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I'm not looking to debate the benefits and risks of ultrasound....But I'm wondering what other midwives require/request/recommend in regards to ultrasound exams. Because in my practice, I recently had an experience that is causing me to re-think, question and ponder my protocols a bit. And I want to explore this topic more with other midwives. Because I think that experience is a great teacher, and questioning and round-table'ing issues is essential in midwifery.<br><br>
Do you ask clients to have a 20-week anatomy scan? Do you require ultrasound if they've had a c-section previously? Do you recommend ultrasound, not recommend it, or have no preference either way? Are your protocols by your choice, or are your ultrasound protocols limited or dictated by your state laws?<br><br>
I'm asking because I always offer my clients a 20-week ultrasound with my sonographer, but I let my clients choose if they want an ultrasound or not. Recently, I had a client who's 20-wk u/s showed a previa... which we followed up on at 34-weeks with a vaginal u/s (as recommended by my very trusted and experienced sonographer). Her anterior placenta had moved up just a touch, barely out of the way, but had a posterior accessory lobe adjacent to the cervix, with the connecting vessels going straight across the cervix. I had to risk her out for vasa previa.<br><br>
Now, vasa previa is rare, I know. But it feels very real to me and to my client right now. And we wouldn't have known about it without the ultrasound exams. So.... the past couple of weeks I've been trying to come to terms with balancing what I know and what I feel...and how I will proceed with recommendations for ultrasound from now on.<br><br>
Thoughts?
 

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<img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/lurk.gif" style="border:0px solid;" title="lurk">:
 

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That's a tough one. I'll be interested to see what others say. I think, philosophically, that you have to look at the kind of midwifery you practice...<br><br>
Up until this point, you have taken the view that birth is inherently safe, is that correct? And you have given your clients the OPTION (so informed consent) to have a 20 week u/s?<br><br>
Do you feel differently about birth? Do you feel that birth is NOT inherently safe?...or that THAT birth was less safe as a vaginal birth? Do you want to go down that slippery slope? How many UNneccesary cesareans could result from future mandatory scans?<br><br>
In the last year, I have seen MANY of the things that those who try to nay-say midwifery use as examples for using obstetric care as the gold standard. And you know what? I still see birth as inherently safe. Because if I took ALL of the births of ALL of the midwives I know?...those things are STILL the minority...and in fact a teeny, tiny minority of the births, at that. And, frankly, the way the women in our care were treated was often so completely different from the care they would have been given by hospital staff alone that they were still much happier with their birth experience...<br><br>
On top of that...taking that decision away from your clients takes a bit of the midwifery out of your practice. I believe strongly that one of the tenets of midwifery is educating our clients and then allowing them to make informed decisions. YES. One of the risks of NOT having an ultrasound is missing something important. What are the risks of HAVING an ultrasound? And for a given client, what has the greater weight? I believe that that is important.
 

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I don't like ultrasound. I really don't.<br><br>
there, I've said it.<br><br>
I do not now, and hope I never do mention u/s to clients without a particular cause for that (which has happened in .5% of my practice thus far). When they mention it themselves, I leave it up to them but I do try to help make sure they understand the risks: a) it is not proven safe yet and, much more important to me right now b) it is not reliable and can lead to unnecessary interventions, stress and/or damage to women and babies.<br><br>
Just as you have that story about a vasa previa, which of course makes you wonder how often a 'routine' u/s might just show you similar things that will positively impact your choices....I now have a story about a sono that pushed a client into a needless and problematic 35.5wk induction. Luckily, at 1 month the baby is finally doing great...but the sono turned out to be all wrong! I knew it would, but the parents were too afraid and chose to trust the docs on that one. And it seems to me that every time I turn around, I am hearing more stories about inaccurate info coming from u/s. Inaccurate info that leads to unnecessary fear and interventive birthing choices (or alternatively, a false sense of security). Of course, often u/s is right, or at least 'right enough'. For me the problem is that we never know which time it will be right! And compounding this is the issue that women seem to generally believe that u/s IS right, it is pretty much totally reliable--so decisions get made on what is a fairly faulty basis.<br><br>
To me homebirth is just different. It's not that I am such a purist, or think that only purist types should try for homebirth. But to embrace homebirth is to embrace a different mindset entirely than when utilizing hospital birth. The times I've seen mws or clients try for that 'best of both worlds' by incorporating a lot of med technology into their practices/pregnancies, are times I've seen too much stress for all concerned (most often) and families who seem never to get off the fence about WHERE AND HOW they are giving birth. And midwives who need to exercise more and more power over thier clients because the mws are simply more knowledgeable of, and more comfortable around, those technologies than the average client will ever be. Then again, I simply do not want to provide 'hospital birth in the comfort of your own home', any more than I ever wanted to provide my children with 'public schooling in the comfort of our own home', and so forth. But some mws feel that this is a perfectly legitimate approach to take--and I do argue their right to practice that way, or clients' rights to accept that kind of care.<br><br>
Rather than coming to rely more and more on technology, placing more and more trust in 'science', I want to facilitate my clients becoming more and more attuned with their intuition and power. I do not believe that 'science' and med technology will EVER be superior to our innate gifts, wisely used....including the gifts of endurance and faith, because we cannot guarantee 'happy outcomes' for all, no matter what tools we utilize in service of pregnancy and birth.<br><br>
This is the short form of this rant....
 

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Discussion Starter · #5 ·
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<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">taking that decision away from your clients takes a bit of the midwifery out of your practice. I believe strongly that one of the tenets of midwifery is educating our clients and then allowing them to make informed decisions.</td>
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Let me clarify that it hasn't even crossed my mind to "require" ultrasound in my practice. That wouldn't sit well with me, personally. My issue that I've been pondering and questioning is: is this something that I will "recommend" in the future, or simply just "offer".<br><br>
"Do you want an ultrasound?" or "I recommend an ultrasound, although it is completely your choice. What would you like to do?" It's a subtle difference, but one that can influence the clients decision.<br><br>
I guess in the end, it simply comes back to what I do with most things in midwifery: present the pros and cons and let the parents choose.<br><br>
Thanks for your thoughts ladies. It certainly helped me clarify the issue. Talking things out always seems to, huh? I love peer review.
 

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This is an interesting question for me. The CPM who is going to be my preceptor was my mw for my 1st and 4th births. There was 5 years between them. With my first, she never even mentioned U/S. With my 4th she suggested/requested we get one. She had a couple of scary incidents that led her to believe it was a good idea to get one. She wouldn't have a problem with a client refusing, but she does prefer they have one done... I'm going to have to talk to her more about this, to get some more info on her reasoning.
 

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I remember asking a very similar question on another forum after I first encountered a vasa previa (while working as an RN in L&D). By that point I was pretty anti-ultrasound and had decided that I would choose to not have a routine ultrasound when I became pregnant myself. Then I witnessed a true vasa previa that was not detected prenatally and I was going hmm... maybe the ultrasound is a good idea after all? But, after thinking about it for a long time, I still *personally* feel that the risks of a false positive for something else far outweigh the possibility of missing a vasa previa diagnosis (or anything else similarly rare).<br><br>
It is very rare. When it does occur the consequences can be very serious. Or, it can turn out just fine. The birth I attended went just fine. The mother HAD had an ultrasound (actually a couple of them, I think) but it was not diagnosed prenatally. No problems during birth whatsoever. We saw it after the placenta was birthed. You could see where the sac had broken, *between* the vessels. It's a darned good thing her membranes broke on her own... I have since heard that when they break spontaneously they usually break between the vessels so that the vessels are somewhat protected. If ARM is done the amnihook can break a blood vessel and, well, that isn't going to turn out well. In this case the OB was about to come in to do an ARM when she had the SROM anyway.... <insert twilight zone music><br><br>
I only worked in the hospital for three years (two in L&D and one in NICU) but I have seen so many problems caused by ultrasound. Unnecessary inductions, amniocentesis, cesareans, etc etc etc. It's crazy how inaccurate they are. And that was at a huge teaching hospital, well respected, level 3 NICU, busiest hospital in Western Canada, etc. I have seen a baby born at 23 weeks and barely survive, with multiple medical problems, because the "routine" ultrasound showed a possible problem which was determined to require further investigation by amniocentesis... mom's sac wouldn't reseal... went into labour at 21 weeks... held off for 2 more, with ruptured membranes the whole time... baby ended up doing relatively okay, but what an ordeal for the family. And, the problem "seen" on the ultrasound? NOT present.<br><br>
That is just one example (definitely one of the more dramatic, but not by much). I have also seen several problems which should have been seen on ultrasound but where missed, including severe cardiac defects and other malformations.<br><br>
The ONE mother I can remember from working in L&D who chose to not have any ultrasounds ended up giving birth to a baby with no lungs. EVERYONE was going "see, that's why you should have an ultrasound!". Well... maybe it would have been diagnosed, maybe not... and what, is having the ultrasound going to change the outcome? Will the baby magically grow lungs?<br><br>
Just my 2 cents.
 

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For all forms of previa found you can take homeopathic Cinnamomum 200C twice daily for 3 days. This has moved partial and full previas up the uterine wall on clients in our area. I have a "marginal placenta previa" right now with my sixth and am doing this regimen.
 

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<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">
<div>Originally Posted by <strong>homewithtwinsmama</strong> <a href="/community/forum/post/9845258"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">For all forms of previa found you can take homeopathic Cinnamomum 200C twice daily for 3 days. This has moved partial and full previas up the uterine wall on clients in our area. I have a "marginal placenta previa" right now with my sixth and am doing this regimen.</div>
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That sounds CRAZY but then again so does the entire idea of homeopathy... I would love to see that work! (And of course, like all homeopathy, if it doesn't work, at least you haven't done any harm.)
 

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<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">
<div>Originally Posted by <strong>homewithtwinsmama</strong> <a href="/community/forum/post/9845258"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">For all forms of previa found you can take homeopathic Cinnamomum 200C twice daily for 3 days. This has moved partial and full previas up the uterine wall on clients in our area. I have a "marginal placenta previa" right now with my sixth and am doing this regimen.</div>
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But, I wonder how this would work with vasa previa, where it is the vessel that is transversing the cervix? I wonder if the homeopathic would affect the vasa previa the same as the placenta previa?
 

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I don't know about the vasa previa but as another poster said, it won't hurt, it just may NOT work. Worth a shot since its ten bucks and little effort. I have enough local success stories to feel that it is a viable option before risking someone out.
 

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I hope it's OK for me to barge in here - Cori, I have a question.<br><br>
Do many sonographers not have the skills to diagnose vasa previa? I recently had a Level II u/s at 20 weeks. I did IVF and while my doctors seem unaware of this, it puts me at a 10-fold increased risk for vasa previa (approx 1 in 300 risk). I was concerned about this and just requested to be checked for it. (I also have a marginal placenta previa right now.)<br><br>
The tech told me 'you can't scan for that - that is something that doesn't happen until birth - I think she confused it with a cord prolapse! Then she told me, "I wouldn't worry about it." So when the peri came in, I asked her to check me, and she, too, asked me why I was 'so worried about it' (Gee, a 10-fold increased risk maybe?) and she just pointed out my cord insertion as proof I didn't have it. I was confused because I know velamentous cord insertion isn't the same thing as VP - they're two separate things, right?<br><br>
So when they did my vaginal u/s to check cervix length I meekly asked if they could please turn on the color doppler and they acted like I was nuts. They did it and pointed out my placenta RIGHT THERE next to the cervix but said, "There is no cord here) and that's about all the info I got that I don't have VP.<br><br>
I'm so frustrated because I don't feel confident that I was cleared of VP. I wonder if you have any advice on what questions I need to ask when I try to find someone who knows what they're doing to clear me of this. Does it HAVE to be diagnosed via VAGINAL color doppler? Because if that's the case, they certainly didn't know what they were doing at all.<br><br>
If anyone has advice, please ... I'm feeling so frustrated right now. Thanks!
 

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<div>Originally Posted by <strong>JavaFinch</strong> <a href="/community/forum/post/9870057"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">So when the peri came in, I asked her to check me, and she, too, asked me why I was 'so worried about it' (Gee, a 10-fold increased risk maybe?) and she just pointed out my cord insertion as proof I didn't have it. I was confused because I know velamentous cord insertion isn't the same thing as VP - they're two separate things, right?<br><br>
So when they did my vaginal u/s to check cervix length I meekly asked if they could please turn on the color doppler and they acted like I was nuts. They did it and pointed out my placenta RIGHT THERE next to the cervix but said, "There is no cord here) and that's about all the info I got that I don't have VP.<br><br>
I'm so frustrated because I don't feel confident that I was cleared of VP. I wonder if you have any advice on what questions I need to ask when I try to find someone who knows what they're doing to clear me of this. Does it HAVE to be diagnosed via VAGINAL color doppler? Because if that's the case, they certainly didn't know what they were doing at all.<br><br>
If anyone has advice, please ... I'm feeling so frustrated right now. Thanks!</div>
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Hi, I am not totally sure about the vaginal colour doppler question - but my understanding is that yes, vasa previa and velementous insertion *are* two different things, but you have to have a velementous insertion to have a vasa previa. In other words, you could have a velementous insertion that was not also vasa previa, but you can't have a vasa previa that is not also a velementous insertion. I hope that makes sense, lol. Basically a velementous insertion is when the umbilical cord inserts into the membranes instead of the placenta. This means that the vessels from the cord have to run through the membranes to get to the placenta. If these vessels lie over the cervix, that is called a vasa previa. I hope that helps a bit!
 

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<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">
<div>Originally Posted by <strong>Mama2Xander</strong> <a href="/community/forum/post/9870258"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">Hi, I am not totally sure about the vaginal colour doppler question - but my understanding is that yes, vasa previa and velementous insertion *are* two different things, but you have to have a velementous insertion to have a vasa previa. In other words, you could have a velementous insertion that was not also vasa previa, but you can't have a vasa previa that is not also a velementous insertion. I hope that makes sense, lol. Basically a velementous insertion is when the umbilical cord inserts into the membranes instead of the placenta. This means that the vessels from the cord have to run through the membranes to get to the placenta. If these vessels lie over the cervix, that is called a vasa previa. I hope that helps a bit!</div>
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Thank you for this explanation. But what about in the case of a placenta previa 'moving up' but 'leaving behind' some vessels over the cervix (basically I read this is due to that part of the placenta dying off, not really 'moving') I hope that makes sense. Can't vasa previa orginate not only from the cord but also the placenta? If that makes sense (and if not, please forgive my ignorance - I wish I didn't even have to be trying to learn all this but I just don't trust my doctors) <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/greensad.gif" style="border:0px solid;" title="greensad">
 

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Well, vasa previa can also occur when there is a succenturiate lobe. It is essentially when there is a vessel transversing the membrane that happens to lie over the cervix. So, the placenta wouldn't 'leave behind' a vessel as the uterus grows and pulls the placenta up away from the cervix. Either there is a vessel that is going through the membranes, or there isn't, and if there is, if it lies over the cervix, it would be considered vasa previa.
 

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I had velementous insertion. I had ultra sound but it went undetected. I often think about the different life I would be leading; no baby as as she likely would have died if I had a vasa previa situation. I am not very educated in this as I am not in the medical field at all and those who are that I have asked have not come across even the VI often.
 

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<div>Originally Posted by <strong>Lennon</strong> <a href="/community/forum/post/9870548"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">Well, vasa previa can also occur when there is a succenturiate lobe. It is essentially when there is a vessel transversing the membrane that happens to lie over the cervix. So, the placenta wouldn't 'leave behind' a vessel as the uterus grows and pulls the placenta up away from the cervix. Either there is a vessel that is going through the membranes, or there isn't, and if there is, if it lies over the cervix, it would be considered vasa previa.</div>
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Thanks Lennon, I forgot that it can also occur with a succenturiate lobe. Good point <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/smile.gif" style="border:0px solid;" title="smile">
 

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<div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">
<div>Originally Posted by <strong>Lennon</strong> <a href="/community/forum/post/9870548"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a></div>
<div style="font-style:italic;">Well, vasa previa can also occur when there is a succenturiate lobe. It is essentially when there is a vessel transversing the membrane that happens to lie over the cervix. So, the placenta wouldn't 'leave behind' a vessel as the uterus grows and pulls the placenta up away from the cervix. Either there is a vessel that is going through the membranes, or there isn't, and if there is, if it lies over the cervix, it would be considered vasa previa.</div>
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I just watched a great presentation on vasa previa, and I urge anyone interested in the subject to watch it: <a href="http://www.thefetus.net/link.php?id=2182" target="_blank">http://www.thefetus.net/link.php?id=2182</a><br><br>
According to that, velamentous insertion and succenturiate/bi-lobed placentas are the two main causes, but the third cause is also when a marginal previa (to put it simply) moves away from the cervix, but leaves behind vessels near/crossing internal os.<br><br>
So please correct me if I'm wrong, but the peri ONLY looking at my cord insertion and not looking at my internal os was NOT properly diagnosing me. I'm also beyond mad at this point that the tech didn't even know what it was. After viewing the above presentation, I am just so confused WHY a tech wouldn't know that??? A tech who works at a perinatologist's office. I'm going to call them and see if I can get an email to send this presentation to that tech - I hope she watches it and learns something.<br><br>
The presentation quoted 1.5-4 per 10,000 as the occurrance rate of VP and 1 in 300 for IVF pregnancies. Is it wrong for me to expect my doctors to know this? (sorry if I sound so aggitated - it's all directed at my doctors, not anyone here - just to be clear <img alt="" class="inlineimg" src="http://www.mothering.com/discussions/images/smilies/smile.gif" style="border:0px solid;" title="smile">) ***** deep breath *****<br><br>
Thanks!
 
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