Kim Wildner, CCE
So, what tests are useful and which are harmful? There is no blanket response to this. Not only does each intervention have a legitimate purpose, but my above position must be clarified at the outset...Parents do have the right to question routine technology and require proof applicability to their own pregnancy, but with this right comes a huge responsibility. Parents who refuse a test or procedure without justification, or who refuse testing in medically indicated situations, are doing themselves a disservice, as well as disrespecting their caregiver.
One problem here is that many women are being labeled "high risk" less judiciously than the tests are being ordered. "High risk" these days can mean too young, too old, too many babies, too few babies, previously infertile (Even when it has been the husband's infertility or no certain known cause as in my own case...go figure!), previously too fertile (meaning a history of twins or other multiples), previous cesarean (even with a non-repeating circumstance and plenty of scientific proof that a past cesarean is not a risk factor), too long of a labor, too short of a labor, breech...the list goes on and on. Included in this list are preventable complications that were actually caused, either indirectly or directly, by the tests or treatments resulting from the tests. I can't even list them all, but some will be touched on as we take a brief look at each test. Some have gone so far as to call pregnancy itself a dangerous condition! There is so much data to refute this (covered on my other pages and links from my pages) that I won't even try to change that belief here. Suffice it to say that it is a belief...an opinion...that cannot be substantiated. Yet many women's pregnancies and births are managed under this delusion.
I also want to point out before I get into specifics, that if you are pregnant and reading for the first time that a procedure you have consented to may carry risks, don't beat yourself up! We do the best with what we have, and when we know better, we do better. Guilt would only be useful if you could or should make different choices in the future. Much of what I teach and write comes from personal experience and this is no different. It took me 5 years of heartache and concentrated effort to conceive my daughter. I was anxious. I had miscarried my first pregnancy the year before. I was also in the midst of midwifery training, which meant I was learning about plenty of things that could go wrong. Even though I knew in my head that the odds were overwhelmingly in favor of a healthy baby and wonderful birth, a part of me still wanted proof that there was still a baby in there. I used a hand-held Doppler for 15 minutes at a time once or twice a week from the time I thought I might be able to hear something, right up until labor. Yes, I knew it was ultrasound and yes, I knew there were some concerns. But what I didn't know is that the hand Doppler u/s is continuous, whereas the ultrasound used in pictures is intermittent.
Because I learned this after the fact, there was nothing to be done about it. I feel no guilt because I didn't know better. Now that I do, should I ever be blessed enough to get pregnant again, I will ask that a fetoscope be used unless there is a specific reason to use the Doppler. My daughter does not have any problems because of my carelessness...that I know of. But the deleterious effects noted with u/s exposure are at a cellular level. I won't know if her eggs were damaged for many years. Still, I didn't know. Now I do.
Does that mean that this tool is never useful? NO. I own a Doppler and have used it with clients. With their permission or at their request. I have used it when a fetoscope was not adequate to hear heart tones as clearly as I felt I needed to hear them. I would permit use in my own labor if I were in a comfortable position, say in a tub, where a fetoscope was not feasible. I'm not sure I'm convinced that u/s is a big huge danger to our children, but as I parent I want to know that there is a concern so that I can make an educated decision. I choose to err on the side of caution. When there is substantiated proof that this is an absolutely safe tool to use in the absence of medical necessity, great. Until then I feel it is my duty as an educator to let mothers know what I learned too late.
Finally, I expect the reader to delve into their own subjects of interest further. There are whole books written on prenatal testing (see the suggested reading at the end of this article). I can only raise some tough questions here...the rest is up to you.
Ultrasound (U/S).
Ultrasound was developed to be able to "see into the womb" when a problem was suspected. It is amazing technology, I admit. I had a client with third trimester bleeding that asked me to accompany her to an ultrasound and it was easy to see why physicians and parents alike are captivated by it. It was extraordinary! I could almost see who the baby looked like!
But this is where common sense must prevail. Just because it's 'cool' doesn't make it right for every woman. What are some common medical indications where the use of ultrasound is justified? Bleeding in the third trimester (Some contend that u/s in the 1st trimester contributes to miscarriage. [1, 2] If u/s is being used because a miscarriage is threatening I have to wonder why they are ordered...an u/s cannot prevent, but may contribute to, the miscarriage, so why are they done so often for this reason?), breech, twins, polyhydramnios (too much fluid) and ogliohydramnios (too little fluid). Some conditions with questionable advisability are in the "we're just checking to make sure everything is okay" category. The "just in case" philosophy assumes that there is a higher probability that something is wrong than that something is right, which isn't the case. Not to mention the fact that very often the parents are stressed out for months over 'possible' problems that simply don't exist and never did. A case that illustrates this...
One friend was told very early in her pregnancy that her placenta was covering the cervix. (if you are pregnant and don't know these terms, please take a good childbirth class!) She was told she needed to have a cesarean and plans were made accordingly. Now, the problem with that is this...imagine (or actually do this) if you were to take a balloon and with a marker and color a circle near the bottom where you blow it up. Not directly on the neck, but where it starts to get the wider, rounder shape. Now, blow it up. What happens to the circle? It doesn't actually move, and yet it does seem to. It 'migrates' up. So do placentas. Placentas also tend to gravitate to areas of better blood flow.[Ultrasound
screening and perinatal mortality: controlled trial of systematic one-stage
screening in pregnancy. The Helsinki Ultrasound Trial.Saari-Kemppainen A, Karjalainen O, Ylostalo P, Heinonen OPLancet 1990 Aug 18;336(8712):387-91] So, when my friend actually was ready to deliver, her placenta was right where it was supposed to be. Fortunately, she gave birth really quickly and there was no time for surgery, otherwise she would have had abdominal surgery with a five times higher mortality rate (than vaginal birth) for no reason at all!
Although there are suspected risks to ultrasound, it is used with abandon. There is no hard evidence that the rise in ADHD, neurological disorders like autism or even cellular changes that could reslut in things like leukemia are a result of ultrasound, but neither is there solid proof that they aren't. If I were bleeding near term or suspected a multiple birth you can be sure I'd look at the risk benefit ratio and agree to use this technology that could save my baby's life or necessitate a change in birth plans. Would I do it just to get an early baby picture or to detect a possible problem that I would refuse to abort for? Not a chance. But that's just me.
An even bigger problem with ultrasound is that if something looks 'suspicious', which happens more often than not, this leads to others tests. There is a domino effect here, as many prenatal tests have high false-positive rates (meaning there isn't anything wrong, but the test says there is) or are just plain not accurate in either direction (meaning they may not detect the problem they are testing for a large portion of the time either).
What
is Ultrasound? A Definition of its Use and Practice [Mothering
Magazine]
Weighing
the Risks: What You Should Know About Ultrasound [Mothering
Magazine]
1. A. Saari-Kemppainen, O. Karjalainen, P. Ylostalo et al., "Ultrasound Screening and Perinatal Mortality: Controlled Trial of Systematic One-stage Screening in Pregnancy," The Lancet 336, no. 8712 (1990): 387-391.
2. R. P. Lorenz, C. H. Comstock, S. F. Bottoms, and S. R. Marx, "Randomised Prospective Trial Comparing Ultrasonography and Pelvic Examination for Preterm Labor Surveillance," Am J Obstet Gynecol 162, no. 6 (1990): 1603-1610.
Gestational Diabetes Testing
This is an example of an inaccurate test. It has a 70% non-reproducibility rate. Seventy percent of the time you can give the test to the same woman under the same circumstances and it will not be the same! Does that mean it has no value? Not at all. It was developed to prevent the problems associated with diabetes in pregnant women, and surely, pregnant diabetics are at risk for a number of problems. Not all women are diabetic but all women are tested. This is causing major problems.
First of all, pregnant women should never go more than 2 hours without food because of the delicate blood sugar balance of pregnancy (low blood sugar is one of the reasons for pregnancy nausea). A short explanation of the physiology of a pregnant woman...
Protein may be the building blocks of creating a baby, but glucose (sugar) makes a baby grow. It is a recent phenomenon that processed sugar has been introduced into our bodies beginning just after birth (it is a main ingredient in infant formula). Our bodies already don't respond well to the huge amounts of the stuff we pour into our bodies daily in the form of soda, cakes, candy and simple starches. There has been a huge increase in childhood diabetes and adult onset diabetes (One source says a 500% increase in the last 30 or 40 years...hmmm...just when breastfeeding fell out of favor...interesting!). Our poor pancreas'!
Anyway, in pregnancy our bodies produce less insulin so that more sugar is available to grow that baby bigger, under the assumption that sugar is a rarity in your diet. But it isn't. It's consumed in large amounts in the Standard American Diet. So, let's ask the obvious...if a pregnant woman is starved for hours and then given pure sugar to drink, will it show up in her blood test? Hell, yes! Does that make her diabetic? Hell no! But she will be treated so. She will be put on a restricted diet that can lead to pre-eclampsia. I've seen it happen so often I can predict it before a women finishes her pregnancy/birth story.
Again, that doesn't negate it's usefulness completely. If a women has a family history of diabetes or if she shows sugar in her urine dip stick test regularly (or even in a finger poke) and it isn't resolved with diet, there are ways to make the test more accurate and do it without starving her. Symptoms associated with diabetes would also put up a red flag for a caregiver. In these instances, having the test could help a mother modify her diet to avoid complications.
And here a word about diet. The diet I've seen recommended to pregnant women with high glucose readings makes them sick. It is low/no sugar, but it also is low calorie, many times low protein and low salt. Pregnant women need these things. Again, we come back to common sense. It's pretty simple. If you are pregnant, don't eat sugar. Eat whole grain bread, not white. Eat fruit, don't drink it as juice. Stay away from pure sugar like cakes, candy and pop all together. Eat brown rice, not instant rice. Eat as though you are growing a body that your baby will use for a lifetime...because you are!
The American Diabetes Association's new recommendations that low risk pregnant women not be screened for GD.
Emperor's New Clothes, article on the Uselessness of Standard Management of Gestational Diabetes by Henci Goer
Chorionic Villi Sampling, Alpha-Fetoprotein/triple test and Amniocentesis
As the cells are dividing to become what will be the baby and what will be the placenta, little root like structures, the chorionic villi, form. Thousands of babies were born without appendages because the cells that would have developed into fingers were removed to test for chromosome abnormalities early enough to abort. The irony is, in many of those instances, the mother wouldn't have aborted even if her baby had defects, but the test caused the certainty of one.
Fortunately, this one has fallen out of favor. In it's place are the other above mentioned. The reason I even included it is because women assume that if a test is recommended, it must be safe. Think again. CVS was used for a couple of years before anyone put two and two together. Many women of my mother's generation were given x-rays in pregnancy and labor and told it was completely safe. Twenty years down the road it's discovered that radiation can cause reproductive damage...not only to the mother, but to her female fetus...born with all the eggs she will ever produce. DES and Thalidomide are other examples. [Note: all of my lab books and medical texts are at my office, which is not where I am composing this web page. I'm writing from memory, but will cite references and check spelling once I get my books.]
Many mothers ask "What's the harm in having the triple test? It's just a little bit of blood." Agreed. But consider this true life example...
Another acquaintance of mine figured just that; no big deal. She had it done, even though she was not in a high risk group and would never consider abortion. Her doctor told her that her baby had Down Syndrome and wanted her to have an amnio. She did refuse that after learning there was a higher risk of losing her baby from the amnio than there was that it would show a problem. But, she was now a 'high risk' mother. She was pressured to have more tests, more ultrasounds and genetic counseling. She was referred to an OB specializing in high risk and told she could expect a cesarean. I still don't understand the logic in that...put mother and baby at greater risk of death even though surgery could not prevent nor cure the suspected problem. This mother went through months of stress, which is known to have a detrimental effect on pregnancy for nothing at all. Her baby was fine.
I could give innumerable examples, but I won't. For one, I think that people already take case examples of inept physicians and let that color their attitudes about all doctors. That's not fair. Sure, some doctors may order unnecessary testing, but not all of them do. And, while the doctor may order it, without the parent's consent, the test cannot proceed. And I guess this is as good of a place to put this next statement as any. Doctors order all this testing because they are the most sued people on the planet and they are covering their butts with all these tests. Are they sued most because they are inept? Some. Most, though, are sued because we, the public, expect them to be infallible. There not. They are people. A mother cannot smoke a pack a day and then sue the doctor because her baby dies due to an abrupted placenta. But they do. And they expect the doctor to pull a miracle off even though it was a predicable outcome due to the mother's own actions (Not to mention plain common sense.)
It's up to the parents to determine if their doctor is using the tests as medically indicated or inappropriately. A solidly respectful and non-authoritarian relationship with excellent communication is the only way to know. Again, it's up to the parents to develop that trust. And remember this quote from Maya Angelou: "When people show you who they are...believe them."
Ultimately, this means when you get a red flag, a feeling in your gut, listen. If you have respectfully approached your caregiver with reasonable requests and solid evidence in support of why you want certain things in your birth plan, and you get responses that include disrespect, anger or ultimatums, run! I have know people to fire their caregiver two weeks before delivery because their requests were met with a dismissive, or even hostile, attitude. You pay these people a lot of money to help you, not to humiliate or harangue you.
So what is a parent to do?
In a healthy, normal pregnancy the first step is to educate yourself and take responsibility for yourself. Prenatal care isn't what happens at your doctor's office, it's what you do for yourself between visits. Your caregiver doesn't have squat to deal with if you don't take care of yourself and your baby.
Ask questions. When your doctor says you need a test, you have every right to ask what it's for, how accurate the test is and what information will be gained by doing it. You should also know before-hand what the next step would be if the test does uncover a problem. Of course, the flip side of that is, if the test doesn't reveal anything, is that the end of it? Or will more testing be recommended? If an intervention will be suggested for any condition found, are there risks or side effects? Are there alternatives, including a wait-and-see attitude? If the treatment is not successful, what would the next step be? Is the problem you are looking for a serious one, and if so, how serious?
Always be polite and respectful. A physician who is requesting tests for a true medical indication will have no problem with you wanting to know more about it. The more you know, the more likely you are to comply. In that same vein, do your homework. If you are going to initiate dialog and be a partner in your own care, you can't expect your midwife or physician to do all the work.
In the end everyone wins with this scenario. If you know that you have done everything possible toward a safer birth, and you have been able to feel some autonomy over this major life transition, you will be willing to give your power over to your physician in the case of a real emergency. After all, that's what you hired him/her for. Obstetrics is a surgical specialty and you want a specialist if your plan becomes something other than the normal birth you envisioned. Unexpected outcomes are even easier to deal with because there is no room for the 'what if' game if you've considered every angle in advance and made your own best decisions.
Suggested Reading:
Understading Diagnostic Tests for the Childbearing Year, Anne Frye
The Tentitive Pregnancy, Barbara Katz Rothman
Obsteric Myths vs Researh Realities, Henci Goer
The Thinking Woman's Guide to Better Birth, Henci Goer
Mothering Magazine, many editions have essays on pregnancy/birth technology
Silent Knife, Nancy Wainer Cohen
Y2Kid Considerations...my musings on parenting in the new millenium
Maternity Matters...Enjoying the journey and growing a healthy baby
Discomforts of Pregnancy & Helpful Hints
Nutrition in Pregnancy
But What If...? Questions often asked of homebirth-ers
