Ultrasound

What is Ultrasound?

Ultrasound is like ordinary sound except it has a frequency (or pitch) higher than humans can hear. When sent into your body from a transducer (probe) resting on your skin, the sound is reflected off internal structures. The returning echoes are received by the transducer and converted by an electronic instrument into an image on a monitor, similar to a television screen. These continually changing images can be recorded on videotape or film. Diagnostic ultrasound imaging is commonly called sonography or ultrasonography.

Who Will Perform the Examination?

The examination is usually performed by a specially trained health care professional called a sonographer. A series of images will be recorded by the sonographer. These images will then be interpreted by a doctor. In some cases, you may be examined by a doctor to confirm or resolve uncertain findings.

Will the Ultrasound Exam Hurt?

There is no pain involved in an ultrasound examination, although you may experience some pressure or discomfort when having a sonogram of certain parts of your body. During the scanning procedure, a gel is applied over the area to be examined and a transducer is placed on your skin or, for certain examinations, inserted into your vagina. The gel may feel cool. It is water soluble and usually wipes off easily, but it is a good idea to wear clothing that is easily washable.

When and How Is Ultrasound Used in Pregnancy?

Common uses for ultrasound in most medical practices would be:

• Confirming the pregnancy
• Dating the pregnancy
• Genetic screening (1st trimester)
• Targeted screening- looking for physical anomalies and gender (2nd trimester)
• Locating the placenta-especially relevant for women considering VBAC
• Bio Physical Profile (BPP)-evaluates the well being of the baby (post-dates or by clinical indication)
• Hand held or bed side fetal monitoring in labor

Is Ultrasound Safe?

Ultrasound safety is still being studied. There are known effects associated with the medical use of sonography such as temperature and cellular changes, but they are not considered “harmful”. Widespread clinical use of diagnostic ultrasound for many years has not revealed any conclusive harmful effects and studies in humans have revealed no direct link between the use of diagnostic ultrasound and any adverse outcome.

Ultrasound use in pregnancy is considered safe in the medical model and is controversial in the midwifery community. There is research to support strong caution against routine ultrasound use, especially in the first trimester of pregnancy. A well researched article on the concerns surrounding ultrasound use in pregnancy appears in Mothering Magazine

What the FDA has to say:

A United States Food and Drug Administration (FDA) report1 states that ultrasound has been used for many years with no obvious detrimental effects. Nevertheless, current evidence is considered insufficient to justify an unqualified acceptance of ultrasound safety. The FDA report recommends that ultrasound be used only when a diagnostic benefit is likely, and that exposure should be limited to that required to produce the needed information.

The World Health Organization (WHO) of the United Nations, in its report on ultrasound,2 recommends prudence in ultrasound exposure to human subjects but agrees that benefits outweigh any presumed risks. The WHO report states that patients should be examined with ultrasound only for valid clinical reasons.

With regard to ultrasound scanning during pregnancy, the FDA states that "ultrasonic fetal scanning is generally considered safe and is properly used when medical information on a pregnancy is needed. But ultrasound energy delivered to the fetus cannot be regarded as completely innocuous. Laboratory studies have shown that diagnostic levels of ultrasound can produce physical effects in tissue, such as mechanical vibrations and rise in temperature. Although there is no evidence that these physical effects can harm the fetus, public health experts, clinicians, and industry agree that casual exposure to ultrasound, especially during pregnancy, should be avoided. Viewed in this light, exposing the fetus to ultrasound with no anticipation of medical benefit is not justified."3

In conclusion, based on experimental and epidemiological data, there is presently no identified risk associated with diagnostic ultrasound. However, a prudent and conservative approach is recommended in which diagnostic ultrasound should be used only for medical benefit and with minimal exposure.

Where can I get an ultrasound during my pregnancy?

Motherland Midwifery clients can obtain ultrasounds at the Philadelphia Pregnancy Center where we can send a referral on your behalf at your request. You may also pursue this testing through a hospital-based OB practice.

1 US Department of Health and Human Services, Public Health Service, Food and Drug Administration: An Overview of Ultrasound: Theory, Measurement, Medical Applications, and Biological Effects. Publication # FDA 82-8190. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1995002

2 Environmental Health Criteria 22: Ultrasound. World Health Organization: Geneva, 1982, p 19.

3 US Food and Drug Administration, Center for Devices and Radiological Health, Diagnostic Devices Branch. Fetal Keepsake Videos. Available at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PatientAlerts/ucm064756.htm

Genetic Screening

Genetic testing, screening and counseling is the process of providing individuals and families with information on the nature, inheritance and implications of genetic disorders to help them make informed medical and personal decisions. Ultimately, the decision to undergo prenatal genetic testing and screening is something each woman decides for herself based on individual indications and personal philosophy. Some prenatal tests are screening tests and only reveal the possibility of a problem or give a risk ratio for the baby having a problem/condition. Other tests are diagnostic, which means they can determine — with a fair degree of certainty — whether a fetus has a specific problem. In the interest of making the more specific determination, the screening test may be followed by a diagnostic test.

Prenatal genetic testing is further complicated by the fact that more abnormalities can be diagnosed in a fetus than can be treated or cured.  In addition, some tests carry inherent risks as the procedure is both physically and emotionally invasive [see our information on ultrasound].

Tests and screens are performed through a variety of methods.  Most common tests utilize maternal blood analysis, analysis of fetal DNA (through amniotic fluid or placental tissue or now via cell free DNA testing), or ultrasound. A decision-making tool with an overview of and timeline for the specific tests and screens can be found here.

Comprehensive genetic screening is offered by the Philadelphia Pregnancy Center where we can send a referral on your behalf at your request. You may also pursue this screening through a hospital-based OB or Nurse-Midwifery practice.

Initial Prenatal Lab Work

The Prenatal Profile is a Maternal Blood Screen that typically includes:

Blood type, Rh factor, and antibody screening

It is important to know your blood type in pregnancy. Blood type is based on particular molecules that sit on the surface of red blood cells. People either have A antigens (type A blood), B antigens (type B), both (type AB) or neither (type O) on their red blood cells. When it comes to Rh factor, some people have the antigen (Rh-positive) and some people don't (Rh-negative.) In other words, your blood type identifies which antigens you have from each group. If you are Rh negative, we will also order an antibody screen and discuss options for prevention of Rh sensitization. [More information on Rh factor and issues for Rh negative mothers.]

Complete Blood Count

A complete blood count (CBC) gives important information about the kinds and numbers of cells in the blood, especially red blood cells, white blood cells, and platelets. A CBC test usually includes:

• White blood cell (WBC, leukocyte) count. White blood cells protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or other organism causing it. White blood cells are bigger than red blood cells but fewer in number. When a person has a bacterial infection, the number of white cells rises very quickly.
• Red blood cell (RBC) count. Red blood cells carry oxygen from the lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count is low (anemia), the body may not be getting the oxygen it needs. If the count is too high (a condition called polycythemia), there is a chance that the red blood cells will clump together and block tiny blood vessels (capillaries). This also makes it hard for your red blood cells to carry oxygen.
• Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space (volume) red blood cells take up in the blood. The value is given as a percentage of red blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's volume is made of red blood cells. Hematocrit and hemoglobin values are the two major tests that show if anemia or polycythemia is present.
• Hemoglobin (Hgb). The hemoglobin molecule fills up the red blood cells. It carries oxygen and gives the blood cell its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good measure of the blood's ability to carry oxygen throughout the body.
• Platelet (thrombocyte) count. Platelets (thrombocytes) are the smallest type of blood cell. They are important in blood clotting

Rubella (German measles) immunity

This test, called a rubella titer, checks the level of antibodies to the rubella virus in your blood to see whether you're immune. Most women are immune to rubella, either because they've been vaccinated or had the disease as a child.

Hepatitis B testing

Some women with this liver disease have no symptoms and can unknowingly pass it to their baby during labor or after birth. This test will reveal whether you're a hepatitis B carrier.

Syphilis screening

This sexually transmitted infection (STI) is relatively rare today, but all women should be tested because if you have syphilis and don't treat it, both you and your baby could develop serious problems. In the unlikely event that you test positive, you'll be given antibiotics to treat the infection.

HIV testing

The Centers for Disease Control and Prevention and the Pennsylvania and New Jersey Departments of Health recommend that all pregnant women be tested for the human immunodeficiency virus (HIV), the virus that causes AIDS.

OTHER BLOOD TESTS

There are other blood tests that are offered in addition to the prenatal profile. There are some tests related to genetic screening and others that might be specific to certain conditions or situations.

Genetic Blood Tests

Gestational Diabetes

Toxoplasmosis- Toxoplasmosis is an infection that has few symptoms for an adult, but can cause serious illness for a fetus. Many adults have been exposed to the parasite that causes the disease, and have developed immunity to it. But if you are not immune, and get your first bout of toxoplasmosis while pregnant, your child could be affected. "Toxo" can be gotten from raw meat, and from cat and kitten feces. So, if you have cats and handle their litter box, you might want to consider this blood test to make sure you are immune to toxo.

ADDITONAL TESTS/CULTURES:

Urinalysis and Urine Culture A urine screen is used to assess bladder or kidney infections, diabetes, dehydration and preeclampsia by screening for high levels of sugars, proteins, ketones and bacteria. Repeated findings of sugar in the urine my necessitate dietary changes to help maintain normal blood sugar levels throughout the day. Higher levels of protein may suggest a possible urinary tract infection, or kidney disease. Preeclampsia may be a concern if higher levels of protein are found later in pregnancy, combined with high blood pressure. This screen is normally performed in our office at each prenatal visit. We will do a Urine Culture with your initial bloodwork to make sure you do not have an asymptomatic urinary tract infection (more common in pregnancy) nor Group B Strep bacteria in your urine.

STI cultures The Pennsylvania and New Jersey Departments of Health also recommends screening for Gonorrhea and Chlamydia, sexually transmitted bacterial infections (STIs). Screening requires a speculum exam in order to swab the cervix.

Newborn Critical Congenital Heart Screening (CCHD)

The latest screening being done for newborns born in the US is a pulse oximetry test to screen for Critical Congenital Heart Defects (CCHD). This screening is done between 24-48 hours postpartum as the baby's circulation makes the transition to life outside the womb. Motherland Midwifery offers this screening at our first postpartum visit. Depending on the nature of any abnormal results and the over assessment of your baby, we can consult with a pediatric cardiologist, or may refer your baby to your pediatrician or to the nearest pediatric hospital.

This blog post  from Science & Sensibility  provides a good overview of the process.

"Critical congenital heart defects refer to heart defects that babies are born with and that require surgical intervention within the first month (or year, depending on the defining organization). About 1 in 100 babies have heart defects (1%), and about 1 in 4 of those with a heart defect have a defect so severe that it needs to be corrected immediately (0.25% of all babies) Only some of these defects will be picked up by prenatal ultrasound, and they may not show up on exam before the baby goes home (or the midwife leaves in the case of a home birth). Depending on the defect, some babies may be able to compensate with structures that were in place during the fetal period but begin to go away after the baby is born."

This resource from March of Dimes is directed towards parents and has thorough and accurate information.

Newborn Vitamin K & Eye Prophylaxis

There are two medications routinely given to newborns born in U.S. hospitals in the immediate postpartum period (i.e. first 6 hours after birth). With Motherland Midwifery you will need to make an informed choice about if you want these medications administered to your newborn. This information, along with our discussions during your visits, will help you make your informed choice about if you would like these medications given to your baby. Vitamin K (section coming soon!)

Newborn eye prophylaxis

Newborn eye prophylaxis refers to the practice of eye drops or ointment containing an antibiotic medication being placed in a newborn's eyes after birth. This is required by law to protect the baby from an unknown Gonorrhea or Chlamydia infection in the mother's body. The primary signs of an eye infection (conjunctivitis) in a newborn are redness and swelling of the lids and sclera of the eye.

Erythromycin ointment is the antibiotic most commonly used and we do carry this ointment if you choose to have your baby receive this preventative treatment immediately after the birth.

This blog post from Evidence Based Birth provides thorough information about this procedure and its risks, benefits and alternatives.

Alternative Treatments

Screening and treating for Gonorrhea or Chlamydia in pregnancy is a very good way to prevent spreading these infections to your baby. Most women will experience some kind of symptoms with both of these infections, but risk factors such as multiple sexual partners can increase the chance of undiagnosed vaginal infections.

Most babies are born with their tear ducts still closed. Without tears, they are unable to rinse their eyes of dust and other irritants. We usually recommend a few drops of your breast milk as a "rinse" of the crusty discharge that often develops in your baby's eyes during the first few weeks of life.  This discharge can be clear or yellow and does not indicate an infection is present.

Good handwashing  (especially after diapering) is an important component of reducing exposure to unfriendly bacteria.  If your baby does develop an eye infection, antibiotic treatment is still an option, as well as herbal rinses of chamomile, eye bright, echinacea, and goldenseal, and homeopathic euphrasia.

Circumcision

Male circumcision is the removal of some or all of the foreskin around the penis.

There is controversy surrounding circumcision. Advocates for circumcision state that it provides important health advantages which outweigh the risks, has no substantial effects on sexual function, has a low complication rate when carried out by an experienced physician, and is best performed during the neonatal period. Opponents of circumcision state that it is extremely painful, adversely affects sexual pleasure and performance, may increase the risk of certain infections, and when performed on infants and children violates the individual's human rights.

US Medical Viewpoint

About 50% of all US male babies are circumcised.  This number is higher than the global percentage (30%), but is actually on the decline.  Part of the decline in this procedure has come out of multiple medical professional organizations issuing statements in the last 10 years that state that there is no significant medical benefit to removing the foreskin of a healthy newborn in the United States.

The American Academy of Pediatrics (1999) stated: "Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In the case of circumcision, in which there are potential benefits and risks, yet the procedure is not essential to the child’s current well-being, parents should determine what is in the best interest of the child." The AAP recommends that if parents choose to circumcise, analgesia should be used to reduce pain associated with circumcision. It states that circumcision should only be performed on newborns who are stable and healthy. [American Academy of Pediatrics Task Force on Circumcision (March 1, 1999)[Circumcision Policy Statement]

The American Medical Association supports the AAP's 1999 circumcision policy statement with regard to non-therapeutic circumcision, which they define as the non-religious, non-ritualistic, not medically necessary, elective circumcision of male newborns. They state that "policy statements issued by professional societies representing Australian, Canadian, and American pediatricians do not recommend routine circumcision of male newborns."[Report 10 of the Council on Scientific Affairs (I-99):Neonatal Circumcision]

The American Academy of Family Physicians (2007) recognizes the controversy surrounding circumcision and recommends that physicians "discuss the potential harms and benefits of circumcision with all parents or legal guardians considering this procedure for their newborn son." [Circumcision: Position Paper on Neonatal Circumcision]

The American Urological Association (2007) stated that neonatal circumcision has potential medical benefits and advantages as well as disadvantages and risks. [Circumcision]

HIV Prevention

In 2007, the World Health Organization and the US Center for Disease Control both issued statements citing recent studies in African countries that showed a decrease in HIV among circumcised males.

http://www.who.int/hiv/topics/malecircumcision/en/index.html

http://www.cdc.gov/hiv/resources/factsheets/circumcision.htm

Anti-Circumcision Evidence/Advocacy

There are numerous national and international organizations dedicated to educating and ending the practice of male and female circumcision.  Concerns include trauma from pain during the procedure (anesthetic is not generally used on newborns due to safety issues), infections or other complications associated with the procedure, and adverse affects on sexual pleasure and function later in life.

Charlottesville based, Dr Annette Owens, MD, PhD specializes in medical aspects on human sexuality.  She has produced a very informative video on research surrounding the sexual aspects of male circumcision.

http://www.youtube.com/watch?v=J2zBaKLYeqQ

More information on circumcision:

National Organization of Circumcision Resource Centers

Local Circumcision Resources:

Midwives do not generally perform circumcisions.  Our practice does not have anyone skilled to provide this service is you desire it for your son.  As circumcision is generally performed from 2 days to 1 week after birth, if you are having a boy or don't know your baby's gender you will need to make arrangements with a local urologist or pediatrician to have the circumcision performed.  We can provide names of mohels who will perform circumcision outside of the hospital upon request.

Newborn Metabolic Screening

Metabolic screening of the newborn is used to detect metabolic birth defects. (Metabolic refers to chemical changes that take place within living cells during the process of digestion and absorption) These conditions cannot be seen in the newborn, but if untreated can cause physical problems, mental retardation and, in some cases, death.

The test requires a sample of blood from your baby and is most accurate if conducted at around the 3rd or 4th day of life.  The blood is collected by sticking your baby's heel with a lancet and collecting 5 drops of blood on a special test card.

Metabolic screening is mandated by the Commonwealth of Pennsylvania and the State of New Jersey. This means that all infants are required to be screened per state law unless a parent or guardian objects on the grounds that the test conflicts with personal or religious practice.

We will provide you with information about metabolic newborn screening and can provide your baby with this test if you desire.  In Pennsylvania, the cost of the basic screening is paid for by the Department of Health. A supplemental newborn screening is strongly recommended by the Department of Health for an additional out-of-pocket cost of approximately $25. In New Jersey, the test costs $100 and is payable when we perform the test at the 48-72 hr postpartum visit.  Results of the screen will be sent to your pediatrician or family practice physician.

A complete listing of metabolic birth defects and their treatments can be found at the March of Dimes website.

Specific information on the Pennsylvania Newborn Screening program can be found at the PA Department of Health website. More information about the New Jersey Newborn Screening program can be found at the NJ Department of Health and Senior Services website.

Download Motherland Midwifery's Informed Consent for Newborn Metabolic Screening here.

Newborn Hearing Screening

Newborn hearing screening is a component of the newborn screening program mandated by the Commonwealth of Pennsylvania.  In the first month of life, all infants are to be screened for congenital hearing loss by a hearing specialist or audiologist.

The National Institute on Deafness and Other Communication Disorders (NIDCD) estimates that 2 or 3 out of every thousand children in the US are born deaf or hard of hearing. The purpose of early screening is to ensure that all babies with suspected hearing loss have the opportunity to benefit from early intervention that could support development of language skills.

Auditory Brainstem Response Screening (ABR )

ABR screening is performed by introducing a soft clicking sound to each ear through the use of earphones placed on the infant’s ear or placed at the opening of the ear canal. Adhesive electrodes are taped to various sites on the infant’s head, which are able to monitor and record the auditory response as it travels from the ear through the auditory system. The ABR response provides information regarding the integrity of the auditory pathway up to and including the brainstem.

Automated ABR screening differs from a diagnostic ABR study in that the equipment is fully automated, eliciting either a pass or refer response. A diagnostic ABR evaluation allows the audiologist the opportunity to manipulate the test parameters, e.g., the stimulus (click or tone burst); the intensity of the signal and the method of stimulus presented (air conduction versus bone conduction). Additional information regarding diagnostic ABR evaluation is included in the Diagnostic Testing section of this website.

This test is routinely performed prior to discharge on babies born in hospital.  For babies born at home, Motherland Midwifery can perform this test at your 2-3 week office visit or you can arrange it through your pediatrician or a local audiologist.  Insurance will cover this test.

You can also contact the New Department of Health and Senior Services or the Pennsylvania Department of Health for more information.