September 3, 2003
Volume 5, Issue 18
Midwifery Today E-News
“Ultrasound”
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ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

In This Week’s Issue:


Quote of the Week

"Obstetricians are educated way beyond their intelligence."

Unknown


Midwifery Today Issue 64

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The Art of Midwifery

Postpartum suturing: If I am really uncertain about what goes where, applying an icepack to reduce the perineal swelling helps greatly. Other helpful tips:

  • Getting yourself and mom really comfortable with good lighting helps you proceed slowly and carefully without hurting your back.
  • The various tissue layers are different colors, so match the colors!
  • Consider the job to be more like basting than embroidery. Your job is to gently bring things into alignment so mom's body can heal itself.
  • If you are really uncertain, get someone else with more experience to either do the job or walk you through it. Healing is better if it is done sooner than later.

Maggie Ramsey, Midwifery Today Forums


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News Flashes

An 18-year cohort study of 48,390 deliveries included 23% of women testing negative for herpes simplex virus, 49% testing positive for only HSV-1 (cold sores) antibodies, 11% with HSV-2 (genital herpes) antibodies, and 17% with both. The group with the highest transmission risk were those women whose blood showed no HSV antibodies (1 in 1900 cases). Women who have acquired HSV in the last trimester are most likely to shed HSV, and their infants are at highest risk from HSV. Women with previous HSV-2 showed 2 in 5,761 risk of transmission, showing that infants with specific antibodies for the virus have a reduced vulnerability rate. The study also showed that HSV transmission rate is highly influenced by delivery management—recognition of lesions, using preventative measures against exposure, maintaining infant's skin integrity during labor (e.g., avoiding use of fetal scalp electrodes). Transmission occurred less frequently among women with genital lesions than among those who were shedding virus into the birth canal, probably because the former was an indication for cesarean section. (University of Washington, www.washington.edu/newsroom/news/2003archive/01-03archive/k010703b.html)


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Ultrasound in Pregnancy

Ultrasound: high-frequency sound waves that travel at 10 to 20 million cycles per second. The pattern of echo waves creates a picture of tissue and bone.

In 1987, UK radiologist H.D. Meire, who had been performing pregnancy scans for 20 years, commented, "The casual observer might be forgiven for wondering why the medical profession is now involved in the wholesale examination of pregnant patients with machines emanating vastly different powers of energy which is not proven to be harmless to obtain information which is not proven to be of any clinical value by operators who are not certified as competent to perform the operations" (1).

Routine prenatal ultrasound (RPU) actually detects only between 17 and 85 percent of the 1 in 50 babies who have major abnormalities at birth (2,3).

RPU can identify a low-lying placenta (placenta previa). However, 19 of 20 women who have placenta previa detected on an early scan will be needlessly worried: the placenta will effectively move up without causing problems at the birth. Furthermore, detection of placenta previa by RPU has not been found to be safer than detection in labor (4).

The American College of Obstetricians has concluded that "in a population of women with low-risk pregnancies, neither a reduction in perinatal morbidity and mortality nor a lower rate of unnecessary interventions can be expected from routine diagnostic ultrasound. Thus ultrasound should be performed for specific indications in low-risk pregnancy (5).

Effects of ultrasound include cavitation, a process wherein the small pockets of gas that exist within mammalian tissue vibrate and then collapse. In this situation "...temperatures of many thousands of degrees Celsius in the gas create a wide range of chemical products, some of which are potentially toxic. These violent processes may be produced by microsecond pulses of the kind which are used in medical diagnosis." (American Institute of Ultrasound Medicine Bioeffects Report 1988). The significance of cavitation in human tissue is unknown.

Studies have suggested that these effects are of real concern in living tissues:

  • Cell abnormalities caused by exposure to ultrasound were seen to persist for several generations (6).
  • In newborn rats (similar stage of development as human fetuses at four to five months in utero), ultrasound can damage the myelin that covers nerves (7).
  • Exposing mice to dosages typical of obstetric ultrasound cased a 22% reduction in the rate of cell division and doubling of the rate of aptosis (programmed cell death), in the cells of the small intestine (8).
  • Two long-term randomized controlled trials comparing exposed and unexposed childrens' development at eight to nine years old found no measurable effect from ultrasound. However, the authors comment that intensities used today are many times higher than there were in 1979 and 1981 (9).

Excerpted from "Ultrasound Scans: Cause for Concern,"
by Sarah Buckley, MD, Midwifery Today Issue 64, also published in Nexux, Oct–Nov 2002

Excerpt references:

  1. Meire, HB (1987). "The Safety of Diagnostic Ultrasound," British J of Ob Gyn 94: 1121–22.
  2. Ewigman, BG et al. (1993). "Effect of Prenatal Ultrasound Screening on Perinatal Outcome: RADIUS Study Group," New Eng J Med 329(12): 821–7.
  3. Luck, CA (1992). "Value of Routine Ultrasound Scanning at 19 Weeks: a Four-Year Study of 8849 Deliveries," Brit Med J 34(6840): 1474–8.
  4. Saari-Kemppainen, A., et al. (1990). "Ultrasound Screening and Perinatal Mortality: Controlled Trial of Systematic One-Stage Screening in Pregnancy. The Helsinki Ultrasound Trial," Lancet 336(8712): 387–89.
  5. American College of Obstetricians and Gynecologists (ACOG) (August 1997). Practice Patterns: Evidence-Based Guidelines for Clinical Issues in Obstetrics and Gynecology. "Routine Ultrasound in Low-Risk Pregnancy." No. 5.
  6. Liebeskind, D. et al. (1979). "Diagnostic Ultrasound: Effects on the DNAS and Growth Patterns of Animal Cells," Radiology 131(1): 177–84.
  7. Ellisman, MH et al.,(1987). "Diagnostic Levels of Ultrasound May disrupt Myelination," Exper Neur 98(1): 78–92.
  8. Brennan P et al. (1999). "Shadow of Doubt," New Scientist 12:23.
  9. Salvesen KA et al. (1999). "Ultrasound in Pregnancy and Subsequent Childhood Non-Right-Handedness: A Meta-Analysis," Ultrasound Obstet Gyn 13(4): 241–6.

For the article in its entirety, MIDWIFERY TODAY ISSUE 64 may be ordered from Midwifery Today's website. Click here to order.


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Web Site Update

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Forum Talk

I am curious about the scope of practice or legal implications for a CNM performing circumcisions. I didn't realize this was an aspect of training for nurse midwives. I have understood it is a surgical procedure. What is your understanding? The CNM I occasionally work with does these a few days following birth in the office. I was quite surprised to discover this.

Penny


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Question of the Week

Q: We have a client who in her first birth had a retained placenta. Retrieving was complicated by a vagal response. She ended up needing to be transported, and the placenta was removed while she was under anesthesia. We are trying to collect data about incidence of repeat retained placentas and any suggestions for reducing its incidence. We are aware of the possible role of vitamin E, and she is minimizing her intake in this pregnancy.

— SC


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: Is it safe to use Epsom salts in the bathwater during labour and to remain in the same bathwater during the actual delivery (can it harm the baby or placenta)? I know Epsom salts are fantastic for relieving muscular pain, so would they reduce the action of the uterine muscles and prolong labour?

I am currently 34 weeks pregnant and experienced a 76-hour labour with my daughter, so I am looking for ways to relax and to hopefully prevent the same thing happening again. I am using a birth centre with midwives only attending me. I intend to use herbal teas and tinctures, essential oils, and visualisation.

— Caron Kambi

A: I am not knowledgeable regarding epsom salts and bath water, but I highly recommend the book "The Birth Book" by William Sears. I had a long hard labor with my first child and read this book in preparation for birthing my second child. As a result I was well prepared mentally, emotionally, and physically. My one encouragement for labor is to change positions frequently and walk as much as possible. Think upright and work with gravity!

— Danielle

A: I've never done a waterbirth using Epsom salts so I cannot comment on it. Apparently, salt water was tried in the early days of waterbirths and plain water was found to be preferable. I should think that plain water would be the best approach.

I recommend to my clients that they consider an Epsom salts bath in early labour to slow down uterine contractility (assuming the amniotic sac is intact). This is based on the theory that Epsom salts relax the muscles and the uterus, being a muscle, could respond to the relaxing effects of the magnesium sulphate that is in Epsom salts. Assuming this theory is true, then it would be advisable to avoid an Epsom salts bath in active labour or second stage as you want progress to occur.

The two things I have found helpful for reducing the length of labour are fish oil and hypnosis. There is quite a lot of research that shows hypnotherapy significantly reduces the length of labour. Fish oil is necessary for the baby's brain and eye development prior to the birth. Anecdotally, women in southern Ontario who consume fish and evening primrose oils throughout the pregnancy (4,000 mg daily) have faster labours, fewer stretch marks, and perineal tears because these oils allow for stretchiness of the cell wall throughout the body. Their babies also receive the critically important DHA that their developing brains need.

Shawn Gallagher, BA, RM, C.CHt, clinical hypnotherapist, registered midwife
Toronto, ON


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mgeditor@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Exclusively on the BirthLove site: Gloria Lemay, celebrated midwife and teacher, is offering advanced online doula education. She covers a vast amount of topics that today's doulas and student midwives need to know: herpes simplex II, medical terminology, pediatric exam of the newborn, prenatal diagnostic tests, business and professionalism, pregnancy-induced hypertension, gestational diabetes and so much more. The course is free for all BirthLove members. Check it out! www.birthlove.com/glo_doula.html


Question of the Quarter for Midwifery Today Print Magazine

Question of the Quarter: What does "instinctive birth" mean to you? How do you facilitate it?

Our favorite responses will be published in Midwifery Today magazine, December 2003. E-mail your response to: mgeditor@midwiferytoday.com. Responses are subject to editing for space and style. Try to keep the word count under 400.
Deadline for submission: Sept. 15, 2003.

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Feedback

I just read your article on breastfeeding herbs [Issue 5:17], and I was pleased to see it. However, in a article on galactagogues, I was surprised to see no mention of fenugreek. Also, although it isn't an herb, I think oatmeal would be a good mention in this regard. Otherwise keep up the good work.

Larry McMahan


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