20 Week Ultra Sound, necessary?

[AustinMom]

We are HBACing, and are 12/13 weeks now. We didn't get any early U/S because we knew our DOC. We don't plan on a late U/S unless something deems it necessary. I can see how the 20 week U/S could be helpful in looking at congenital malformations, but I also have read that these malformations can be missed up to 50% of the time. Somethings are more important to find out than others, IMO, like heart defects are more important than cleft lip.

Heart defects, of what I know (being very little) can be dangerous, and may need medical attention soon after birth. How common are these defects? How often are they serious? And most importantly, are they something that can be detected in other ways than US, like irregular heart beats, etc.?

A lot of the birth defects wouldn't be handled any differently at the hospital than they would at home, but what ones should be "handled" or addressed by the hospital? How often do they occur?

We don't plan on getting one unless it's needed. And even ACOG says routine U/S is not recommended and should only be used if medically indicated. Sadly, this isn't practiced by those part of ACOG.

Please fill me in.....

[MaerynPearl]

home birthing I would get the 20 week just to check on the placental location to know if its something that needs to be kept an eye on or nothing to worry about at all. if its over the cervix it makes home birthing very very very dangerous (granted there are usually symptoms of this such as bleeding... sometimes there's not)

[AustinMom]

Right, which is why I was planning on a 20 week u/s, but the placental location was detected at our last prenatal (yes, with the doppler, not the fetoscope) and it's high, and out of the way of the cervix. If it was low, or close to the cervix, I'd have a u/s at 20 weeks, and if it was still low, or covering any of the cervix, I'd have another at 37 weeks or so to see if it has moved as my uterus grew.

But I don't have to do that, do I'm mainly "concerned" about the life threatening abnormalities that would need prompt medical attention.

[judybean]

it's a pretty personal thing whether one chooses ultrasound or not.

For me, I dont' see the need. Really. With dd3, I did have a hospital birth, but the dr. really didn't care if we had an u/s or not, so we didn't. We weren't going to find out the gender anyway.

This time around we're not birthing in a hospital so the decision was even easier.... no ultrasound at all again I'm perfectly content with it... and I'll admit, it's kind of fun being completely in the dark!

[CorasMama]

If I were having a hospital birth, with good interventions at the ready, I might feel comfortable skipping it (well, not me personally with future pregnancies, considering what's going on with this one, but the general "I").

However, with a homebirth, I think one ultrasound, just to set everyone's mind at ease, is a good idea, and certainly can't hurt. 20 weeks is a better time than 12 weeks, if you're only going to get one, because you can more easily see more of the things that would be a problem.

My anecdata (really rare situation, but there are a number of situations that could have the same result, and are far less rare): We were planning an out-of-hospital birth, with minimal interventions, including minimal ultrasounds. Something told me to go ahead and get the 12-week u/s, and I'm awfully glad I did. This baby HAS TO be born via c-section, and an out-of-hospital birth could have been extraordinarily disastrous. But if we'd gotten the all-clear, (statistically far more likely), I would have just felt that much more comfortable with the birth we had planned.

[birthangeldoula]

I would..
My son was born with a heart defect that needed treatment immediately after birth. I had no risk factors beforehand that would predispose me to having a child with a defect so had I not have known, I wouldn't have been at a hospital equipped to take care of such thing.

[AustinMom]

This is kinda where I am at. Yes, life threatening, prompt medical attention needed birth defects are very rare. Yes, but when going into a HB, I would feel like I would want to know if I had one of those defects just to rule out the unsafety. Even if I was having a hospital birth, I would want to know if my baby would need major surgery minutes to hours after birth. Knowing this, why don't organizations like ACOG, NHI, and other major players recommend them, at least at 20 weeks. I'm not saying mandate, but at least recommend? I feel like I am missing something. I've seen the studies on mice, and know there are potential dangers in them (as with every medical procedure), but I feel I'm playing the safer route waiting till 20 weeks than in the first trimester.

I don't know, I think I will get the 20 week one. That's where I'm at. BTW, Corasmama, do you mind me asking what the u/s found? If it's too personal, I completely understand.

[mischievium]

As someone who both knows the ACOG recommendations AND who worked as a NICU nurse, I decided to get the 20 wk US with my first pregnancy. I was low-risk and planning to deliver at a free-standing birth center. For me, it came down to how would I feel if there was something wrong and I didn't bother to look for it before delivering the baby in a place with only minimal forms of resuscitation available? I know that things get missed on US. I have worked with babies whose defects were so severe that I wondered if the person that did the US had their eyes open because the defects were missed. BUT, the majority of babies that I worked with who had congenital defects were prenatally diagnosed. I knew that something could be missed OR that they might think they see a problem when there isn't one, but for me, I had to feel like I did my due diligence and looked to see if there was a problem.

RE: heart defects: they are, I believe the most common congenital defects. I don't know the stats regarding what percentage get missed on US, but my anecdata is that it isn't uncommon for them to get missed. There are different levels of US when it comes to the heart-- most babies are screened at the 20wk US and only if there appears to be a problem will they be referred for a higher level cardiac US. This obviously catches most babies with heart conditions, but not all. There are congenital defects that generally require immediate intervention and ones that maybe could wait-- but I wouldn't roll the dice. Even among specific defects (like: transposition of the great vessels, hypoplastic left heart syndrome, tetrology of fallot, total anomalous pulmonary venus return), there are going to be both variations of how severe the physical defect is and in how resilient a particular baby is going to be in responding to it. And, really, it's one thing to look at the baby's heart by US in utero, it's a whole different thing once they are born-- I've both seen kids with more severe defects and less severe defects than what the prenatal US showed. Some defects are "ductal dependent" and how long it takes the ductus arteriosus to close in any particular baby is going to range from hours to days after birth-- and you won't know what it's going to be until it happens. Those babies can appear to be mostly fine until that vessel closes (as it should in a baby with a normal heart) and then they quickly crash-- you do not want to be at home when that happens.

Beyond cardiac defects, other defects I would not want to deliver out of a hospital include oomphalocele, gastroschisis, and congenital diaphragmatic hernia. I know that midwives are supposed to have guidelines of how to handle babies in these situations, but if I had a kid with a defect and I knew it, I would want them in the most experienced hands possible. Midwives specialize in low-risk situations and manage them quite well-- I know that and believe it to the point that I planned to birth with midwives. But being prepped to deal with the unexpected is not the same as dealing with it everyday. I would want to know ahead if I could because I would want a baby who is going to face medical challenges to get the best start possible and not add more challenges by having them delivered into a setting that is not as prepared as possible to deal with their needs. Like I said, I know things get missed on US, but I felt better having checked before committing to an out of hospital birth. While I intellectually know that the babies I worked with each had rare conditions that affect a small percent of the population, emotionally, for me, those percents have faces and names and bewildered parents.

Also, I don't agree with the philosophy that this can be avoided because the mother will magically know something is wrong and ask for an US-- sometimes that happens, but many times parents have NO IDEA that anything is wrong until they see it on the US or until the baby is born.

For me, the risk that they might think they see something on US that really isn't there or isn't a problem and that I may have to deal with the stress of that or have it risk me out of an out of hospital birth was not worth the risk of not identifying a congenital defect that would require prompt medical attention.

[AustinMom]

Right, and i feel that same way.

I read through the info I could find on the RADIUS study, and one thing that was found was that the only thing worse than not having an u/s is having one done by someone not skilled. They found that in the unskilled hands doing the exam, 99% of heart defects were missed and 40% of other congenital malformations. So my question is, what is a "skilled" examiner? Obviously not the OB (necessarily) more so an licensed sonographer. But is that good enough? Who would y'all recommend?

[MaerynPearl]

Originally Posted by AustinMom

Right, and i feel that same way.

I read through the info I could find on the RADIUS study, and one thing that was found was that the only thing worse than not having an u/s is having one done by someone not skilled. They found that in the unskilled hands doing the exam, 99% of heart defects were missed and 40% of other congenital malformations. So my question is, what is a "skilled" examiner? Obviously not the OB (necessarily) more so an licensed sonographer. But is that good enough? Who would y'all recommend?

ask around. Find one with a lot of experience/time actually doing the job vs. very few if any complaints.

Ive gone to the same lady with all three of my babies (different one with my loss) she actually remembers me because I went to her so often with DD. She certainly hasn't missed anything yet for me and I totally trust her with my 20 week u/s to not miss anything as well. We chatted a bit at my last ultrasound (mostly telling her how amazed I was that she could spot all of this stuff so fast without really having to look) and she told me that the hospital requires her to be retrained every time they get new equipment and since she is only one of two trained sonographers on the staff and has been working there for 20 years... its like second nature to her.

While... yeah... the unskilled ones need the practice... id rather not be the one they practice on lol.

[WaitingForKiddos]

I think it's necessary.

First being a vbac you might want to be REALLY sure of the placenta and your C-scar. Then finding out placenta location and cord insertion is good to know before a out of hospital birth.


There's all the baby stuff too....which has been mentioned.

[honeybee]

I am perfectly comfortable not having an ultrasound for a homebirth. If you look at all the homebirth studies, the statistics show that there are no worse outcomes for mothers and babies... and I don't believe those are sorted out into pregnancies with and without ultrasounds. The ACOG studies clearly show that there is no greater risk to baby for detecting a problem at birth or beforehand. However, the risk of prematurity, induction, and c-section increases with adding a routine 20-week ultrasound... because actions are taken due to suspected problems.

I guess it's a matter of faith to me. I believe I will be guided to be in the place I need to be. If there's something we need to know ahead of time, there will be a reason to have an ultrasound. If we need to be at the hospital, there will be indications.

[jennica]

Originally Posted by honeybee

I guess it's a matter of faith to me. I believe I will be guided to be in the place I need to be. If there's something we need to know ahead of time, there will be a reason to have an ultrasound. If we need to be at the hospital, there will be indications.

Maybe you feel comfortable relying on this method, but most people aren't led around by the hand by some force who protects them from danger. Things can and do happen to people in homebirth or hospital settings, and when weighing the risks and benefits of a certain procedure, it would be irresponsible to to trust that some magical voice will tell us if something is wrong. Tragedies happen, and no magical voice told those people that something was wrong.

[birthangeldoula]

Originally Posted by jennica

Maybe you feel comfortable relying on this method, but most people aren't led around by the hand by some force who protects them from danger. Things can and do happen to people in homebirth or hospital settings, and when weighing the risks and benefits of a certain procedure, it would be irresponsible to to trust that some magical voice will tell us if something is wrong. Tragedies happen, and no magical voice told those people that something was wrong.

Ditto.

[CorasMama]

Originally Posted by AustinMom

I don't know, I think I will get the 20 week one. That's where I'm at. BTW, Corasmama, do you mind me asking what the u/s found? If it's too personal, I completely understand.

Baby has a giant omphalocele, and we have since found a bowel defect and possibly something with the heart (need a second fetal echo for more info.)

There is NO indication of problems other than diagnosis by ultrasound, until birth or after, with most congenital defects. You simply cannot say that you'll have indications before it's too late. My pregnancy is going horribly, with possible HG, and blood pressure problems, but none of that has anything to do with the baby's problems, so I wouldn't have any indication that something was wrong until having a vaginal birth out of the hospital and possibly the baby's omphalocele sac rupturing or liver being damaged. The fact is, the majority of pregnancies end in healthy babies, but that isn't because those mothers had faith or whatever, it's because they were on the good side of the statistics. As I've said before, I fought the law (of statistics) and the law won. I had faith in my body's ability to grow and birth a healthy baby, but it just didn't happen that way.

[velveeta]

Originally Posted by jennica

Maybe you feel comfortable relying on this method, but most people aren't led around by the hand by some force who protects them from danger. Things can and do happen to people in homebirth or hospital settings, and when weighing the risks and benefits of a certain procedure, it would be irresponsible to to trust that some magical voice will tell us if something is wrong. Tragedies happen, and no magical voice told those people that something was wrong.

I am sure you must have had a bad experience, and that is what informs your post. But, I have to say, this is pretty disrespectful of this poster. A routine, 20 week ultrasound is not a failsafe, and if a mother is relying on it to prevent an unwanted outcome, she will often be disappointed.

Tragedies *do* happen, with or without routine ultrasound. And, evidence shows that they happen *more* often *with*.

I do not use *routine* ultrasound in pregnancy, and my choice is based on research-based evidence, not "magic." Please don't presume that those of us who choose not to use routine ultrasound are doing so because we are relying on magic.

There is NO EVIDENCE to suggest that the use of ROUTINE ultrasound (which the 20 wk US falls under) provides better birth outcomes. There are many, other evidence-based practices that research shows *do* provide better outcomes. For example, fundal height measurements are a good indication of when a diagnostic ultrasound might be a good idea. Intrauterine heart defects are more likely to affect growth.

I am always concerned when I see mothers making choices based on anecdotal information. That does not mean that the individual events do not matter -- they matter most of all. But, not when it comes to making the safest choices.

edited to add: as honeybee mentioned: even the ACOG does not recommend the routine use of ultrasound. Why? Because its use is not evidence-based. There are other ways of detecting problems (like fundal height measurements). It just isn't a matter of opinion.

[jennica]

Originally Posted by velveeta

I am sure you must have had a bad experience, and that is what informs your post. But, I have to say, this is pretty disrespectful of this poster. A routine, 20 week ultrasound is not a failsafe, and if a mother is relying on it to prevent an unwanted outcome, she will often be disappointed.

Tragedies *do* happen, with or without routine ultrasound. And, evidence shows that they happen *more* often *with*.

I do not use *routine* ultrasound in pregnancy, and my choice is based on research-based evidence, not "magic." Please don't presume that those of us who choose not to use routine ultrasound are doing so because we are relying on magic.

There is NO EVIDENCE to suggest that the use of ROUTINE ultrasound (which the 20 wk US falls under) provides better birth outcomes. There are many, other evidence-based practices that research shows *do* provide better outcomes. For example, fundal height measurements are a good indication of when a diagnostic ultrasound might be a good idea. Intrauterine heart defects are more likely to affect growth.

I am always concerned when I see mothers making choices based on anecdotal information. That does not mean that the individual events do not matter -- they matter most of all. But, not when it comes to making the safest choices.

edited to add: as honeybee mentioned: even the ACOG does not recommend the routine use of ultrasound. Why? Because its use is not evidence-based. There are other ways of detecting problems (like fundal height measurements). It just isn't a matter of opinion.

My comments were directed at a specific part of Honeybee's post, which I felt was extremely disrespectful to the very diverse audience here on MDC. I was not arguing for the 20 week ultrasound, in fact I am having a homebirth and probably wont be getting the 20 week scan. I never implied that people who choose not to get the 20 week scan are doing so because magic voices talk to them - but rather I was saying that when we weigh the risks and benefits of any medical procedure, it is irresponsible to suggest that we don't need a certain procedure because we will be guided in some way towards safety if something really is wrong. That is simply not true. When bad outcomes happen it wasn't because of those peoples religious persuasions or the amount of faith they had in their god/body/birth/etc. To suggest otherwise is extremely offensive and insensitive to the wide variety of beliefs, or lack of beliefs here on MDC, as well as to people who did have bad outcomes.

[AustinMom]

Be nice everyone, I didn't open this thread to start a war.....lol

I do believe that the thought that is trying to come across is when your motherly intuition leads you to take/look at other tests/procedures, you should usually do this, this is of course, not intuition fed by obstetrics.

I would love to see the studies Velveeta mentions on the use of routine u/s leading to more interventions. I can see if they were done by unskilled hands, or at late term to "measure" (I laugh at this) a baby for suspected macrosomia, or for "low fluid", "aging placenta" or other scare tactics some CP pull on moms. But are these studies on skilled sonographers? Are they with second and third opinions? If there was any problem suspects, I'd get a second, and third, opinion from a different practice. This is the kind of stuff I'm looking for though, the defects that are life threatening, and how to know when/if they are occurring in ways other than u/s, like fundal height. This is the stuff I want to know more about.

Again, the place of the placenta can be determined by listening, I know where my scar and cervix all are, and the placenta is high, away from both. I'm not worried about placenta problems.

Corasmama, I do see what you mean. It's all about seeing which is riskier. To me, there must be a some what notable risk to routine U/S for ACOG, NIH, and everyone else to NOT recommend it. Yes, I do sympathize with your experience, but I would hope you would take into account the ability of your caregiver to recognize these issues in other ways without u/s. That's what I am looking for. I would think that HB MW are more apt to look for complications in ways other than U/S because, 1) they can't do U/S usally 2) a lot of parents going through a HB MW don't get any u/s and 3) no MW wants to walk into a birth with a baby born with complications that could have been screened out in ways THEY themselves can screen, like the example of fundal height measuring. I doubt most OBs and hospital birthing MW go off such basic techniques to look for problems, mainly because they have all this other "better" technology at their disposal. Just my thought, I'm not meaning for this to be offensive in any way, but there was a lot of stuff our Birthing Center MW didn't know, and I wish I would have had a better CP last pregnancy.

[nia82]

I am torn about this decision for my next pregnancy, but my health plan just made it for me: they do NOT cover a 20 week ultrasound. And I saw the bill for DS's back in 2008 - $1400 was billed for it to my health insurance. I certainly won't pay $1400 bucks out of pocket for this.
My mother never had ultrasounds with us, they weren't around.... DH's ex-coworker's wife had plenty of ultrasounds and the perinatlogist totally missed that their son had like claps in his tubes from the kidneys to the bladder. When he was a couple weeks old he went into complete kidney failure - and when they got those u/s pics out of the file it was visible, the peri just didn't notice (too busy, tired, who knows). Ultrasound can find abnormalities and they can totally oversee things.
Anyways, the high price tag makes the decision for me. Unless I'm in Europe at 20 weeks, no u/s for me (it's 185 Euros with a highly skilled peri there).

[lunarlady]

I decided to get a 20 week u/s even though I'm home birthing just in case there are major organ issues or spina bifidia. If either is indicated, I would consider birthing at our local hospital known for their NICU unit. That being said, I know that sometimes major issues are missed on the u/s. One of my friends had a DD born with major heart defect that was missed on u/s. She needed airlifting to the NICU and immediate open heart surgury. I know that is a possiblity for homebirth as well, and I figure delayed cord cutting might help buy us the 20 minutes we would need to rush the newborn to the hospital with a great NICU. In the end, that 20 minute drive would actually be shorter than the hour it took to airlift my friends child, so I still feel homebirth is safe even if some undiagnosed issues are present. But a clear u/s does help put my mind at ease, so that is why I'm doing it. I don't know if I would go so far as to say it is necessary, more just reccomended. I think you can have a perfectly safe labor and delivery without one!