kurt Vonnegut, had a different style than most other authors. I liked how he made comments about humans big brains that always gave them foolish or reckless ideas that almost always had negative results. The way he showed how a world changed because people no longer thought that paper money was valuable provoked many thoughts about how something like that could actually happen. B. I saw myself a few times throughout the book. For example, I saw myself in Mandarax; always a source of some information, none of which is of use to most people. Mandarax would always have something to say under any circumstance, but usually what it said had nothing to do with what was going on. Much like an internet search engine, you give it a bit of information and in return you get a whole lot of nothing. I also saw myself in Leon Trout. When the blue tunnel into the afterlife came for him, he didnt want to go until he found out what happened to the people on the ship. Once I start reading something and it gets to a situation where someone is in trouble; I dont like to stop until I know they are safe. From this story I learned a lesson. Dont always trust your big brain?! Though it may tell the rest of your body to do the things that make you live and breathe, it will sometimes tell you to something that might endanger or kill you. For instance, Mary Hepburns brain told her to put a plastic dress bag over her head to kill herself. I also learned to not judge someone by first sight or based on little knowledge. When Mary Hepburn first met James Wait, he was feeding some starving children. Sh...

Galapagos essays

Galapagos essays A. After I read Galapagos, I thought it was a good story. It was a little different from other novels I have read in that the author, Kurt Vonnegut, had a different style than most other authors. I liked how he made comments about humans big brains that always gave them foolish or reckless ideas that almost always had negative results. The way he showed how a world changed because people no longer thought that paper money was valuable provoked many thoughts about how something like that could actually happen. B. I saw myself a few times throughout the book. For example, I saw myself in Mandarax; always a source of some information, none of which is of use to most people. Mandarax would always have something to say under any circumstance, but usually what it said had nothing to do with what was going on. Much like an internet search engine, you give it a bit of information and in return you get a whole lot of nothing. I also saw myself in Leon Trout. When the blue tunnel into the afterlife came for him, he didnt want to go until he found out what happened to the people on the ship. Once I start reading something and it gets to a situation where someone is in trouble; I dont like to stop until I know they are safe. From this story I learned a lesson. Dont always trust your big brain?! Though it may tell the rest of your body to do the things that make you live and breathe, it will sometimes tell you to something that might endanger or kill you. For instance, Mary Hepburns brain told her to put a plastic dress bag over her head to kill herself. I also learned to not judge someone by first sight or based on little knowledge. When Mary Hepburn first met James Wait, he was feeding some starving children. Sh...

RESEARCH PROPOSAL Example | Topics and Well Written Essays - 3000 words

Research Proposal Example (Sowney, & Barr, 2008). At the same time, little is known about the experiences of nurses or the families of these patients nor the nature of the challenges that are faced. There is a lack of understanding that weakens the ability of the nursing staff to reduce barriers and provide a service that is equitable for people with intellectual disabilities. There is the belief that because many of the issues that occur, care should be given in a community setting instead of a hospital setting, however this is under debate (Lennox, Rey-Conde, Purdie, et.al., 2007). People with intellectual disabilities comprise about 2% of the UK population. Demographics have been changing, however, and intellectual disabilities increased by 54% over a period of 35 years from the year 1960 to 1995 (Cooper, Melville, & Morrison, 2004). There then followed another 9% increase over the years of 1998 to 2008. These changes have occurred due to improvements in socioeconomic conditions, intensive neonatal care, and increasing survival rates. The health needs of people who have intellectual disabilities impact primary healthcare services as well as secondary healthcare specialties. There are many health inequalities in this group of people and their disabilities may affect their experience in the hospital as well as their family and the staff working there in either a positive or negative way based on how prepared everyone involved is. There are many special issues in healthcare in with people who have intellectual disabilities. The majority of people with intellectual disabilities live in the worlds less developed countries. However, there is a lack of understanding in their care in all countries. There is still so little known about the types of care that are needed most. There is also a great lack of understanding as to the experiences of this group of adults and what their perspectives

Barriers to Business Communications Essay Example | Topics and Well Written Essays - 250 words

Barriers to Business Communications - Essay Example Because the lack of feedback is exist between the call centre agents and the customers due to the cultural customs. In our society the status symbol does exist and this problem is heading upwards in the organizational structure when the manager is on the executive post and he/she cannot transform his/her policies or the programs properly to the lower management the reason behind are the status or designation that creates a hurdle in an effective communication. Moreover, individual personal behavior is essential and an effective role in communication (L. Erven, 2008). If the distortion is exist between the sender and receiver due to any reason like technical jargon, social, racial, educational background, and ethnic etc background also creates a lack of communication (L. Erven, 2008). Organizational culture and norms in which the employee is working also the prime element behind effective communication. Like ignoring the employees in a few prickly matters, completely ignoring, embarrass every time when the employee is eager to share his/her ideas, inputs or thoughts etc. The factors of reluctance, refusal etc also the lack behind effective communication (L. Erven, 2008).

The Controversy of Homosexuality Essay Example for Free

The Controversy of Homosexuality Essay I. â€Å"I now pronounce you husband and husband†, when many people hear this statement whether in real life or in movies, it brings about many different opinions and reactions. Same sex marriage is still a controversial issue, and it’s questionable in many societies, in fact it is acceptable in very few communities in the world. People who oppose gay marriage are actually opposing unethical behavior that goes against many beliefs and different religions.  Although some might think it is a person’s right to love and marry whoever he/she wants, gay marriages should be prohibited in all parts of the world for it goes against most religions, nature, ethics and humanity II. God created Adam; he created for him a wife, not a husband. God’s intentions were clear, and that meant that marriage and family would always be between man and woman. Many religious people, whether holy men or regular people who hold their beliefs close, argue that gay marriage should not be allowed to happen and that it destroys the sanctity of this bond between two people. III. Gay marriages are mostly considered to be unethical marriages that are not based on any moral grounds and therefore are frowned upon. Many believe that the idea of a gay marriage is utterly outrageous because it involves the bond between two people of the same sex which some might find disturbing or repulsive. IV. the children of gay marriages are always being denied either a father or mother. People who oppose gay marriages believe that the children of such gay couples deserve better, actually, they deserve more; all children deserve to have a mother and a father. V.  Some claim that same sex marriages should not be frowned upon and should eventually become a normal part of everyday life. They believe that homosexuality is not an abnormality; however is just another form of relationships. Just like women are attracted to men and men are attracted to women, men can be attracted to men and women can also be attracted to women. It is just as normal as any other phenomenon and might even make more sense than heterosexuality sometimes. However, how right can this point of view be? Same sex marriages are not only unethical, but also are against many eligions, defy the political and moral standards and are not beneficial for the future of our societies. In addition, homosexuality is a new phenomenon that is bringing about uprisings in many different societies. Also, marriages have always been based on the bonds of holy matrimony between a man and a woman and nothing more. VI. The world should not change its natural laws, its religions and its morality due to a group of people who claim it is only natural for them to be with the same sex. Abstract Media and celebrities has been increasing demand for gay marriage to be allowed like Angelina Julie and Brad Pitte.  Whereas gay marriage should be banned, since it is against most religions, nature, ethics, and humanity. â€Å"I now pronounce you husband and husband†, when many people hear this statement whether in real life or in movies, it brings about many different opinions and reactions. Same sex marriage is still a controversial issue, and it’s questionable in many societies, in fact it is acceptable in very few communities in the world. People who oppose gay marriage are actually opposing unethical behavior that goes against many beliefs and different religions. Although some might think it is a person’s right to love and marry whoever he/she wants, gay marriages should be prohibited in all parts of the world for it goes against religion, nature, ethics and humanity. When God created Adam, he created for him a wife, not a husband. God’s intentions were clear, and that meant that marriage and family would always be between man and woman. Many religious people, whether holy men or regular people who hold their beliefs close, argue that gay marriage should not be allowed to happen and that it destroys the sanctity of this bond between two people. Holy books have discussed this topic since the beginning of time by stating that God created man and woman to be fertile and to reproduce. Therefore, whoever believes in a God should oppose same sex relationships, as they are an offence to God. Edwards claimed â€Å"in Australia the religious right has advanced a number of arguments to isolate legally sanctioned heterosexual relationships in an inviolate conceptual and social space. † And then in the year 2004 the Australian government banned same-sex marriage. Thus, the simple act of being a homosexual and having same sex relations is considered a sin because it goes against what God intended, and therefore should be punished. Not only is homosexuality against religion, it is also unnatural. Moreover, heterosexual marriages are a natural and normal bond that agrees with nature and is considered good. However, nature depicts gay marriages as bad. Many people believe that marriage is a moral and social right that was instituted by God in nature. â€Å"Nature does not include same-sex relationships in its design and no biological imperative therefore exists for sex between women or between men. (Van Grend, 2007). In addition, marriage is not just any relationship between human beings. It is rooted in nature and therefore is governed by natural law. These natural laws are universal and immutable and generally apply to the whole human race, equally. The National Marriage Coalition in Edwards released a statement in 2007 announcing that to them marriage was the commitment between a male and a female; it is an expression of love and a beautiful sacred bond. It is not only unnatural to have homosexual relations; it also negatively affects the way children involved view the world. Furthermore, the children of gay marriages are always being denied either a father or mother. People who oppose gay marriages believe that the children of such gay couples deserve better, actually, they deserve more; all children deserve to have a mother and a father. The absence of parents with different sexes can affect a child’s view on the world, and their emotional stability. In many cases the presence of two gay dads can affect a little boy’s behavior or conduct in the world since the dads can’t provide what a mother can. This in itself removes the balance in the child’s life. Children adopted by or brought into gay families may not be aware of the life outside the family in their early years, but when they do start to understand, they may have a lot to face and a lot to adjust to. They tend to grow up with certain ideas about the world, taught by their foster parents, which may not be at all realistic or acceptable. Also, these children might eventually be bullied in school for having two dads or two moms. Being bullied is a major crisis in a child’s life and might therefore impact their ducation or social states. Moreover, children who grow up with parents of the same sex might inherit their personality traits and characteristics and might therefore think that being gay is what is meant for them to be. They might think that being gay is what is socially acceptable and therefore adopt these habits. Also, children need the compassion of a mother to be able to handle the difficulties in l ife. Yet, a father figure is also needed to make the children strong and have the right amount of security and protection in order for them to grow up properly. Thus, a marriage should provide both communal and assertive figures for the children. Heterosexual and homosexual marriages differ in gender-linked effects because of socialization pressures for women to be communal and men to be assertive. There is evidence that women are more expressive than men, develop more positive models, and are better integrated into social support systems then men are. Hence there is never a solidity and balance in a homosexual household since gay men see themselves as more communal and lesbians see themselves as more argentic and assertive. Lesbians and gays are not considered to be family members but only individuals. Such an issue as same-sex marriage isn’t only religious; it is also political. In many countries where politics and religion are tied together, a candidate can lose voters if they admit that he or she actually supports gay marriage. People with strong religious and ethical beliefs will protect themselves and their families from anyone they believe to be a bad influence, whether it’s actually someone who is gay, or just someone who supports the idea of gay marriage. These people’s beliefs are not subject to change, since normally they are active members of churches, and the community, and possibly traditionalists. In the 2012 presidential elections in the U. S, Mitt Romney announced that he was against same-sex marriage, as most Americans are. He believes that it isn’t a matter of tolerance, but about the â€Å"purpose of the institution of marriage†. And that won him many votes, mostly from the more conservative people. As many Americans believe, he also believes that marriage is between man and woman, and the sharing of domestic responsibilities falls on both sexes, which is the purpose of marriage. Gay marriages are mostly considered to be unethical marriages that are not based on any moral grounds and therefore are frowned upon. Many believe that the idea of a gay marriage is utterly outrageous because it involves the bond between two people of the same sex which some might find disturbing or repulsive. In contrast to heterosexual marriages which are considered a bedrock institution, homosexual couples in specific don’t really enjoy the support of their families and therefore may not benefit from any stabilizing influence such support gives. They are considered to be immoral and absurd for having gone out of the ordinary and irrationally choosing the same sex partner as a lawfully wedded man or wife. Families of such gay members might view the marriage as an end of the family name or a huge disgrace to the family name. A gay person’s own family might not accept the fact that he/she turned gay and might start questioning the reasons behind it bringing about many other questions. However, some might argue that every person is free to choose their own life partner because the heart wants what the heart wants. Some claim that same sex marriages should not be frowned upon and should eventually become a normal part of everyday life. They believe that homosexuality is not an abnormality, however is just another form of relationships. Just like women are attracted to men and men are attracted to women, men can be attracted to men and women can also be attracted to women. It is just as normal as any other phenomenon and might even make more sense than heterosexuality sometimes. People who support homosexuality state that lesbians and fays are more diverse, variable, resilient, and thriving than heterosexuals. Moreover, they sometimes make better fathers or mothers and better partners. In addition, supporters of gay rights believe that the children involved in same sex marriages are actually being saved from foster homes and given an education and a family rather than remaining among the millions of homeless or loveless parentless children. They believe that these children actually benefit more because they are being raised by such parenthood since the parents bring in new ideas and different views on life so that the children can learn never to be biased or restricted in thought and beliefs. However, how right can this point of view be? Same sex marriages are not only unethical, but also are against many religions, defy the political and moral standards and are not beneficial for the future of our societies. In addition, homosexuality is a new phenomenon that is bringing about uprisings in many different societies. Also, marriages have always been based on the bonds of holy matrimony between a man and a woman and nothing more. Therefore, homosexuality can’t just come and change that entity. A marriage cannot simply change its definition because of what’s happening in the world. The people should adapt to the world as it is, not the other way around. The world should not change its natural laws, its religions and its morality due to a group of people who claim it is only natural for them to be with the same sex. In conclusion, there will always be a controversy between the two different points of view about same sex marriages, but the truth is life has always been a certain set of rules and regulations and should not, could not, and will not change for the purpose of homosexuality. Same sex marriages should be prohibited because they do not belong to any religious concept, moral ground or ethical conduct. Heterosexuality has always been what’s right and should remain the same way throughout all of history.

Causes of Stillbirth

Causes of Stillbirth Abstract: Feto-infant mortality is increasing worldwide. Stillbirth is defined as uterofetal death at 20 weeks of gestation or greater. Stillbirths contribute as a primary factor to the growing magnitude of feto-infant mortality. The reasons for stillbirth are usually not reported. In many cases, the specific cause of fetal death remains unknown. The key risk factors include smoking, increased maternal age, being overweight, fetal-maternal hemorrhage. Even though there has been remarkable development in prenatal and intranatal care, stillbirths have been consistently increasing and remain an important problem in obstetrics and gynecology. Current research studies focus mainly on the epidemiology of stillbirths. I review the known and suspected causes of stillbirth. It also describes the recommended diagnostic tests to evaluate definite cause of stillbirth. In this paper, I also review analysis of stillbirths in the United States (US). The National Center of Health Statistics recorded 26,359 stillbirths in 2001. The number of stillbirths can be greatly reduced if the specific reasons for stillbirth are understood. Introduction: A pregnancy ending in stillbirth can be mentally devastating to a patient and her family. The most widely accepted definition of stillbirth is death of the fetus inside the uterus at 20 weeks of gestation or greater (Cartlidge et al., 1995). Much information is available on protocols for evaluating other types of postmortem examination but little work has been done on the evaluation of the causes of stillbirths (Mirlene et al., 2004). No universally followed protocol is available to guide the evaluation of stillbirths. In part because a wide variety of causes can be involved in stillbirths and it can be difficult to designate a specific cause of death. A stillbirth might result from various diseases, infections, trauma or genetic defects in the mother or fetus (Gardosi et al., 2005). In many cases, a specific reason is not known. Even though stillbirths are a serious problem, few resources have been focused on them and most obstetricians lack a sound method of evaluating of stillbirths (Petersson, 2002). In this document, I will review the accepted causes of still birth and the suggested diagnostic tests for evaluating the reason behind stillborn infants. In the year 2001 in the US, the National Center of Health Statistics recorded 26,359 stillbirths (Ananth et al., 2005). When compared to 27,568 infant deaths were reported in the same year. More than half of the stillbirths are before 28 weeks of gestation and almost 20% are close to the term. If a history of stillbirth exists then there is a 5-fold increase for subsequent stillbirth to occur. Prominent racial discrimination occurs in the rates of stillbirths. Stillbirths are almost three times more prevalent in African Americans when compared to whites (Puza et al., 2006). In 2001, the rate of stillbirths among white mothers was 5.5 per 1000 live births and 12.1 per 1000 among the black mothers. According to an analysis of U.S. vital statistics between 1995 and 1998, the increased risk of black, compared with white, stillbirths is greatest among singleton stillbirths (Puza et al., 2006). Reduction of proportion of fetal deaths at gestation of 20weeks or longer to 4.1 per 1000 live births and also reduction of fetal deaths for all racial and ethnic groups are the objectives of U.S. National Health for 2010. Categorization of Stillbirths: Different attempts were made in order to classify causes of stillbirth. Baird and his colleagues were among the first to classify the causes of perinatal death from the available clinical information. Depending on the British perinatal mortality survey, in 1958 Butler and Bonham designed a classification scheme that included the results of postmortem examinations. The most widely used is the 9 category classification system formulated by Wigglesworth and his coworkers (Wigglesworth, 1980). A new classification scheme which does not include neonatal deaths was proposed by Gardosi and his colleagues known as the ReCoDe Classification which focuses on the relevant conditions at the time of death in the uterus. It includes factors which affect the fetus followed by the factors which affect the mother (Gardosi et al., 2005). When compared with the Wigglesworth classification, a remarkable decrease in the number of unclassified stillbirth was achieved using this classification. One of the most vital aspects is to develop a proper definition of the factors that lead to death of the fetus. The basic definition for the â€Å"cause of death† is injury or disease responsible for a death. Froendefined cause of death in stillbirth as â€Å"an event or condition of sufficient severity, magnitude, and duration for death to be expected in a majority of such cases in a continued pregnancy in the clinical setting where it was observed† (Froen, 2002). When the definition of â€Å"cause of death† is reviewed, it is observed that only a few disorders are directly responsible for fetal death while many others are not. Causes of Stillbirth: Infection: Infections such as viral, protozoal and bacterial are linked with stillbirth. Almost 10-25% of stillbirths result from feto-maternal infections in the developed countries where as bacterial infections are common in developing countries (Goldenberg et al., 2003). Stillbirths that result from infection might be due to various factors which include direct infection, placental damage, and severe maternal illness. Usually the stillbirths in the initial weeks of gestation are linked with infection. Bacterial infections caused by Escherichia coli, group B streptococci, and Ureaplasma urealyticum are a cause of stillbirth in developed countries (Goldenberg et al., 2003). If syphilis epidemic occurs in an area then it might be the cause of a considerable proportion of stillbirths. If women come in contact with a parasite like malaria for the first time then stillbirth might be attributed to it. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, Q fever, and Lyme disease are associated with the occurrence of stillbirth (Goldenberg et al., 2003). The magnitude of stillbirths due to viral infections is not known mainly due to the absence of a well defined systematic evaluation of infections in stillborn infants. The problem lies behind the fact that these viruses are difficult to culture and moreover, a positive viral serological diagnostic test identifying the DNA or RNA of the virus in the fetal tissue or placental tissue does not definitely determine that infection was the reason behind death. In most of the cases, infection is linked with stillbirth in early gestational weeks around twenty weeks. If molecular diagnostic technology (DNA and RNA polymerase chain reaction [PCR]) is utilized, it will help in diagnosis of viral infections without any error. Parvovirus B-19 appears to have the strongest association with stillbirth. According to a Swedish survey, in 8%of stillbirths B-19 PCR positive tissues were observed (Enders et al., 2004). In the United States, less than 1% of all stillbirths are reported to be due to parvovirus infection Parvovirus B19 moves across the placenta spreading the infection to fetal erythropoetic tissue resulting in fetal anemia leading to fetal death (Wapner et al., 2002). Myocardial damage may also occur due to Parvovirus B19. Here the virus directly attacks the fetal cardiac tissue. Parvovirus infection that leads to stillbirth usually occurs before 20 weeks of gestation (Wapner et al., 2002). Enteroviruses which include Coxsackie A and B, echoviruses and other enteroviruses are associated with stillbirth. Coxsackie viruses can cross the placenta and lead to villous necrosis, inflammatory cell infiltration, calcific pancarditis, and hydrops. Echovirus infection begins with severe maternal illness and finally ends with stillbirth. Cytomegalovirus (CMV) belongs to herpesvirus family and it is a congenital viral infection. Initially, the mother is infected and then it is transmitted to the fetus. CMV causes placental damage leading to intrauterine fetal growth restriction, but an association with stillbirth remains controversial (Goldenberg et al., 2003). Viral infections in the mother like rubella, mumps and measles are linked with stillbirth. If the vaccinations are administered on time then the proportion of stillbirths occurring due to infections can be reduced greatly. Genetics: Genetic causes are responsible for a considerable magnitude of stillbirths. 6- 12% of stillbirths attributed to genetic etiologies are due to karyotyping abnormalities. Due to the fact that in some of the cases cells cannot be cultured, karyotyping is not possible. Such factors alter the exact estimate of stillbirths resulting from chromosomal abnormalities. In stillborn fetuses which show apparent structural defects the probability of chromosomal abnormality is much higher when compared to normal stillborn fetuses. The usually focused abnormalities include monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%). There are many instances where the karyotype of the stillborn is normal yet the cause of death is a genetic abnormality. Indeed, 25-35% of stillborn infants undergoing autopsy have intrinsic abnormalities (Wapner et al., 2002) .These include single malformations (40%), multiple malformations (40%), and deformations or dysplasia (20%) (Wapner et al., 2002). Almost 25% ofstillborns due to intrinsic defects show an abnormal karyotype whereas the rest of the 75% may have genetic defects which are not identifiable by the regular cytogenetic tests. This holds good for fetuses with multiple abnormalities. Single gene mutations may be responsible for death of the fetus in early weeks of development. Stillbirths in the midgestational weeks might be due to abnormal placental growth, development, or angiogenesis. Some autosomal recessive disorders including glycogen storage diseases and hemoglobinopathies have been reported as the cause of stillbirth (Wapner et al., 2002). In male fetuses, X-linked disorders may prove to be fatal. Many other genetic defects that are not recognized by the conventional cytogenetic diagnostics may lead to stillbirth. For example, conventional karyotype cannot identify chromosomal microdeletions that are linked with unexplained mental retardation. Confined placental mosaicism has also been associated with fetal growth impairment and stillbirth (Kalousek et al., 1994). Heritable Thrombophilia is another probable etiology of stillbirth.It is thought that placental infarction occurs due to thrombosis in the uteroplacental circulation leading to death. This poses concern over other thrombophilic defects and their effects on stillbirth. It is noteworthy that many heritable thrombophilias are common in normal individuals without a history of thrombosis or pregnancy loss (Rey et al., 2003). Even though many studies relate thrombophilias to fetal loss, most of the women with thrombophilias have healthy pregnancies with no lethal complications. It can be said that in the absence of any previous obstetric problems, thrombophilia will not result in stillbirth. Feto-maternal Hemorrhage: Feto-maternal hemorrhage has been linked to almost 3- 14% of all stillbirths which implies that it is responsible for a considerable number of stillbirths. Obstetric procedures such as external cephalic version and cesarean section lead to fetal maternal hemorrhage. Hemorrhage can also result due to placental abruption and/or abdominal trauma during pregnancy. Fetal maternal hemorrhage must be identified and quantitated using a proper dependable diagnostic test to attribute this reason behind the death of fetus. Hypoxia and anemia are indicators of death due to fetal hemorrhage. So, they should be confirmed by autopsy as in some normal cases too, few fetal cells can be seen in maternal blood. Maternal Features: Delayed child bearing or increased maternal age, prepregnancy obesity and stress are found to have their effects on the occurrence of stillbirth. The underlying mechanisms of action are unknown; however, with both obesity and delayed child-bearing on the rise, their importance as potential causes of stillbirth deserves greater attention (Cnattingius et al., 2002). Women whose only risk factor is being overweight have about a 2-fold increased risk of stillbirth (Nohr et al., 2005). Likewise, compared with women younger than 35 years of age, the stillbirth rate is increased 2- fold for women 35-39 years of age, and 3- to 4-fold for women aged 40 years old or olderwhereas some age-associated risk is due to higher rates of maternal complications, in uncomplicated pregnancies there may be a 50% increased risk associated only with maternal age 35 years or older (Nohr et al., 2005). Stress is a suspected cause of stillbirth which might occur as a result of a major life event (such as loss or poverty) (Huang et al., 2000) or through unexplained health changes related to adverse childhood experiences (Hillis et al., 2004). Different exposures are attributed to stillbirth. One of the most prevalent and preventable cause of stillbirth is cigarette smoking (Hillis et al., 2004). Smoking negatively affects fetal growth and oxygen supply to the tissues as it produces high levels of carboxyhemoglobin and decreases blood supply to the placenta. Smoking is also associated with increased risks of placenta previa and placental abruption and women who stop smoking in the first trimester have stillbirth rates equivalent to women who never smoked which indicates that quitting smoking in early pregnancy may significantly reduce the chances of occurrence of stillbirth (Hillis et al., 2004). A variety of complications result due to continuous exposure of different recreational drugs. Consumption of cocaine during pregnancy is also linked with stillbirth because it causes fetal growth restriction and/or abruption. The use of meth amphetamines leads to premature deliveries and stunted growth but its association with stillbirth remains unknown. In some cases, alcohol consumption during pregnancy has been associated with an increased risk of stillbirth (Mary et al., 2006). According to a study in Scandinavia, for women who consume less than 1 drink per week, the rate of stillbirth is 1.37 per 1000 births while the rate increases to 8.83 per 1000 births in women who consume 5 drinks or more per week. If smoking habits, caffeine intake, prepregnancy body mass index, marital status, occupational status, education, parity, and fetal gender are considered, the risk of stillbirth for women consuming 5 drinks or more per week was 2.96 (95% confidence interval 1.37 to 6.41) (Mary et al., 2006). Some studies show a protective effect on both stillbirth and fetal growth restriction rates if small amounts of alcohol are consumed during pregnancy (Mary et al., 2006). A link between pesticide exposure and stillbirth was observed by Pastore and his colleagues in 1997. Occupational exposures prove to be deleterious compared to residential exposure because the occupational exposures cause congenital abnormalities in addition to risk of stillbirth. A noteworthy fact is that the use of fertility drugs is also associated with stillbirths. This finding is problematic due to the fact that many women make use of fertility treatments to conceive. However, data on stillbirths due to exposures is obtained from retrospective studies which are prone to bias. The link between exposures and stillbirth should therefore be dealt with great attention and care. Maternal Diseases: Diabetes: There is always an increased danger of stillbirths in second and third trimester for mothers who are affected with type I or type II diabetes mellitus (DM) pregestationally. Even with modern obstetric care and diabetes management, stillbirth rates in women with type 2 DM have been reported to be 2.5-fold higher than nondiabetic women (Mary et al., 2006). The rate of stillbirth is the same between women with gestational diabetes (GDM) as well as normal women when the whole population is taken into account. The magnitude of danger involved with fetal death in women with type II DM is identical to women with GDM who in fact entered the pregnancy with undiagnosed type II DM. Therefore, women with GDM who have an undiagnosed type II DM are usually at a greater danger of encountering stillbirth. Examples of women with undiagnosed type II DM include history of GDM in previous pregnancies, high fasting glucose values;random glucose values greater than 200mg/dL or diagnosis of GDM early in pregnancy. The reason behind fetal death in late gestation in diabetic women is not known precisely. In addition to an increased risk of fetal death in diabetic women, there also exists a higher magnitude of danger associated with fetal abnormalities in these women compared to healthy women. Stress, hypertension and obesity complement each other in DM patients. In women with DM, there is a higher risk of stillbirth as it may lead to fetal abnormalities which may be either abnormally increased growth rate or retarded growth. To maintain the physiological range of the plasma glucose level, tremendous amounts of insulin is produced by the fetus resulting in fetal hyperglycemia. This fetal hyperglycemia is acquired from maternal hyperglycemia which finally results in fetal death due to excessive growth. The precise limit of plasma glucose level which poses a threat to the fetal life is not well defined. The most that could be done is to detect and deal with it using needed medications to lower the incidents of stillbirths.Many other maternal diseases have been linked to stillbirth, including thyroid disease, cardiovascular disease, asthma, kidney disease, and systemic lupus erythematosus (Simpson, 2002). These are subclinical diseases which in many cases has not been proven to be direct causes of stillbirth and women had normal pregnancies giving birth to healthy babies. Multiple Gestation and Stillbirth: Nearly 3% of all births and 10% of all stillbirths result from multiple pregnancies. According to national vital statistics, 1.8% of twin, 2.4% of triplet, 3.7% of quadruplet, and 5.6% of quintuplet fetuses suffered intrauterine fetal deaths (Salihu et al., 2003). The stillbirth rate among singleton pregnancies is approximately 0.5%. The reason behind fetal death in multiple pregnancies is difficult to be resolved when compared to singleton pregnancies. The broad causes of fetal death in multiple pregnancies include fetal growth retardation, preclamsia, abruption and cord accidents. It is vital to determine the chorionicity of multiple gestations as the rate of stillbirth is higher in monochorionic multiple gestations (Salihu et al., 2003) (Lynch et al., 2007). Assisted Reproductive Technology (ART) is an essential aspect in the occurrence of multiple pregnancies and stillbirth (Helmerhorst et al., 2004). Complications in Fetus: Fetal Growth Restriction: Some stillbirths result from fetuses which are smaller for a particular gestational age (SGA) compared to normal fetuses. Birth weight and risk of stillbirth are inversely proportional. If one increases, the other decreases. The main fact behind stillbirths in this condition is retardation of fetal growth and not the small size of fetus. An obstacle that occurs in determining the precise time of death of fetus due to SGA is the fact that the death might have occurred a long time before but the gestational age at the time of delivery is considered to be the time of death. This gives a false implication of the magnitude of stillbirths resulting from SGA. This problem can be solved by analysis of early and mid pregnancy placental hormones which are very specific for gestational periods (Smith et al., 2004). An evaluation of the amounts of these hormones relates directly to the time of death. Umbilical Cord Accidents: An increased number of stillbirths are due to â€Å"accidents† of umbilical cord like cord occlusion or blockage due to true knots, nuchal cords and compression of the cord. In almost 30% of normal healthy infant deliveries, nuchal cord and true knots in umbilical cords are observed. According to a study in Sweden, 9% of stillbirths were due to cord accidents (Petersson, 2002). Determination of cord accidents leading to fetal death by autopsy is smaller in proportion (up to 2.5%) (Horn et al., 2004). This difference indicates that in the absence of a proper cause, many times fetal death is attributed to cord entanglement. Due to the increased load of complications with live infants, little concern is expressed towards dead fetuses. In order to precisely relate a fetal death to cord accident, a clear indication of either hypoxic tissue injury or cord occlusion must be observed in autopsy. As nuchal cords are observed in normal deliveries also, the exact proportion of stillbirths due to cord accidents is biased. Obstetric Complications: Some of the obstetric complications are preclampsia, preterm premature rupture of membranes, preterm labor, cervical insufficiency, abruption, placenta previa, and vasa previa. These may either be direct or primary causes or may be indirect or secondary causes of stillbirth. Almost 10-19% of stillbirths occur due to abruption. Since cervical insufficiency or preterm labor lead to neonatal death, their role in causing stillbirth is not well defined. Evaluation of Stillbirth Stillbirth in itself may be emotionally devastating to many patients and their families. There the likelihood of carrying out genetic testing or autopsy on the fetus may not be readily agreeable from the family and culture. Lastly the procedures for evaluation must be cost effective and within reach. The two important facts that should be kept in mind while deciding which tests would prove as the most useful ones are primarily the consideration of cost of that test. It should not be beyond limits. Secondarily, if this test would be helpful in prevention of recurrent or sporadic stillbirths. In recurrent stillbirths, medical interference may prove helpful by preventing them in future. Analyzing the etiology of sporadic stillbirths might lead to reassurance and avoid irrelevant diagnostic tests in future pregnancies. The single most useful diagnostic test is a fetal autopsy (Peterson et al., 1999). Not only does the visible genetic and structural abnormalities but also an autopsy would be of great help in relating specific etiologies to stillbirth. The frequency of fetal autopsy is very less due to the fact that it is costly, not many trained pathologists are available and also it may be of great discomfort to the family and clinicians to deal with such a case. If autopsy is refused, partial autopsy or postmortem magnetic resonance imaging (MRI) scans may provide the necessary data. Embryonic membranes, placenta and umbilical cord must be physically and histologically examined while evaluating stillbirth etiology. This would give a precise cause of fetal death and might also provide clues for death due to secondary causes like infections, thrombophilia, and anemia. In most cases, families do not object on placental evaluation. In the cases where autopsy is not performed karyotyping the fetus would prove helpful. Cells and tissues from placenta (especially chorionic plate), fascia lata, skin from the nape of the neck, and tendons can be isolated and cultured and used for diagnostic tests like karyotyping. Comparative genomic hybridization shows tremendous promise for the identification of chromosomal abnormalities in stillbirths wherein fetal cells cannot be successfully cultured (Silver et al., 2006). An autopsy followed by a careful histological examination might help in relating stillbirths that result due to infections from the bacteria or virus. Parvovirus serology may be useful because this virus has been implicated in a meaningful proportion of cases (Erik et al., 2002). Diagnostic tests are performed for the detection of syphilis also since it contributes to the list of accepted causes of stillbirth. For various viral and protozoal agents like toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV) {TORCH}, serological screening is carried out. For bacterial and viral infections in the fetus, nucleic acid based tests are more helpful when compared to tissue cultures. Feto-maternal hemorrhage can be detected using Kleihauer – Betke test (KBT). Most laboratories use manual KBT which is prone to error. It has been found that flow cytometry is a better tool in detecting fetal erythrocytes in maternal blood. In order to eliminate red cell alloimmunization as an etiology of stillbirth, an indirect Coomb’s test is performed. Autopsy and examination of placenta are helpful in this situation. During the initial prenatal visits, if the antibody screen comes out to be negative then there is a need for recurrent testing. Diagnostic tests for conditions like diabetes and heritable thrombophilias must be carried out on a regular basis to prevent any complications which may lead to stillbirth. The treatment of such conditions at the appropriate time may prevent similar complications in subsequent pregnancies. Heritable thrombophilia might be of concern in the cases where there is recurrent fetal loss or there is a history of thrombosis or with complications involving placental insufficiency like placental infarction and intrauterine growth restriction. Administration of illicit drugs through various modes may be a cause of stillbirth in many cases. Toxicological examination may reveal the results for women who are subjected to such exposures. A simple urinary examination may prove helpful. The advanced and cost effective technology like ELISA (Enzyme Linked Immuno Sorbent Assay) can be used to detect a variety of metabolites like steroids in various tissues like blood, hair, and homogenized umbilical cord. Conclusion: Many medical and nonmedical agents govern the best approach to evaluate a stillbirth. The obstacles faced by obstetricians in solving these issues include the fact that in most of the cases the reason behind fetal death is unknown. Also the magnitude of stillbirths resulting from a single cause is not known precisely. Here there arises a need for population based studies to attribute stillbirths to their specific etiologies. There is a clear cut need of experts in the field of perinatal pathology and the required funding should be provided at the national level to promote it. Moreover, the clinician should be aware of the history of pregnant women in better evaluation. In cases where the local clinicians cannot reach a conclusion, the tissue samples must be sent to senior pathologists who have a thorough command on the subject and can help in reaching decisive conclusions. A universally accepted protocol is required for a systematic evaluation of stillbirths. Due to its absence a difference of opinion occurs among the obstetricians and gynecologists. The institutions like Stillbirth Collaborative Research Network should formulate guidelines for the proper judgement of stillbirth etiologies. The responsibility lies in the hands of the clinicians to do the best they can to reach a definite conclusion from the available data. It is noteworthy that the proportion of stillbirths that are â€Å"explained† is much higher in centers using systematic evaluations for recognized causes and potential causes of stillbirth (Petersson, 2002) (Horn et al., 2004). In conclusion, autopsy, placental evaluation, karyotype, Kleihauer-Betke, antibody screen, and serologic test for syphilis are useful in evaluating the etiologies of stillbirth. Depending on the case, other relative tests should be performed. The approach towards the testing of potential causes of stillbirth is not clear if it should be very specific and sequential or should it be comprehensive which means that it is targeted towards a broad spectrum of causes. Each of these has its own advantage. Sequential testing avoids false positive results and is directed to a specific cause and more over, it is cost effective. Comprehensive testing may prove helpful in cases where more than one factor is responsible for stillbirth. The problem with autopsy, placental evaluation, karyotype, screen for fetal-maternal hemorrhage, and toxicology screen is that they are dependant on time, that is, these tests should be performed immediately after the delivery. Autopsy cannot be delayed because death of the fetus already occurred and this would lead to physiological changes in the whole body and decay begins. The necessary evidence for stillbirth is easily available from fresh samples of placenta and also for toxicology screen. As the time since death increases, the physiology of fetus also changes leading to false positive or false negative results. If the time of fetal examination is delayed, fetal hemorrhage may be mistaken for postmortem lividity. Therefore a serious call for action is expected from institutions like Stillbirth Collaborative Research Network (SCRN) which would help in creating the most applicable diagnostic setting for evaluation of stillbirth (Silver et al., 2006). SCRN was developed by the National Institute of Child Health and Human Development to target the range of etiologies of stillbirth in the U.S. The aim of SCRN is to focus on the following objectives. The use of standardized surveillance in a geographic catchment area will show that the stillbirth rates are greater than those reported in the vital statistics catchment. The use of a prospectively implemented, standardized, postmortem, and placental examination protocols will improve diagnosis of fetal or placental conditions that cause or contribute to stillbirth. Maternal biologic and environmental risk factors in combination with genetic predisposition increase the risk for stillbirth. This is a population based study which is carried out in different counties of different states in the U.S. This study would take into account all the stillbirths and live births occurring in rural as well as urban areas in different racial groups. Even though occurrence of stillbirths cannot be stopped completely, yet attempts of such sort can be made atleast to prevent them to a maximum extent. Glossary Abruptio placenta totalis A placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before the baby is born. Achondrogenesis Dwarfism characterized by various bone aplasias and hypoplasias of the extremities and a short trunk with delayed ossification of the lower spine. Alloimmunization Development of antibodies in response to alloantigens; antigens derived from a genetically dissimilar animal of the same species. Angiogenesis The formation of new blood vessels. Anomaly abnormality Autosome a chromosome other than the X and Y sex-determining chromosomes. Camptomelia bending of the limbs that produce a permanent curving or bowing. Cholestasis a condition caused by rapidly developing or long-term interruption in the excretion of bile (a digestive fluid that helps the body process fat). Chondrodysplasia Congenital dwarfism similar to but milder than achondroplasia, not familial and not evident until mid-childhood, in which the skull and facial features remain normal. Chorioamnionitis Inflammation of the fetal membranes. Dystocia Difficult delivery or parturition. Erythema infectiosum mild infectious disease occurring mainly in early childhood, marked by a rosy-red maculopapular rash on the cheeks, often spreading to the tr Causes of Stillbirth Causes of Stillbirth Abstract: Feto-infant mortality is increasing worldwide. Stillbirth is defined as uterofetal death at 20 weeks of gestation or greater. Stillbirths contribute as a primary factor to the growing magnitude of feto-infant mortality. The reasons for stillbirth are usually not reported. In many cases, the specific cause of fetal death remains unknown. The key risk factors include smoking, increased maternal age, being overweight, fetal-maternal hemorrhage. Even though there has been remarkable development in prenatal and intranatal care, stillbirths have been consistently increasing and remain an important problem in obstetrics and gynecology. Current research studies focus mainly on the epidemiology of stillbirths. I review the known and suspected causes of stillbirth. It also describes the recommended diagnostic tests to evaluate definite cause of stillbirth. In this paper, I also review analysis of stillbirths in the United States (US). The National Center of Health Statistics recorded 26,359 stillbirths in 2001. The number of stillbirths can be greatly reduced if the specific reasons for stillbirth are understood. Introduction: A pregnancy ending in stillbirth can be mentally devastating to a patient and her family. The most widely accepted definition of stillbirth is death of the fetus inside the uterus at 20 weeks of gestation or greater (Cartlidge et al., 1995). Much information is available on protocols for evaluating other types of postmortem examination but little work has been done on the evaluation of the causes of stillbirths (Mirlene et al., 2004). No universally followed protocol is available to guide the evaluation of stillbirths. In part because a wide variety of causes can be involved in stillbirths and it can be difficult to designate a specific cause of death. A stillbirth might result from various diseases, infections, trauma or genetic defects in the mother or fetus (Gardosi et al., 2005). In many cases, a specific reason is not known. Even though stillbirths are a serious problem, few resources have been focused on them and most obstetricians lack a sound method of evaluating of stillbirths (Petersson, 2002). In this document, I will review the accepted causes of still birth and the suggested diagnostic tests for evaluating the reason behind stillborn infants. In the year 2001 in the US, the National Center of Health Statistics recorded 26,359 stillbirths (Ananth et al., 2005). When compared to 27,568 infant deaths were reported in the same year. More than half of the stillbirths are before 28 weeks of gestation and almost 20% are close to the term. If a history of stillbirth exists then there is a 5-fold increase for subsequent stillbirth to occur. Prominent racial discrimination occurs in the rates of stillbirths. Stillbirths are almost three times more prevalent in African Americans when compared to whites (Puza et al., 2006). In 2001, the rate of stillbirths among white mothers was 5.5 per 1000 live births and 12.1 per 1000 among the black mothers. According to an analysis of U.S. vital statistics between 1995 and 1998, the increased risk of black, compared with white, stillbirths is greatest among singleton stillbirths (Puza et al., 2006). Reduction of proportion of fetal deaths at gestation of 20weeks or longer to 4.1 per 1000 live births and also reduction of fetal deaths for all racial and ethnic groups are the objectives of U.S. National Health for 2010. Categorization of Stillbirths: Different attempts were made in order to classify causes of stillbirth. Baird and his colleagues were among the first to classify the causes of perinatal death from the available clinical information. Depending on the British perinatal mortality survey, in 1958 Butler and Bonham designed a classification scheme that included the results of postmortem examinations. The most widely used is the 9 category classification system formulated by Wigglesworth and his coworkers (Wigglesworth, 1980). A new classification scheme which does not include neonatal deaths was proposed by Gardosi and his colleagues known as the ReCoDe Classification which focuses on the relevant conditions at the time of death in the uterus. It includes factors which affect the fetus followed by the factors which affect the mother (Gardosi et al., 2005). When compared with the Wigglesworth classification, a remarkable decrease in the number of unclassified stillbirth was achieved using this classification. One of the most vital aspects is to develop a proper definition of the factors that lead to death of the fetus. The basic definition for the â€Å"cause of death† is injury or disease responsible for a death. Froendefined cause of death in stillbirth as â€Å"an event or condition of sufficient severity, magnitude, and duration for death to be expected in a majority of such cases in a continued pregnancy in the clinical setting where it was observed† (Froen, 2002). When the definition of â€Å"cause of death† is reviewed, it is observed that only a few disorders are directly responsible for fetal death while many others are not. Causes of Stillbirth: Infection: Infections such as viral, protozoal and bacterial are linked with stillbirth. Almost 10-25% of stillbirths result from feto-maternal infections in the developed countries where as bacterial infections are common in developing countries (Goldenberg et al., 2003). Stillbirths that result from infection might be due to various factors which include direct infection, placental damage, and severe maternal illness. Usually the stillbirths in the initial weeks of gestation are linked with infection. Bacterial infections caused by Escherichia coli, group B streptococci, and Ureaplasma urealyticum are a cause of stillbirth in developed countries (Goldenberg et al., 2003). If syphilis epidemic occurs in an area then it might be the cause of a considerable proportion of stillbirths. If women come in contact with a parasite like malaria for the first time then stillbirth might be attributed to it. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, Q fever, and Lyme disease are associated with the occurrence of stillbirth (Goldenberg et al., 2003). The magnitude of stillbirths due to viral infections is not known mainly due to the absence of a well defined systematic evaluation of infections in stillborn infants. The problem lies behind the fact that these viruses are difficult to culture and moreover, a positive viral serological diagnostic test identifying the DNA or RNA of the virus in the fetal tissue or placental tissue does not definitely determine that infection was the reason behind death. In most of the cases, infection is linked with stillbirth in early gestational weeks around twenty weeks. If molecular diagnostic technology (DNA and RNA polymerase chain reaction [PCR]) is utilized, it will help in diagnosis of viral infections without any error. Parvovirus B-19 appears to have the strongest association with stillbirth. According to a Swedish survey, in 8%of stillbirths B-19 PCR positive tissues were observed (Enders et al., 2004). In the United States, less than 1% of all stillbirths are reported to be due to parvovirus infection Parvovirus B19 moves across the placenta spreading the infection to fetal erythropoetic tissue resulting in fetal anemia leading to fetal death (Wapner et al., 2002). Myocardial damage may also occur due to Parvovirus B19. Here the virus directly attacks the fetal cardiac tissue. Parvovirus infection that leads to stillbirth usually occurs before 20 weeks of gestation (Wapner et al., 2002). Enteroviruses which include Coxsackie A and B, echoviruses and other enteroviruses are associated with stillbirth. Coxsackie viruses can cross the placenta and lead to villous necrosis, inflammatory cell infiltration, calcific pancarditis, and hydrops. Echovirus infection begins with severe maternal illness and finally ends with stillbirth. Cytomegalovirus (CMV) belongs to herpesvirus family and it is a congenital viral infection. Initially, the mother is infected and then it is transmitted to the fetus. CMV causes placental damage leading to intrauterine fetal growth restriction, but an association with stillbirth remains controversial (Goldenberg et al., 2003). Viral infections in the mother like rubella, mumps and measles are linked with stillbirth. If the vaccinations are administered on time then the proportion of stillbirths occurring due to infections can be reduced greatly. Genetics: Genetic causes are responsible for a considerable magnitude of stillbirths. 6- 12% of stillbirths attributed to genetic etiologies are due to karyotyping abnormalities. Due to the fact that in some of the cases cells cannot be cultured, karyotyping is not possible. Such factors alter the exact estimate of stillbirths resulting from chromosomal abnormalities. In stillborn fetuses which show apparent structural defects the probability of chromosomal abnormality is much higher when compared to normal stillborn fetuses. The usually focused abnormalities include monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%). There are many instances where the karyotype of the stillborn is normal yet the cause of death is a genetic abnormality. Indeed, 25-35% of stillborn infants undergoing autopsy have intrinsic abnormalities (Wapner et al., 2002) .These include single malformations (40%), multiple malformations (40%), and deformations or dysplasia (20%) (Wapner et al., 2002). Almost 25% ofstillborns due to intrinsic defects show an abnormal karyotype whereas the rest of the 75% may have genetic defects which are not identifiable by the regular cytogenetic tests. This holds good for fetuses with multiple abnormalities. Single gene mutations may be responsible for death of the fetus in early weeks of development. Stillbirths in the midgestational weeks might be due to abnormal placental growth, development, or angiogenesis. Some autosomal recessive disorders including glycogen storage diseases and hemoglobinopathies have been reported as the cause of stillbirth (Wapner et al., 2002). In male fetuses, X-linked disorders may prove to be fatal. Many other genetic defects that are not recognized by the conventional cytogenetic diagnostics may lead to stillbirth. For example, conventional karyotype cannot identify chromosomal microdeletions that are linked with unexplained mental retardation. Confined placental mosaicism has also been associated with fetal growth impairment and stillbirth (Kalousek et al., 1994). Heritable Thrombophilia is another probable etiology of stillbirth.It is thought that placental infarction occurs due to thrombosis in the uteroplacental circulation leading to death. This poses concern over other thrombophilic defects and their effects on stillbirth. It is noteworthy that many heritable thrombophilias are common in normal individuals without a history of thrombosis or pregnancy loss (Rey et al., 2003). Even though many studies relate thrombophilias to fetal loss, most of the women with thrombophilias have healthy pregnancies with no lethal complications. It can be said that in the absence of any previous obstetric problems, thrombophilia will not result in stillbirth. Feto-maternal Hemorrhage: Feto-maternal hemorrhage has been linked to almost 3- 14% of all stillbirths which implies that it is responsible for a considerable number of stillbirths. Obstetric procedures such as external cephalic version and cesarean section lead to fetal maternal hemorrhage. Hemorrhage can also result due to placental abruption and/or abdominal trauma during pregnancy. Fetal maternal hemorrhage must be identified and quantitated using a proper dependable diagnostic test to attribute this reason behind the death of fetus. Hypoxia and anemia are indicators of death due to fetal hemorrhage. So, they should be confirmed by autopsy as in some normal cases too, few fetal cells can be seen in maternal blood. Maternal Features: Delayed child bearing or increased maternal age, prepregnancy obesity and stress are found to have their effects on the occurrence of stillbirth. The underlying mechanisms of action are unknown; however, with both obesity and delayed child-bearing on the rise, their importance as potential causes of stillbirth deserves greater attention (Cnattingius et al., 2002). Women whose only risk factor is being overweight have about a 2-fold increased risk of stillbirth (Nohr et al., 2005). Likewise, compared with women younger than 35 years of age, the stillbirth rate is increased 2- fold for women 35-39 years of age, and 3- to 4-fold for women aged 40 years old or olderwhereas some age-associated risk is due to higher rates of maternal complications, in uncomplicated pregnancies there may be a 50% increased risk associated only with maternal age 35 years or older (Nohr et al., 2005). Stress is a suspected cause of stillbirth which might occur as a result of a major life event (such as loss or poverty) (Huang et al., 2000) or through unexplained health changes related to adverse childhood experiences (Hillis et al., 2004). Different exposures are attributed to stillbirth. One of the most prevalent and preventable cause of stillbirth is cigarette smoking (Hillis et al., 2004). Smoking negatively affects fetal growth and oxygen supply to the tissues as it produces high levels of carboxyhemoglobin and decreases blood supply to the placenta. Smoking is also associated with increased risks of placenta previa and placental abruption and women who stop smoking in the first trimester have stillbirth rates equivalent to women who never smoked which indicates that quitting smoking in early pregnancy may significantly reduce the chances of occurrence of stillbirth (Hillis et al., 2004). A variety of complications result due to continuous exposure of different recreational drugs. Consumption of cocaine during pregnancy is also linked with stillbirth because it causes fetal growth restriction and/or abruption. The use of meth amphetamines leads to premature deliveries and stunted growth but its association with stillbirth remains unknown. In some cases, alcohol consumption during pregnancy has been associated with an increased risk of stillbirth (Mary et al., 2006). According to a study in Scandinavia, for women who consume less than 1 drink per week, the rate of stillbirth is 1.37 per 1000 births while the rate increases to 8.83 per 1000 births in women who consume 5 drinks or more per week. If smoking habits, caffeine intake, prepregnancy body mass index, marital status, occupational status, education, parity, and fetal gender are considered, the risk of stillbirth for women consuming 5 drinks or more per week was 2.96 (95% confidence interval 1.37 to 6.41) (Mary et al., 2006). Some studies show a protective effect on both stillbirth and fetal growth restriction rates if small amounts of alcohol are consumed during pregnancy (Mary et al., 2006). A link between pesticide exposure and stillbirth was observed by Pastore and his colleagues in 1997. Occupational exposures prove to be deleterious compared to residential exposure because the occupational exposures cause congenital abnormalities in addition to risk of stillbirth. A noteworthy fact is that the use of fertility drugs is also associated with stillbirths. This finding is problematic due to the fact that many women make use of fertility treatments to conceive. However, data on stillbirths due to exposures is obtained from retrospective studies which are prone to bias. The link between exposures and stillbirth should therefore be dealt with great attention and care. Maternal Diseases: Diabetes: There is always an increased danger of stillbirths in second and third trimester for mothers who are affected with type I or type II diabetes mellitus (DM) pregestationally. Even with modern obstetric care and diabetes management, stillbirth rates in women with type 2 DM have been reported to be 2.5-fold higher than nondiabetic women (Mary et al., 2006). The rate of stillbirth is the same between women with gestational diabetes (GDM) as well as normal women when the whole population is taken into account. The magnitude of danger involved with fetal death in women with type II DM is identical to women with GDM who in fact entered the pregnancy with undiagnosed type II DM. Therefore, women with GDM who have an undiagnosed type II DM are usually at a greater danger of encountering stillbirth. Examples of women with undiagnosed type II DM include history of GDM in previous pregnancies, high fasting glucose values;random glucose values greater than 200mg/dL or diagnosis of GDM early in pregnancy. The reason behind fetal death in late gestation in diabetic women is not known precisely. In addition to an increased risk of fetal death in diabetic women, there also exists a higher magnitude of danger associated with fetal abnormalities in these women compared to healthy women. Stress, hypertension and obesity complement each other in DM patients. In women with DM, there is a higher risk of stillbirth as it may lead to fetal abnormalities which may be either abnormally increased growth rate or retarded growth. To maintain the physiological range of the plasma glucose level, tremendous amounts of insulin is produced by the fetus resulting in fetal hyperglycemia. This fetal hyperglycemia is acquired from maternal hyperglycemia which finally results in fetal death due to excessive growth. The precise limit of plasma glucose level which poses a threat to the fetal life is not well defined. The most that could be done is to detect and deal with it using needed medications to lower the incidents of stillbirths.Many other maternal diseases have been linked to stillbirth, including thyroid disease, cardiovascular disease, asthma, kidney disease, and systemic lupus erythematosus (Simpson, 2002). These are subclinical diseases which in many cases has not been proven to be direct causes of stillbirth and women had normal pregnancies giving birth to healthy babies. Multiple Gestation and Stillbirth: Nearly 3% of all births and 10% of all stillbirths result from multiple pregnancies. According to national vital statistics, 1.8% of twin, 2.4% of triplet, 3.7% of quadruplet, and 5.6% of quintuplet fetuses suffered intrauterine fetal deaths (Salihu et al., 2003). The stillbirth rate among singleton pregnancies is approximately 0.5%. The reason behind fetal death in multiple pregnancies is difficult to be resolved when compared to singleton pregnancies. The broad causes of fetal death in multiple pregnancies include fetal growth retardation, preclamsia, abruption and cord accidents. It is vital to determine the chorionicity of multiple gestations as the rate of stillbirth is higher in monochorionic multiple gestations (Salihu et al., 2003) (Lynch et al., 2007). Assisted Reproductive Technology (ART) is an essential aspect in the occurrence of multiple pregnancies and stillbirth (Helmerhorst et al., 2004). Complications in Fetus: Fetal Growth Restriction: Some stillbirths result from fetuses which are smaller for a particular gestational age (SGA) compared to normal fetuses. Birth weight and risk of stillbirth are inversely proportional. If one increases, the other decreases. The main fact behind stillbirths in this condition is retardation of fetal growth and not the small size of fetus. An obstacle that occurs in determining the precise time of death of fetus due to SGA is the fact that the death might have occurred a long time before but the gestational age at the time of delivery is considered to be the time of death. This gives a false implication of the magnitude of stillbirths resulting from SGA. This problem can be solved by analysis of early and mid pregnancy placental hormones which are very specific for gestational periods (Smith et al., 2004). An evaluation of the amounts of these hormones relates directly to the time of death. Umbilical Cord Accidents: An increased number of stillbirths are due to â€Å"accidents† of umbilical cord like cord occlusion or blockage due to true knots, nuchal cords and compression of the cord. In almost 30% of normal healthy infant deliveries, nuchal cord and true knots in umbilical cords are observed. According to a study in Sweden, 9% of stillbirths were due to cord accidents (Petersson, 2002). Determination of cord accidents leading to fetal death by autopsy is smaller in proportion (up to 2.5%) (Horn et al., 2004). This difference indicates that in the absence of a proper cause, many times fetal death is attributed to cord entanglement. Due to the increased load of complications with live infants, little concern is expressed towards dead fetuses. In order to precisely relate a fetal death to cord accident, a clear indication of either hypoxic tissue injury or cord occlusion must be observed in autopsy. As nuchal cords are observed in normal deliveries also, the exact proportion of stillbirths due to cord accidents is biased. Obstetric Complications: Some of the obstetric complications are preclampsia, preterm premature rupture of membranes, preterm labor, cervical insufficiency, abruption, placenta previa, and vasa previa. These may either be direct or primary causes or may be indirect or secondary causes of stillbirth. Almost 10-19% of stillbirths occur due to abruption. Since cervical insufficiency or preterm labor lead to neonatal death, their role in causing stillbirth is not well defined. Evaluation of Stillbirth Stillbirth in itself may be emotionally devastating to many patients and their families. There the likelihood of carrying out genetic testing or autopsy on the fetus may not be readily agreeable from the family and culture. Lastly the procedures for evaluation must be cost effective and within reach. The two important facts that should be kept in mind while deciding which tests would prove as the most useful ones are primarily the consideration of cost of that test. It should not be beyond limits. Secondarily, if this test would be helpful in prevention of recurrent or sporadic stillbirths. In recurrent stillbirths, medical interference may prove helpful by preventing them in future. Analyzing the etiology of sporadic stillbirths might lead to reassurance and avoid irrelevant diagnostic tests in future pregnancies. The single most useful diagnostic test is a fetal autopsy (Peterson et al., 1999). Not only does the visible genetic and structural abnormalities but also an autopsy would be of great help in relating specific etiologies to stillbirth. The frequency of fetal autopsy is very less due to the fact that it is costly, not many trained pathologists are available and also it may be of great discomfort to the family and clinicians to deal with such a case. If autopsy is refused, partial autopsy or postmortem magnetic resonance imaging (MRI) scans may provide the necessary data. Embryonic membranes, placenta and umbilical cord must be physically and histologically examined while evaluating stillbirth etiology. This would give a precise cause of fetal death and might also provide clues for death due to secondary causes like infections, thrombophilia, and anemia. In most cases, families do not object on placental evaluation. In the cases where autopsy is not performed karyotyping the fetus would prove helpful. Cells and tissues from placenta (especially chorionic plate), fascia lata, skin from the nape of the neck, and tendons can be isolated and cultured and used for diagnostic tests like karyotyping. Comparative genomic hybridization shows tremendous promise for the identification of chromosomal abnormalities in stillbirths wherein fetal cells cannot be successfully cultured (Silver et al., 2006). An autopsy followed by a careful histological examination might help in relating stillbirths that result due to infections from the bacteria or virus. Parvovirus serology may be useful because this virus has been implicated in a meaningful proportion of cases (Erik et al., 2002). Diagnostic tests are performed for the detection of syphilis also since it contributes to the list of accepted causes of stillbirth. For various viral and protozoal agents like toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV) {TORCH}, serological screening is carried out. For bacterial and viral infections in the fetus, nucleic acid based tests are more helpful when compared to tissue cultures. Feto-maternal hemorrhage can be detected using Kleihauer – Betke test (KBT). Most laboratories use manual KBT which is prone to error. It has been found that flow cytometry is a better tool in detecting fetal erythrocytes in maternal blood. In order to eliminate red cell alloimmunization as an etiology of stillbirth, an indirect Coomb’s test is performed. Autopsy and examination of placenta are helpful in this situation. During the initial prenatal visits, if the antibody screen comes out to be negative then there is a need for recurrent testing. Diagnostic tests for conditions like diabetes and heritable thrombophilias must be carried out on a regular basis to prevent any complications which may lead to stillbirth. The treatment of such conditions at the appropriate time may prevent similar complications in subsequent pregnancies. Heritable thrombophilia might be of concern in the cases where there is recurrent fetal loss or there is a history of thrombosis or with complications involving placental insufficiency like placental infarction and intrauterine growth restriction. Administration of illicit drugs through various modes may be a cause of stillbirth in many cases. Toxicological examination may reveal the results for women who are subjected to such exposures. A simple urinary examination may prove helpful. The advanced and cost effective technology like ELISA (Enzyme Linked Immuno Sorbent Assay) can be used to detect a variety of metabolites like steroids in various tissues like blood, hair, and homogenized umbilical cord. Conclusion: Many medical and nonmedical agents govern the best approach to evaluate a stillbirth. The obstacles faced by obstetricians in solving these issues include the fact that in most of the cases the reason behind fetal death is unknown. Also the magnitude of stillbirths resulting from a single cause is not known precisely. Here there arises a need for population based studies to attribute stillbirths to their specific etiologies. There is a clear cut need of experts in the field of perinatal pathology and the required funding should be provided at the national level to promote it. Moreover, the clinician should be aware of the history of pregnant women in better evaluation. In cases where the local clinicians cannot reach a conclusion, the tissue samples must be sent to senior pathologists who have a thorough command on the subject and can help in reaching decisive conclusions. A universally accepted protocol is required for a systematic evaluation of stillbirths. Due to its absence a difference of opinion occurs among the obstetricians and gynecologists. The institutions like Stillbirth Collaborative Research Network should formulate guidelines for the proper judgement of stillbirth etiologies. The responsibility lies in the hands of the clinicians to do the best they can to reach a definite conclusion from the available data. It is noteworthy that the proportion of stillbirths that are â€Å"explained† is much higher in centers using systematic evaluations for recognized causes and potential causes of stillbirth (Petersson, 2002) (Horn et al., 2004). In conclusion, autopsy, placental evaluation, karyotype, Kleihauer-Betke, antibody screen, and serologic test for syphilis are useful in evaluating the etiologies of stillbirth. Depending on the case, other relative tests should be performed. The approach towards the testing of potential causes of stillbirth is not clear if it should be very specific and sequential or should it be comprehensive which means that it is targeted towards a broad spectrum of causes. Each of these has its own advantage. Sequential testing avoids false positive results and is directed to a specific cause and more over, it is cost effective. Comprehensive testing may prove helpful in cases where more than one factor is responsible for stillbirth. The problem with autopsy, placental evaluation, karyotype, screen for fetal-maternal hemorrhage, and toxicology screen is that they are dependant on time, that is, these tests should be performed immediately after the delivery. Autopsy cannot be delayed because death of the fetus already occurred and this would lead to physiological changes in the whole body and decay begins. The necessary evidence for stillbirth is easily available from fresh samples of placenta and also for toxicology screen. As the time since death increases, the physiology of fetus also changes leading to false positive or false negative results. If the time of fetal examination is delayed, fetal hemorrhage may be mistaken for postmortem lividity. Therefore a serious call for action is expected from institutions like Stillbirth Collaborative Research Network (SCRN) which would help in creating the most applicable diagnostic setting for evaluation of stillbirth (Silver et al., 2006). SCRN was developed by the National Institute of Child Health and Human Development to target the range of etiologies of stillbirth in the U.S. The aim of SCRN is to focus on the following objectives. The use of standardized surveillance in a geographic catchment area will show that the stillbirth rates are greater than those reported in the vital statistics catchment. The use of a prospectively implemented, standardized, postmortem, and placental examination protocols will improve diagnosis of fetal or placental conditions that cause or contribute to stillbirth. Maternal biologic and environmental risk factors in combination with genetic predisposition increase the risk for stillbirth. This is a population based study which is carried out in different counties of different states in the U.S. This study would take into account all the stillbirths and live births occurring in rural as well as urban areas in different racial groups. Even though occurrence of stillbirths cannot be stopped completely, yet attempts of such sort can be made atleast to prevent them to a maximum extent. Glossary Abruptio placenta totalis A placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before the baby is born. Achondrogenesis Dwarfism characterized by various bone aplasias and hypoplasias of the extremities and a short trunk with delayed ossification of the lower spine. Alloimmunization Development of antibodies in response to alloantigens; antigens derived from a genetically dissimilar animal of the same species. Angiogenesis The formation of new blood vessels. Anomaly abnormality Autosome a chromosome other than the X and Y sex-determining chromosomes. Camptomelia bending of the limbs that produce a permanent curving or bowing. Cholestasis a condition caused by rapidly developing or long-term interruption in the excretion of bile (a digestive fluid that helps the body process fat). Chondrodysplasia Congenital dwarfism similar to but milder than achondroplasia, not familial and not evident until mid-childhood, in which the skull and facial features remain normal. Chorioamnionitis Inflammation of the fetal membranes. Dystocia Difficult delivery or parturition. Erythema infectiosum mild infectious disease occurring mainly in early childhood, marked by a rosy-red maculopapular rash on the cheeks, often spreading to the tr

A Personal Integrated Theory of Counseling Essay

Abstract This personal model of counseling addresses the importance of developing a biblical theory of Christian Counseling, which also integrates psychology, theology and spirituality, without diminishing the relevance of each. The working model for counselors should provide practical techniques for the inclusion of believers and non-Christians, as they work towards a personal relationship with God. This paper will discuss the personality traits, external influences that build a personal integrative theory of scientific disciplines and theological truths. The works of relevant theorists and authors will be reviewed as comparable viewpoints on Christian Counseling and how integration can benefit individuals, couples and families. The paper will begin to create a personal guideline for the author’s counseling practices with clients from all backgrounds. It will conclude with personal thoughts to identify areas for growth and improvement. A Personal Integrated Approach to Counseling Introduction A comprehensive personal theory of counseling should integrate Psychology, Theology and Spirituality. One of the most important goals of counseling is develop a theoretic approach through the integration of Psychology, Theology and Spirituality. Individually, each discipline offer concepts that are unique and relevant, yet separately they lack the inferences of other viewpoints that may be overlooked. There is a basic understanding for counselors to focus the treatment on the client, as well as temporal systems that exist which have influence on the client. Therefore, the intent of integrating these theories will provide the counselor with a more comprehensive wisdom and faith to combine the key elements of each to implement into their counseling practices. A concern for counselors is the prioritization of theology over psychology. This can be difficult as well as thought provoking for and individual to undertake because of the historical debate between faith and science. An individual deeply rooted in their biblical worldview will argue that with faith, they require no further belief, while others with a secular based worldview requires the proof of statistics and data for their belief. (Entwistle, 2010, p. 9) Secular viewpoints are bound by the limitations of earthly living and its standards. The Christian viewpoint is directly related to the fact that their eternal destiny is ordained because they are a child of God. The counselor who will be successful at integration will find it necessary to increase their competence in all areas. (McMinn, 2011) states that the best at interdisciplinary integration are those that have an informal and formal preparation of both psychology and theology. While there can be preference in either theory, counselors are cautioned not to minimize the doctrines of Theology or misrepresent the clinical applications of Psychology. Personality Development of Personality Human personality is a set of characteristics and traits, as well as emotions and behaviors that make each person unique. An individual’s personality usually remains consistent throughout life. However, personality can be altered by an individual’s environment, temporal systems as well as traumatic events. For counselors it can be challenging when attempting to understand Human Personality without exploring the clients past. This can uncover many of the misbeliefs, hurt feelings originating in childhood that manifest into maladaptive behaviors in adulthood. (Backus & Chapian, 2000) The Christian worldview allows the understanding of all human functioning parts: The physical and the personal. The physical represents the body and the personal acknowledges the spirit or soul. A counselor’s focus is centered with both the conscious and unconscious parts of the mind where misbeliefs and attitudes are held. They must first look at the totality of a client through the u se of concentric circles. This theory allows the counselor the viewpoint of the various circles that create human personality. The innermost circle represents the self. It represents the core where the image of God, the Holy Spirit, and issues of sin reside. Also within the core is the heart where scripture shows the heart as vital function of providing life giving blood. The heart is that part of a human that chooses the basic direction they will follow in life. (Crabb, 1977) The outer layers consist of the soul of a human infused with the Holy Spirit. When we are born, we inhabit a soul that allows us to think, feel and choose. Your spirit is in union with God if he is the choice for the center of your life. Scripture notes that those who alternatively do not accept God into their life will become vulnerable to the influence of Sin and Satanic forces. Consequently, it is the choices that guide the soul and the resulting emotions, thoughts and behaviors that impact human interactions and relationships. As you move to the outer circles there is theory that is presented that exhibits the correlation of the body and the effects on human personality. The physical circle illustrates the connection with the body and physical health as humans relate to life challenges. Our bodies alert us to potential dangers in the form of pain and discomfort. When the body is in distress, messages sent to the brain are distorted. The outcomes of physical pain, will affect a person’s mood, energy and cognitive abilities. The physical circle illustrates the connection with the body and physical health as humans relate to life challenges. (Hart, 1999) Finally, there are two components of circles in this theory. The first is the temporal system. These are the external forces or the earth systems such as family, friends, religious affiliations, economic conditions and society that create positive and negative personality traits in humans. The author Crabb suggests that humans have two basic needs; sig nificance and security in order to function effectively. (Crabb, 1977) When we feel secure and significant we are then deemed to be worthwhile. However, the interactions of Hawkins temporal systems will jeopardize these assurance and the results are maladaptive behaviors that lead clients to therapy. The final outer circle is supernatural systems. (Hawkins, 2009) In this system, God, Angel, Satan and Demonic forces are introduced. Spiritual forces inhabit all humans, yet there is a battle between the dark forces of Satan, and the truth in God’s word. . Author Neil Anderson describes the forces at work on the formation of human personality. (Anderson, 2000) These evil forces disguise themselves and aggressively seek to intervene with deception of the Holy Spirit. Without a personal relationship with God, Satan has opportunity to manipulate thoughts and create misbeliefs which are the direct cause of emotional turmoil, and maladaptive behaviors. (Backus & Chapian, 2000) The supernatural outer circle aids in the quest for a realization that spiritua l disciplines can help begin the process for an internal change. Motivation One of the major premises of counseling is to develop an understanding why people do what they do. An individual’s actions are directly connected to their personality profile. Behind every action there is energy or a force that results in a specific behavior. Every human has motivations that are based often on self-centered needs. The basic needs are physical which encompasses the elements critical to life, the need for emotional relationships as well as the need for significance and security. Counselors are aware that Human Need will continue and this need moves people into false outside systems in order to reach the type of gratification they desire, rather than seek a relationship with God. That relationship indicates the temperament of the unbeliever as opposed to a believer. The unbeliever thinks of himself first, and evaluates life in terms of the world system and the behavior is motivated and designed to meet his or her own needs. While the believer will still experience misbeliefs in his conscious mind, however this individual makes a deliberate choice to evaluate his or her world based on a biblical framework. The biggest difference is the believer’s purpose is to live for Christ and exhibit behaviors that are Christ like and subsequently will receive them in return. (Crabb, 1977, p. 107) Human Development All Humans have a desire for autonomy in the world from a very early age. This search for self-governing freedom to establish their place in the world but is conflicted by the distortion of good and evil. The boundaries or acceptable behaviors guide the decision making process. These boundaries are for self-preservation. (Cloud & Townsend, 1999) Positive choices, allow the capacity to be loving and kind to others, use physical energy creatively, and live a purpose driven life. The alternative choice directs individuals on a path of sin and brokenness that prevents both growth and maturity. (McMinn, 2011) Without self-control individuals a counselor has the ability to guide this development process by helping them realize their position in the kingdom of God. Scripture emphasizes the purpose for an intimate relationship with God in that acknowledges a rebirth as a child of God, and confirms that life is no longer in the flesh but now life is in Christ. The intent of a counselor is to progress the client toward the development of an optimal balance of mental and spiritual health. Individual Differences Every human has a viewpoint of the world that is used as base of understanding of the world and their place in it. It is model of assumptions and evaluations that impacts personality traits and behaviors and forms a standard of living. (Clinton & Ohlschlager, 2002, p. 59) Most people’s worldview are inherited rather than chosen and are shaped by cultural, religious and social influences. The presumptions can transcend into discriminatory beliefs to those who have opposing viewpoints. Counselors who are willing to address cultural difference in their client are mostly those that do not see them as impediments, but as an opportunity for growth. Individuals with an understanding & acceptance of themselves will achieve a greater sense of emotional and spiritual health. Health and Illness Health is more than a state of physical, mental, and social well-being. There are other components such psychological, and spiritual. The goal is achieve perfect health on all levels, however this can be challenging for clients to achieve and difficult for counselors to measure. A lifestyle that consists of a balanced diet, physical activities should result in good health; however, these alone are not sufficient. (McMinn, 2011) offers a triad approach that includes an accurate sense of self, healing relationships and an accurate sense of need. Those that are committed toward moving toward total health learn self-love and worth, to recognize needs as well as the importance of therapeutic relationships. There are biological, physical and social systems that all contribute to the symptoms of an illness. The pain and discomfort are presented in the physical body, while anxiety, sinful behavior and other temporal systems affect health. Conflicting messages delivered to the brain trigger and imbalance of worry and stress that are manifested in personality disorders. When people try to function in areas that affect untended and unhealed hurts, they will hurt others. (Wilson, 2001) Psychological and Spiritual Illness Sin is a pervasive element of human condition. In biblical terms, it dates back to Adam and Eve as committing the â€Å"original† sin. It is often misused by those who commit that they are ill; therefore they engage in sinful behavior. Through the use of attributional style, decipher if mental illness or the absence of spirituality are the sources of maladaptive behaviors. (McMinn, 2011) Consequently there must be a conscious choice to identify what sin represents in preventing an intimate relationship with God. Spiritual illness is living outside the will of God who desires peace and tranquility for those who accept him in their life. James 4:17 (King James) Integration and Multitasking McMinn (1996) stresses the need for counselors to evaluate a client’s problems from several viewpoints simultaneously. Through a multidimensional lens, there is the ability to explore theological, psychological perspectives. Developing the ability to multi-task, integrates the science of psychology, the truth in Theology and Spirituality, with the focus on theological truth as a foundation, without diminishing the significance of other perspectives. Effective multitasking acknowledges the forces that influence personality. Nine elements including the body, the human spirit, volition, sin and temporal systems illustrate how humans can obtain a healthy balance when there is a spiritual foundation. Interdisciplinary Integration requires competence that goes beyond the understanding of theology and psychology. Spirituality is not viewed as a study of credentials. It is the personal relationship with God that confronts weaknesses and dependence on God. The author also expresses tha t counselors must engage in the practice of personal devotion and exploring their own spiritual beliefs, through additional training and study Elements of Theory This theory of counseling incorporates integrative applications of disciplines and concepts with emphasis on the core of the human as the source where the spirit resides, cognitive behaviors are developed, and personality structures emerge. As a counselor develops a plan of treatment for a client, attention must be given to both parts of a human. The material or physical self and the immaterial or spirit self. Each part of the self represents areas for the counselor to learn and explore influences on the client’s emotions and dysfunctional behavior. My theory mirrors (Crabb, 1977) presents a unique theory of counseling which he refers to the concepts of Tossed Salad and Nothing Buttery approach to counseling. There is a balanced integration however the focus is on teaching the truth in God’s word from biblical perspective as the most important. I believe effective counseling combines the strengths of various disciplines, without diminishing or promoting one over the other. A comprehensive theory removing deeply rooted misbeliefs and replace with biblical truths. My theory leads clients into an intimate relationship with God and provides a guide to initiate the process of change. (Hawkins, 2009) Process and Techniques Four elements are introduced in the counseling relationships that work together in a successful counseling experience: the spirit, the counselor, the counselee and the bible. The counselor establishes trust, engages the client by attentive listening as they explore the client’s problems, and create a working process that toward goals for both counselor and client. The counselor teaches principles of integration identify patterns of healing, guides the client toward change. The client acknowledges their spiritual relationship with God, takes ownership for emotions and behaviors, and commits to change from within. True transformation begins with a renewal of the mind. (Adams, 1986) Expectations and Effectiveness of Theory The effectiveness of the theory is evaluated through the client progression towards a balanced h awareness of self, God, healthy relationships. (Crabb, 1977) theory suggests that success is measured in Spiritual and Psychological Maturity. The presentation of symptom relief, decreased maladaptive behaviors promote well-being. As counselors enter into experiences with our clients, we trust that God will bless their honesty and courage, as they display progression toward overall improvements in life functioning (Petrocelli, 2002) Worldview and Influence on Theory The basis for my theory is based on a worldview of personal experiences and reflection. It demonstrates a biblical foundation that incorporates the integration of psychology, spirituality and theology. The emphasis of theory reviews the systems surrounding the core self that affect personality, including temporal and supernatural systems. This theory allows a better understanding of the motivation behind a client’s choices. Approach to Integration My approach dispels the myth that Christianity is just a religious belief and psychology is just science of profession, it illustrates that combined integration counselor can understand that you can be a religious person, and still find solutions and order in the science of psychology that examines human behavior. Christianity does not inhibit scientific progress; in fact it is viewed as a major force to the further the exploration of the science. The Spoiled Egyptian Approach has a secular approach to psychology, the weeds out elements that oppose the truth in the scripture. (Crabb, 1977) Conclusion This theory is grounded in a well-balanced foundation. It addresses the theories of integration, Multitasking and Worldviews. The goal of a counselor is summarized into two parts; to lead my clients into an intimate relationship with God and guide the process of change. I believe the strong desire to help my clients begins within the heart of a counselor whose life inhabits the truth in the word of God, as a foundation for their personal theory of counseling. References Adams, J. E. (1986). How to Help People Change. Grand Rapids, Michigan: Zondervan. Anderson, N. T. (2000). The Bondage Breaker; Overcoming Negative Thoughts, Irrational Feelings, and Habitual Sins. Eugene, Oregon: Harvest House Publishers. Backus, Dr., W., & Chapian, M. (2000). Telling Yourself the Truth. Bloomington, Minnesota: Bethany House Publishers. Clinton, T., & Ohlschlager, G. (2002). Competent Christian Counseling: Foundations and practices of compassionate soul care. Colorado Springs, Colorado: Waterbrook Press. Cloud, Dr., H., & Townsend, Dr., J. (1999). Boundaries in Marriage. Grand Rapids, Michigan: Zondervan. Crabb, Dr., L. (1977). Effective Biblical Counseling; A Model for Helping Caring Christians Become Capable Counselors. Grand Rapids, Michigan: Zondervan. Entwistle, D. N. (2010). Integrative Approaches to Psychology and Christianity (2nd ed.). Eugene, Oregon: Cascade Books. Hart, Dr., A. D. (1999). The Anxiety Cure. Nashville, Tennessee: Thomas Nelson, Inc. Hawkins, R. (2009). Constructing a Theory of Counseling. McMinn, M. R. (2011). Psychology, Theology, and Spirituality in Christian Counseling. Carol Stream, Illinois: Tyndale House Publishing. Petrocelli, J. V. (2002). Processes & Stages of Change: Counseling with the Trans theoretical model of change [journal]. Journal of Counseling & Development, 23(4). Social, cognitive processes in behavioral health; Implications for Counseling. (1995). Counseling Psychologist, 2(4). Retrieved from http://search.proquest.com.ezproxy.liberty.edu Wilson, S. D. (2001). Hurt People, Hurt People; Hope and Healing for Yourself and Your Relationships. Grand Rapids, Michigan: Discovery House Publishers.