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Should I Have an Ultrasound?

 
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If you’re worried about ultrasound safety, good for you! You should be. The use of ultrasound in pregnancy has become almost a given. Most women in the US and Canada experience at least one ultrasound during pregnancy. Some experience several. There are certainly appropriate situations for the use of ultrasound, but a healthy pregnancy isn’t one of them.

If, after weighing the pros and cons of an ultrasound, you decide to have one, that’s entirely within your right. What’s important here is to make an informed decision rather than just exposing you and your baby to high-frequency sound waves as a matter of practice.

Is Ultrasound Necessary?

The answer to this question really differs from person-to-person and even situation-to-situation. When a health care provider recommends ultrasound to a pregnant woman, the FDA recommends that mom speaks with them to understand why the ultrasound is needed, what information will be obtained, how the information will be used, and any potential risks.

Medicine is big business. There is significant financial incentive for obstetricians to recommend ultrasounds to their patients, as they can bill many hundreds of dollars to insurance companies for each use. According to the Center for Disease Control (CDC), over-use of technology is one of the major reasons for the rise in healthcare costs.

More and more modern obstetricians have been trained to use ultrasound in place of hands-on skills to evaluate the health of the pregnancy. They use it to evaluate fetal growth and position in the third trimester, which can often be assessed by hands-on examination. They also use it to date pregnancies, which can typically be done with a little detective work.

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Ultrasound is often used to determine whether a baby will be too large to be birthed naturally via the birth canal. However, ultrasound has been shown to be an inaccurate measure of birth weight. Further, our pelvic bones are joined together with ligaments that allow the pelvis to widen enough for birth to safely take place - especially when supported in upright and asymmetrical mobile positioning. This is true in almost every case, even when the mother is especially small or the baby especially large.

There are some situations in which an ultrasound is warranted. For example, bleeding in pregnancy or a serious abnormality that requires immediate or high risk hospital care. Or if mom has very irregular or absent cycles during breastfeeding, providing no real guideline for gestational age. Sometimes, if mom has a lot of anxiety about the health of her pregnancy and baby, a normal ultrasound mid pregnancy can provide some reassurance - while still not a guarantee.

The American Institute of Ultrasound in Medicine advocates for use of ultrasound solely for medical purposes, and never for things like keepsake images. And the American College of Nurse-Midwives’ position is that “Ultrasound should only be used when medically indicated.”

What Do We Know About Ultrasound Safety?

Ultrasound waves have the potential to produce biological effects on the body. They can heat bodily tissue, as well as produce small pockets of gas in bodily fluids or tissues (known as cavitation). The long-term consequences of these effects are still unknown.

Dr Sarah Buckley provides an extensive article in which she weighs ultrasound safety. In it she says,

“If there is bleeding in early pregnancy, for example, ultrasound may predict whether miscarriage is inevitable. Later in pregnancy, ultrasound can be used when a baby is not growing, or when a breech baby or twins are suspected. In these cases, the information gained from ultrasound may be very useful in decision-making for the woman and her carers. However the use of routine prenatal ultrasound (RPU) is more controversial, as this involves scanning all pregnant women in the hope of improving the outcome for some mothers and babies.”

Dr Buckley goes on to say,

“Studies on humans exposed to ultrasound have shown that possible adverse effects include premature ovulation, preterm labour or miscarriage, low birth weight, poorer condition at birth, perinatal death, dyslexia, delayed speech development, and less right-handedness.”

Despite its rampant use, there has not been sufficient testing for ultrasound safety - especially concerning routine use in healthy pregnancy. In fact, there has been very little testing at all since the 1980s even though the FDA allowed exposure limits to increase by 8 fold in 1992.

It’s important to acknowledge here that technology is often assumed safe until proven otherwise. Just a couple generations back, it was general practice to x-ray pregnant mothers. Sounds crazy now that we know more about the dangers of x-rays to the developing fetus, but back then it made perfect sense.

As Dr Kelly Brogan states, “Multiple Cochrane reviews have demonstrated a lack of perinatal mortality benefit for routine ultrasound in a normal pregnancy, and an increased risk of cesarean section with third trimester screening. A review of outcomes literature condemns ultrasound when used for dating, second trimester organ scan, biophysical profile, amniotic fluid assessment, and Doppler velocity in high and low risk pregnancies.”

While our reasons for using ultrasound are typically focused on healthy pregnancies and healthy babies, there has been virtually no proof that more ultrasounds in a population equate with better health. In fact, false positives of congenital malformations are not unusual. Sadly, this has lead to more invasive testing and abortions misunderstood to be medically necessary when there is nothing actually wrong. At the very least, this puts undue stress on momma, partner and baby.

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In my opinion, technology has put distance between mommas and care providers. In situations where a midwife historically would take a literal hands-on approach to mom and baby’s health, technology now allows for a disconnect where mom is sometimes never touched by her birthing support team. My belief is that this impersonal approach can do just as much harm as the technology can.

The over-use of ultrasound also undermines a woman’s trust in her healthy body’s ability to grow and birth her healthy baby, as modern day families are putting more and more trust in technology over themselves.

Alternatives to Ultrasound

We do not fully understand the effect of directing loud sound waves at baby so frequently, but it does alter DNA in the test tube and there is strong evidence to show that any damage done is cumulative. So, if you must have an ultrasound, keep it as brief as possible and limited to as few as possible. If all is well and you know your cycles or date of conception, but you really want one, do it mid pregnancy…and of course, make sure to request a keepsake picture of your baby.

A doppler is an ultrasound device that can detect fetal heartbeat as early as 10-12 weeks, depending on the device, the location of baby, and position of mom’s uterus. It is used for each prenatal visit in many obstetrical care offices and clinics. If you want to minimize ultrasound exposure, ask for the fetoscope.

A fetoscope, which is similar to a stethoscope and works to amplify baby’s heartbeat, can be used in place of ultrasound or doppler after around 20 weeks gestational age to listen to the fetal heartbeat. It can also help assess baby’s position in later pregnancy.

When baby starts to move regularly, especially in the third trimester, I teach fetal movement awareness and kick counts. Basically, babies sleep a lot, especially when you are busy running around; but they tend to get up and become active after you eat and when your’e resting. Become aware of when and how often your baby is most active and take notice of your baby’s typical daily patterns of movement. An active baby, moving as much as usual, is a sign of fetal health and well-being. If you did not feel your baby move as much usual on a given day, eat food that has previously stimulated lots of fetal activity - usually carbohydrates like a peanut butter and jelly whole grain sandwich or cereal and nut milk - plus have two glasses of orange juice and a cup of coffee; recline in 30 - 40 minutes and count at least 10 separate kicks, body shifts, punches in the hour. Most babies will produce more than that in a few minutes, but if you are not feeling 10 separate moves in that hour, call your provider.

For most of history we did not know we were having a boy or a girl until the birth of our baby. There is something special about the surprise. But for those wanting to know the sex of their baby, blood tests are now available and are actually more accurate than ultrasound for this purpose.

Your Choice

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Medical interventions like ultrasound often play into our fears and turn us away from our intuition. We have come to have less trust in the process and believe that we need to rely on technology to assure us that our babies are safe. As mommas, we have thousands of years of the birthing wisdom of our elders that we carry in our DNA. Is that less reliable than a relatively new, under-tested technology when all is well?

Midwives typically use touch and hand skills in place of technology like ultrasound. As a wholistic and integrative midwife that specializes in healthy pregnancy, I always give the option for ultrasound, and discuss the pros and cons with each family in my care. Some opt out of all unless there is an issue or complication when the benefits outweigh the potential risks of sonogram. Some do want one to confirm they have a baby in the uterus with a heart beat before it is too early to tell in the office, and a basic scan between 18 -22 weeks. For those birthing at home, some want just this mid-pregnancy ultrasound to check baby’s anatomy and that the placenta is in the right place, so they are reassured there is nothing detected that warrants birth in higher risk hospital setting.

As midwives, we do not fix what is not broken. We instill trust in the pregnancy and birth process, and have confidence in a mom’s ability to do it.

Learn more about how you can date your pregnancy,  as well as have a holistically healthy journey and birth with confidence.

 

RhoGam Shot in Pregnancy

 

Risks and Benefits of RhoGAM

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Many expecting parents have questions about whether or not to get the Rh immune globulin (RhoGAM) shot if the momma to-be is Rh-negative. This applies to a small number of women, but it is extremely important for them to be armed with all the information prior to making a decision.

If you are among the roughly 10 - 15% of people who are Rh negative, your pregnancy could be affected if your baby is Rh positive.  In this situation, obstetric providers often recommend RhoGAM.


However, it’s not always that simple. If you’re not sure you have all the information for an informed decision, you’re in the right place. Below are some frequently asked questions and points to consider.

What is the Rh factor?

The Rh factor is a protein that can be found on the surface of red blood cells. If your blood cells have this protein, you are Rh positive. If they do not have this protein, you are Rh negative. This is the negative or positive after your blood type: A, B, O or AB. It is simply about different normal variations in red blood cells. For example, you can be A positive or O negative. The negative or positive is your Rh factor. A pregnant woman will get a blood type, Rh and antibody screen as part of the routine prenatal blood tests; if she is Rh-negative, her antibody response will get tested several times as indicated throughout the pregnancy to check for Rh sensitization.

What is Rh incompatibility and sensitization?

Rh incompatibility is when the blood of a fetus is Rh-positive but the momma’s is Rh-negative. In this situation, if baby’s blood gets into mom’s bloodstream, the mother creates a defense system against the different type of blood; it is perceived as foreign by her body, even though it belongs to her baby. She will react against it by making anti-Rh antibodies. When a pregnant mother makes antibodies against the Rh factor on her baby’s red blood cells, it is called sensitization. Once a mom is sensitized, it stays with her forever.

This rarely causes complications in a first pregnancy, as the primary immune response takes time to develop and initially produces IgM antibodies that are too large to cross the placenta. However, it could be dangerous in future pregnancies for the fetus or newborn baby, when the secondary immune response is more rapid and the body has made smaller IgG antibodies that easily cross the placenta. Once these antibodies can cross the placenta, they try to destroy the fetus’s red blood cells.

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How can Rh problems affect the fetus during subsequent pregnancies?  

Rh sensitization can lead to a wide variety of mild to serious health issues in a fetus or newborn of the next pregnancy. The main concern is a severe type of anemia in the fetus, in which red blood cells are destroyed faster than baby can replace them. Red blood cells carry oxygen to all parts of the body. Without sufficient red blood cells, the fetus will not get enough oxygen, and this can result in hemolytic disease of the fetus and newborn causing jaundice, brain damage, heart failure and death.

How can my fetus’s blood get into my bloodstream?

During healthy pregnancy, a mom and her fetus usually do not share blood, thanks to the placenta that keeps the fetal and maternal blood circulation separate. But sometimes a small amount of blood from the fetus can mix with the mother’s blood. Typically, there is no mixing sufficient enough to risk sensitization unless there is are complications like miscarriage, placental abruption or previa, abdominal trauma, or an invasive medical/surgical procedure like chorionic villus sampling or amniocentesis, abdominal surgery and even ultrasound. 

Sensitization is usually associated with a rapid and large volume of fetal-maternal blood mixing. The most common time for Rh-positive fetal red blood cells to enter mother’s bloodstream, is during childbirth, though it can occur at other points during pregnancy - mainly in the third trimester.

Traumatic and difficult births with a high level of invasive procedures increase the likelihood for baby’s blood to mix with mom’s. So can certain routine interventions including use of the synthetic drug Pitocin to induce or augment labor, local or regional anesthesia, forced directed pushing, clamping the umbilical cord too early, pulling on the cord and putting pressure on the fundus to hasten delivery of the placenta.

A gentle birth process with minimal intervention and time allowance for the placenta to separate provides a reduced risk of significant mixing of blood between mother and baby.

While not a guarantee, planning for a natural undisturbed physiologic pregnancy and birth may certainly help prevent the mixing of fetal and maternal blood that leads to sensitization and hemolytic disease.

Can you tell if the baby is Rh-positive?

There is a new noninvasive blood test, which can detect fetal blood type using a blood sample of the pregnant mom. It is said to be highly accurate, almost as reliable as the conventional test, that uses a blood sample of the newborn after birth. It is almost, but not 100% accurate; and it is not available everywhere or covered by all insurances.

I recommend dad getting his blood type and Rh factor tested. If the father is Rh-positive and the mother is Rh-negative, there is about a 75% chance baby is Rh-positive, and providers will probably recommend RhoGAM. But if both parents are Rh-negative, baby will also be Rh-negative; in that case, there is no risk of Rh sensitization, and no need for RhoGAM.

What is RhoGAM?

RhoGAM is a drug made from human blood plasma, that prevents the mother from making antibodies against the positive Rh factor in baby’s blood. It is given via intramuscular injection, to prevent the immune response of sensitization against baby’s Rh positive blood, and subsequent hemolytic disease of the fetus or newborn in future pregnancies.

 
What are the benefits of RhoGAM?


RhoGAM’s effectiveness has been demonstrated in multiple studies around the globe. According to Dr. Murray Enkin et.al of A Guide To Effective Care in Pregnancy and Childbirth , one of the widely respected and authoritative founders of evidence based care, RhoGAM given after birth reduces the rate of hemolytic disease from 15% down to 1.6%.  RhoGAM administration prenatally in the third trimester has been shown in studies to further decrease the incidence to 0.06%.

The administration of RhoGAM medication to Rh-negative mothers is thought to be a major achievement of modern obstetrics by many in the medical profession. Before RhoGam’s introduction into routine practice in the 1970s, hemolytic disease of the newborn was a major cause of serious illness, death and long term disability in babies.

RhoGAM does not typically benefit firstborn babies unless the mom who is Rh negative has previously experienced a reaction to a mismatched blood transfusion, an abortion, miscarriage or ectopic pregnancy untreated with RhoGam.  

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When is RhoGAM recommended, and why?

For women who are Rh-negative, health care providers routinely recommend a shot of RhoGAM around 28 weeks of pregnancy and then again within 72 hours after birth, in order to protect the baby of a subsequent pregnancy.

Providers must decide about the RhoGAM shot and its dose based on how likely it is for the baby to have Rh-positive blood, as well as how likely it is for the baby and mother’s blood to significantly mix during pregnancy and birth.

Is there controversy around RhoGAM?

This standard approach is not without its critics, especially regarding its routine use during pregnancy, in which only about 1.5% of Rh negative moms with Rh positive fetuses develop antibodies and become sensitized against the baby’s positive Rh factor. Risk of sensitization is significantly higher after birth. Administration of RhoGAM postpartum is much less controversial, where benefits of the medication more clearly outweigh potential risks.

“The problem with routine prescription of prenatal RhoGAM is that many babies who are Rh negative like their mothers will be exposed to the drug, and there has been no systematic study of the long term effects of this product in babies.” - Ina May Gaskin

 “RhIG is not given for the direct benefit of the recipient or even her current fetus. The only beneficiary will be an RhD-positive fetus during a subsequent pregnancy (although the woman would also benefit in the event of a wrongly typed transfusion during the time of birth). Furthermore, prenatal prophylaxis unnecessarily exposes the 35% of fetuses who are RhD-negative to RhIG. These babies are at no risk of RhD sensitization. RhIG is completely unnecessary when a baby is the last child in the family. In the absence of clear answers to these pressing questions, the routine use of RhIG assumes that the birth process for RhD-negative women is inherently flawed.” - Anne Frye

Reliable research and meta analysis of the studies on benefit and harm of routine use of RhoGam in pregnancy are still limited, especially as it relates to who, when and which dose is needed, as well as its cost effectiveness.

Some argue that there may be other factors that contributed to the marked decline in severity and prevalence of perinatal morbidity and mortality associated with Rh incompatibility and sensitization, and medicating healthy pregnant women undermines those who trust the inherent wisdom in the natural process of childbearing. That being said, the issue remains an issue which, still today, impacts babies of pregnant women who are Rh negative.

What are the risks of RhoGAM?

Despite excellent results, the medication retains an FDA Pregnancy Category C: “Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.”

The known possible side-effects to RhoGAM include local swelling inflammation at the site, skin rash, body aches and sometimes hives. Infection from the blood product of modern preparation is rare, but still a possibility.

Expecting mommas should also keep in mind that standard RhoGAM preparation in many countries contains the mercury compound known as thimerosal, which has a litany of health risks.  However, pregnant mommas can request the use the mercury-free RhoGAM, if it is available where they live. In the United States, RhoGam is said to be mercury-free, although it may still contain traces.

So, is the RhoGAM shot absolutely necessary during pregnancy? 

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This is a hard question to answer for each individual person, on a blog.  Although much of the research is compelling, it is dated, was largely funded by the pharmaceutical companies and it is not without bias, flaws and some conflicting conclusions. For an eye opening text analysis of the data though 2001 and guidance from a traditional midwifery perspective, check out “Anti-D in Midwifery: Panacea or Paradox? 2nd Edition”, by Sara Wickham.

As always, pregnant mommas should empower themselves with knowledge and talk with their provider to fully understand the benefits and risks of all medications unique to their situation. 

I encourage my clients to take great care of themselves, be well-educated on their health-related issues, and to be in tune with their bodies.  While I aspire to provide evidence based information about medications and recommended treatments, I also know that there is much we do not know, and I am wary of routine medical and surgical interventions in a healthy natural process Too often they are widely used before sufficiently evaluated or harm has been identified. I feel informed and empowered moms are best able to make decisions for themselves.

Understanding that the vast majority of woman who are Rh-negative will not become sensitized during pregnancy, as it is rare that mixing happens until birth, is an important consideration when balancing the risks and benefits of using a pharmaceutical therapy while pregnant.

If you are Rh-negative and baby’s dad is Rh-negative, no, you do not need the shot. If baby’s dad is Rh-positive, and you choose to refuse the shot in pregnancy, you may still need it later if you suspect bleeding or another reason for sensitization, or if you change your mind. If you have done your research, you believe you are low-risk, and you do not feel comfortable with the shot while pregnant, do not let a provider pressure you. 

According to those who advocate a gentle birth process with minimal intervention and time allowance for the placenta to separate, there is usually less risk of significant mixing of blood between mother and baby. But mixing and sensitization can certainly still occur during healthy natural birthing. Traumatic, highly interventive and difficult births increase the likelihood for fetomaternal hemorrhage and sensitization. So can certain routine interventions including ultrasound, use of the synthetic drug Pitocin to induce or augment labor, local or regional anesthesia, forced directed pushing, clamping the umbilical cord too early, pulling on the cord and putting pressure on the fundus to hasten delivery of the placenta - anything that possibly disrupts the delicate physiology of placental separation or cause tiny fetal blood vessels to rupture and bleed. Planning for a natural undisturbed physiologic birth may certainly help prevent the mixing of fetal and maternal blood that leads to sensitization and hemolytic disease.

If you are feeling overwhelmed, or do not even know what questions to ask, I can help you! Check out my number one international best selling book Natural Birth Secrets and my online course - an online version of how I have helped thousands in my local practice. Both resources are unique, but each provide an in depth, one-of-a-kind holistic approach created by me, a seasoned nurse midwife of over two decades, who has seen everything!

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If you need more personalized guidance and help navigating these and other tough decisions, you can arrange a consultation with me, bundled with my online course. Or I invite you to choose from a variety of services I offer to the global community. Rock Your Journey To Motherhood is my most comprehensive, supportive offering for pregnant mommas anywhere in the world.  You will have personal access and guidance from me as we co-create your joyful journey from pregnancy to postpartum healthy bliss.