At the end of Pregnancy Help Institute, we invite our attendees to write a letter to the Board of a pregnancy center who might be trying to decide whether to send staff for training or not. Every year, we are inspired by their reactions to working with other like-minded individuals as they sharpen their skills to continue serving on the front lines of pregnancy help. Here's what a few of our 2017 Pregnancy Help Institute graduates had to say.
Dear Board Member,
If you are looking for one single thing that you can do to grow the ministry that you are a part of, please consider sending your director to Pregnancy Help Institute. I know when the budget is tight it is hard to spend money and allow your director to be out of the office. But it is worth every penny. Equipping your director to do his/her job better is a huge part of Pregnancy Help Institute, but the encouragement they will find there, you cannot put a price tag on.
Sincerely,2017 Pregnancy Help Institute GraduateNew Director Track
If you are considering sending your medical staff for ultrasound training at Pregnancy Help Institute, please do it! It will equip your staff to not only learn/be able to perform basic ultrasound exams, but to give that mother a chance to view LIFE! Not only will they learn the skill of ultrasound, but they will also be encouraged spiritually to effectively help a mother see her unborn. Your staff will leave blessed when they go in, and blessed when they leave (Deuteronomy 28:6).
Sincerely,2017 Pregnancy Help Institute GraduateUltrasound Training Track
What I have discovered is how important it is to take some time away to refresh and rediscover our purpose and energize our soul for the work we do. Being a part of the Pregnancy Help Institute training in development has helped me not only affirm much of what I have been focused on, but also to discover new ways to take our ministry to the next level. Development involves everyone on the team, and I have taken away so many ideas that I can present to our team to help us be the best we can be.
This week, I have been challenged, affirmed, and inspired to take what we do for God to the next level. I can take my skill set and use it for so much good. I have met amazing people who I will keep in touch with and bounce new ideas off of. It is so important to value the resources we have through Heartbeat International and to allow your team to participate so that they are more equipped to serve women and their families and affect generations to come and most importantly, be able to put on the armor of God to do the work we have been called to do. It’s an investment for God.
Sincerely,2017 Pregnancy Help Institute GraduateDevelopment Track
The investment for the heartbeat International training is not only faith-filled, but full of amazing information that can and will be incorporated into our plans for the home. I firmly believe this is something new members, as we add them to our team, need to attend. Not only has it been an amazing and information-filled week, but it has renewed my fire and excitement for our ministry.
Thank you,2017 Pregnancy Help Institute GraduateLeadership Track
The 2017 Pregnancy Help Institute Ultrasound Track was a great success!
Heartbeat International was incredibly blessed to have Tammy Stearns, RDMS and Bryan Williams, RDMS facilitate the ultrasound training portion of PHI. Tammy and Bryan, along with several other volunteer sonographers, spent the week training ten participants, including nurses, an RDMS, a Nurse Practitioner and a physician, from Pregnancy Centers around the country. Trisonics and Preferred Medical Systems, in a joint collaboration, provided ultrasound machines for use during the week of training.
The ultrasound training not only contained a didactic portion and scan labs, but a spiritual component as well. Tammy opened each day reminding the class that this is a ministry, not just a skill, and that this ministry is something that can only come out of God’s overflowing presence in our lives, and not from within our own selves. Each day, Tammy’s devotions emphasized how the spiritual side of things was a big part of the ultrasound ministry.
“I appreciate that this training was tailored to working in a CPC. I learned not only technical training but the spiritual aspect of giving these babies a voice for the first time.”
Each morning there was a classroom-style teaching which covered topics from physics and QA in the ultrasound setting, to anatomy of mom and baby, and abnormal findings while performing ultrasounds. For many of the participants, this was the first time they had undergone such a training, and the curriculum was designed to be real and applicable.
The afternoon scan labs were a huge success. There were 7 instructors who were involved in the hands-on training, and about 40 “models” from the community who volunteered their time (and bellies) for the students to take turns scanning. In total, about 200 scans were performed by the class (about 20 per student) which went towards the recommended 50-75 training scans that is recommended for Limited OB Ultrasound training. The students learned the basics of scanning a typical client that may present in the PRC, as well as the unique instruction on how to dialogue with the abortion-minded client during a scan.
“This was a very informative training. Each sonographer had a helpful hint to give, each one gave critical information for getting good ultrasounds. The didactic information was explained fully and in a helpful way. I believe I got way more than my money’s worth.”
The overall success of this year's ultrasound training will prove to be a huge tool in the PRC tool-belt as more qualified medical professionals are learning the ultrasound skills they need to be successful in the collective quest for life.
Recognizing the great service your Medical Directors give to your centers, Heartbeat International also wants to support them in their mission. Please pass on the information below about a great opportunity to your Medical Director.
The AIUM American Institute of Ultrasound in Medicine is presenting
Register today for Gynecologic and Early Obstetric Ultrasound---- Solving Problems With Imaging. This course is brimming with essential, illuminating sessions such as:
Join Course Chair Beryl Benacerraf, MD, FAIUM, AIUM president, and other esteemed faculty September 25-26, 2015, in Las Vegas, Nevada. This course offers up to 11 AMA PRA Category 1 Credits™ (accepted by the ARDMS) or ARRT Category A Credits. Learn more here.
By Susan Dammann RN
The FDA has issued a warning. While the FDA's main focus in the warning is to advise pregnant women to avoid commercial sonogram services for nonmedical purposes that could pose a danger to the developing fetus, emphasizing that these are prescription medical devices, are to be used only by trained health care professional and only with a prescription, included within the warning are guidelines/recommendations which we in the pregnancy help medical clinics should be aware of.
Below are three excerpts from the 12/16/14 FDA Consumer Update which may pertain to the use of ultrasound imaging in the PMC, and a question for you to consider.
"Fetal ultrasound imaging provides real-time images of the fetus. Doppler fetal ultrasound heartbeat monitors are hand-held ultrasound devices that let you listen to the heartbeat of the fetus. Both are prescription devices designed to be used by trained health care professionals. They are not intended for over-the-counter (OTC) sale or use, and the FDA strongly discourages their use for creating fetal keepsake images and videos."
Question: Are the sonograms in your center being performed by trained health care professionals?
"The long-term effects of tissue heating and cavitation are not known. Therefore, ultrasound scans should be done only when there is a medical need, based on a prescription, and performed by appropriately-trained operators."
Question: Are the sonograms performed in your center based on a prescription for a medical need?
"Similar concerns surround the OTC sale and use of Doppler ultrasound heartbeat monitors. These devices, which are used for listening to the heartbeat of a fetus, are legally marketed as "prescription devices," and should only be used by, or under the supervision of, a health care professional."
Question: If your center uses Doppler, is it being used under the supervision of a health care professional?
As you consider the above FDA recommendations in relation to the ultrasound services performed in your PMC keep in mind also that one of the points in the Commitment of Care and Competence to which all Heartbeat Affiliates sign in agreement is:
Medical services are provided in accordance with all applicable laws, and in accordance with pertinent medical standards, under the supervision and direction of a licensed physician.
To read the full FDA Consumer Update click here.
by Kevin T. Rooker, RT(R), RDMS, RVT, Sonography Consultants
Is ultrasound safe? Will it hurt my baby? These are questions we sometimes hear from our clients. We need to be able to answer those questions with confidence for several reasons. First, because our patients deserve an honest answer, and second because we never know who is listening. We know that there are some that think you should not be performing limited OB ultrasound and will always be looking for reasons to justify their position. Let's not give them that opportunity on the issue of ultrasound safety. Unfortunately, we, the medical community, have not done as well as we can at educating ourselves on the safety of ultrasound1.
Ultrasound is a wave of mechanical energy that penetrates human tissue as an oscillating (alternating) wave of high and low pressure. As it does so, there are two potential types of biological effects; Mechanical and Thermal. In 1993, the FDA allowed ultrasound manufacturers to significantly increase the amount of ultrasound energy created in diagnostic ultrasound systems, as long as they displayed the MI (Mechanical Index) and TI (Thermal Index) on the screen for the operator (and our clients) to see. The premise being that if we know what the MI and TI are, what their limits are, and most importantly how to lower them, then we are being as safe as we possibly can.
The Mechanical Index is a safety metric which lets the operator know how much energy is being transmitted into the patient during a sonography examination. Remember that sound is created by pressure waves, so mechanical energy is transmitted into any object which receives sound. Sound waves can be quite powerful. For example, think of the thump on your chest when sitting next to a teenager's car with the high dollar stereo system. It is defined as the peak negative pressure (PNP) of the ultrasound wave (point of maximal rarefaction). In easier terms; think pressure change divided by time. Lots of pressure change over short periods of time can be damaging. The FDA has established a maximum MI of 1.9 for diagnostic imaging. Any machine capable of generating MI greater than 1.0 must display the MI onscreen. The FDA MI limit for obstetric sonography is 1.0.
The Thermal Index is another safety metric which lets the operator know the potential of creating heat (hyperthermia) with the ultrasound beam. Many assumptions are made in this calculation, and it is often thought that the heating potential is underestimated. So keep in mind that the TI formulation was not intended to, and cannot provide an accurate measure of temperature rise within a specific patient. Instead it was designed to provide the operator with a relative measure of risk for a particular imaging mode. A Thermal Index of one (TI 1) indicates conditions under which the rise in temperature would be likely to be 1°C. The thermal index is different for different types of tissue, and can be displayed on your system accordingly: soft tissue (TIs), bone (TIb) and cranium (TIc). In the first trimester, when using Doppler to hear and demonstrate the fetal heart, the TIs setting us used. The limit for TI varies with time, please reference the chart below from the British Medical Ultrasound Society, the entire document may be found here.
Enough about what the MI and TI are, how do we as operators keep them at safe levels? There are two basic concerns to remember.
First is the AIUM ALARA policy2; which is an acronym for As Low As Reasonably Achievable. Simply translated, it means to keep the output power settings as low as possible, that still allows for adequate images. Most ultrasound systems can operate with output power settings at about 50% and still produce quite satisfactory OB images. Have your system presets adjusted so that when you are performing OB sonography both (abdominally and transvaginally), the output power settings are set low. You can always increase them if clinically necessary. And keep in mind that you can increase the gain to make your image brighter, as gain is just how well the system is "listening", it has no effect on the TI.
The second concern is time. Keep the overall examination as short as is reasonable. If using Doppler to allow Mom to hear her baby's heartbeat, depending upon your ceter's policy, keep the Doppler exposure to about 5-10 seconds. Know where to find the MI and TI displays on your system. If you don't know, consult your operator's manual or contact the manufacturer of your ultrasound system for more information.
Diagnostic ultrasound in obstetrics has been around for the better part of 40 years. To date, no one has been able to prove (and many have tried) that diagnostic ultrasound, when used prudently (MI,<1.0 and TI<0.7), has had any adverse effects developing fetuses; and this includes the limited use of Doppler in the first trimester "Thus far, there have been no significant thermal effects documented in humans and at this time the possibility of having all the factors present to is highly unlikely 3." However, it has been shown that aborting a living fetus is fatal, every time.
1. Ultrasound Is Safe . . . Right? Resident and Maternal-Fetal Medicine Fellow KnowledgeRegarding Obstetric Ultrasound Safety. J Ultrasound Med 2011; 30:21–27Sheiner E, Abramowicz JS. Clinical end users worldwide show poor knowledge regarding safety issues of ultrasound during pregnancy. J Ultrasound Med. 2008;27(4):499-501
2. As Low As Reasonably Achievable (ALARA) Principle Approved 4/2/2014 aium.org/officialStatements/39
3. FDA Recommendations for the Safe Use of Ultrasound in Obstetrics CNE article authored by Sherri A. Longo, M.D. Assistant Professor in the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Tulane University School of Medicine in New Orleans, Louisiana; e-edcredits.com/nursingcredits/article.asp?testID=29
Connie Ambrecht RDMS, Executive Director Equip Leaders Now/Sonography Now Beverly Anderson, J.D., CEO Dove Medical Susan Dammann RN LASm Medical Specialist
In April 2014, the American Institute of Ultrasound in Medicine (AIUM) sent an email to its members stating it had "Updated Guidelines and Official Statements." Included in the list was the guideline titled "Documentation of an Ultrasound Examination."
First, it is valuable to revisit who AIUM is, as well as its role in ultrasound imaging. In its own words, "the AIUM is an association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of guidelines, and accreditation."
In the first section of the guidelines, AIUM outlines what it considers high-quality patient care. The guidelines state a permanent record should always be kept of the images, and an interpretation should be provided for patient records. All medical professionals involved should be able to communicate well and work as a team to provide what is expected: quality patient care.
The next section lists what should be included in the official report. In some clinical settings, the interpretation of the images is transcribed and a separate report page is generated for the patients chart. In the PMC setting it is common that a signature is obtained on the ultrasound report page and serves as the final report.
Section three discusses the final report from the interpreting physician or medical director of the clinic. According to this April 2014 update, the final report should be generated in 24 hours. I know you are thinking or asking... "How can we do that?!"
We restate the following from the AIUM guideline: Practice guidelines of the AIUM are intended to provide the medical ultrasound community with guidelines for the performance and recording of high-quality ultrasound examinations. The guidelines reflect what the AIUM considers the minimum criteria for a complete examination in each area but are not intended to establish a legal standard of care.
This AIUM Guideline is NOT a legal requirement. It is a national practice standard.
We at Sonography Now live in the service trenches with you as we train on-site. We understand that getting interpretations in a timely fashion versus every 24 hours can seem unnecessary. Taking one step at a time can ease such a transition. If you want to make changes to accommodate a faster interpretation time, it doesn't need to change immediately.
Building a plan of action can remedy the feeling of urgency. Some clinics we work with have images interpreted daily so that the final report can be given to the patient. You have the freedom to choose your course of action based on your mission and vision.
Concerning our routine ultrasound report procedure, we need to answer the questions:
Our patients feel an urgency to have definitive information about their pregnancy. They need their confirmed diagnosis, not the nurse's preliminary findings.
My nightmare concerning delays in the physician reading Dove Medical's ultrasound exams is that our nurse will miss an ectopic pregnancy the physician would have caught, the patient will not have received the appropriate instructions and/or referral for immediate care, and the patient will suffer injury as a result. I strive to insure both the skill level of our nurses and also the prompt reading of all exams.
While some Medical Directors feel it would be consistent with the highest level of care which we strive for, that these standards should be recommended/set and then the center should work toward them, other Medical Directors who have discussed the issue feel strongly that we do not need to comply with the 24 hour mandate and that it would be impossible for most centers to do so.
We must remember that our Medical Directors are volunteering their services. If pressure is put upon them to comply with this standard, are we risking losing them as a Medical Director? If that scenario is a high probability, we must ask "How is this patient best served?" What do we tell the patient?
We can't do the sonogram because we can't turn the report around in 24 hours? Is a longer turn around period better for the patient than having no service at all? Also it is critical that we not alienate our Medical Directors who are sacrificing their time and skills to serve the patients in our clinic. Without them, we cannot offer ultrasound services at all.
If we set this as policy because it meets national standards but we cannot comply, what are the consequences? Is it better to adopt a policy set on the highest excellence we are feasibly able to provide so that we can continue serving our patients, rather than potentially losing our medical director or other consequences which would impede serving the patient? Then as we can, going forward, do what is possible to shorten the turn-around time.
Centers should make efforts to have ultrasound reports read, signed and returned within the shortest time frame that is reasonably feasible. Any scans with questionable findings of concern or emergency problems should be referred promptly to a physician or hospital emergency room. This policy should be made known to the patient on the intake form.
You may want to consider the following options, among others, as means to improve your turn-around time. This is only a sampling of options and not a recommendation of any specific option.
Inform your Medical Director of the recommendation by the AIUM and have a conversation with them. Let him/her know that it is a practice standard, not law. Discuss the best and most feasible policy for your center. Examine your current policy and practice – how well is that working? Does it meet the goal for the best service your clinic can provide for the patient? Look at and discuss some of the options for improving the turn-around time. Are there any steps you feel you should take at this time? Set a time to re-examine and evaluate.
The AIUM Official Statement concerning Limited Obstetric Ultrasound (LOU), reaffirmed on 4/2/2014, makes some clear statements about the services we provide. I am reminded again that we must see ourselves as competent medical professionals and our services as medical diagnosis. Points of emphasis in the AIUM Official Statement include:
As an education organization Equip Leaders Now and Sonography Now have responsibility to keep ourselves informed of changes that may impact your specialized clinical setting. Our role is to pass information along and let you decide how it fits in your clinic. At Sonography Now, our mission is to provide education related to imaging, at Equip Leaders Now, our mission is to build leaders by providing the tools needed to make informed decisions to build strong communities. In doing this we have an obligation to give you information so you can be empowered with the information to form your own talking points and messaging so you can be represented well in your community and to the patients you serve.
Contact Connie Ambrecht or Beverly Anderson at 702-925-8737 with any questions or for a private webinar for your team on this topic.
As the Ebola outbreak has spread from West Africa to isolated cases in parts of Europe and now the United States, there has been no shortage of panic and paranoia among Westerners—even those working in the health care fields.
Still, it is an established and repeated fact that Ebola's spread can be prevented simply by following proper safety procedures in a medical setting. An informational page on Ebola published at the World Health Organization's (WHO) website points to the sad reality of Ebola's largely preventable spread:
Health-care workers have frequently been infected while treating patients with suspected or confirmed EVD [Ebola Virus Disease]. This has occurred through close contact with patients when infection control precautions are not strictly practiced.1
As those involved in the life-saving work of pregnancy help in the medical setting, how can you protect yourself, your clinic, and your clients from this deadly virus?
The answer starts with educating yourself, your staff and volunteers, and your clients as to how Ebola spreads, which, again according to WHO, involves the following:
Ebola... spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people, and with surfaces and materials (e.g. bedding, clothing) contaminated with these fluids.2
Consider the functions of your Pregnancy Help Medical Center or Clinic.
With these points of contact posing risks in light of the Ebola virus—in addition to several diseases that are much more likely to spread—make sure your center is paying special attention to policies such as Universal Precautions as defined by the Centers for Disease Control (CDC) and OSHA Regulations.
Under Universal Precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, (Hepatitis B), and other blood-borne pathogens. Universal Precautions involve the routine wearing of gloves, other protective clothing, hand washing, and such infection control measures that are designed to place a barrier between potentially infectious blood or body fluids and employees.3
For more information on how you can keep your center protected from the spread of viral infection, check out Heartbeat International's Medical Essentials for Pregnancy Help Organizations©.
1. "Ebola virus disease," World Health Organization, http://www.who.int/mediacentre/factsheets/fs103/en/ (accessed Oct. 17, 2014).
3. Medical Essentials for Pregnancy Help Organizations©, Heartbeat International, 2014, Part IV, page 4.
Healthy Pregnancy/Healthy Baby Series: Part 1
By Helen Risse RN MSN
If you work with pregnant women, you have a great opportunity to improve birth outcomes. When a new client visits your pregnancy help organization, this may be the only contact you have with her.
What should she be sure to know before she leaves you? Does she know her due date? Will you be telling her based on the first day of her last menstrual period?
It is important to define due date and term pregnancy. Remind your new mother that her due date is really a due time that looks at two weeks before to two weeks after that date as being "term". Many people still think of pregnancy in terms of nine months. Explain that pregnancy is defined as 40 weeks or 10 lunar months.
At the end of 2013, the American College of Obstetrics and Gynecology (ACOG) redefined the meaning of "term".
Research has noted that the brain of a baby at 35 weeks, 0 days grows in size by two-thirds in the following four weeks.
Research has noted that although the weight of a baby may look normal, babies born before 39 weeks are sleepier babies. These babies do not latch and suckle as well as babies born at 39 weeks 0 days. They have more problems with higher bilirubin levels. These concerns can lead to serious consequences. The choice of an elective delivery date must factor in these findings.
Women should also be taught the signs of preterm labor. Teach women about contractions. Explain what they may feel and describe those symptoms that should put them on alert.
Describe contractions as feeling like:
Describe vaginal discharge or bleeding:
Describe water breaks:
General feeling that something is not right.
What should she do if she thinks she may be having preterm labor? Below are some guidelines you may discuss with your Medical Director to develop a policy/procedure for your center.
If the contractions are coming more than every 15 minutes or 4-6 in an hour, call your doctor.
It is important to stay well hydrated. Dehydration can often cause a woman to experience contractions.Women should know the risks that increase concerns for preterm labor. Women who are at greatest risk for preterm labor are those who have had a previous preterm birth, as well as those who are pregnant with multiples, and those with certain abnormalities of their uterus or cervix.
Other risk factors include smoking, drinking alcohol, using illegal drugs, domestic violence, including physical, sexual or emotional abuse, or lack of support.
Additional risks factors related to her health include infections, including urinary tract infections, sexually transmitted infections, diabetes, high blood pressure, second trimester bleeding from the vagina, being underweight before pregnancy, obesity, and a short time period between pregnancies.
When asked if there is anything that can be done to prevent preterm labor, tell a woman to:
If you have one visit from a pregnant woman and pass on this information, you may contribute to an improved outcome. Every extra day her baby is in a healthy intrauterine environment is positive for the development of her baby, which in turn can be a big help to a new mother.
Spong CY. Defining "Term" Pregnancy: Recommendations From the Defining "Term" Pregnancy Workgroup. JAMA. 2013;309(23):2445-2446. doi:10.1001/jama.2013.62
ACOG Clinical Guidelines: Definition of term pregnancy. Committee Opinion No. 579. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1139–40.35Go the Full 40 Campaign tool Kit :http://www.health4mom.org/pregnancy/healthy_pregnancyo
The last weeks of pregnancy count: July 5th, 2012l Kit: http://newsmomsneed.marchofdimes.com/?tag=brain-development
By Kimela Hardy, MA, RT(R), RDMS
Ultrasound is highly developed technology, a modality that remains a prescription device, and affords an easy opportunity to “Take A Peek” at an unborn/preborn child, and in pregnancy centers demonstrating life to an abortion - vulnerable woman.
The efficacy of using ultrasound in crisis pregnancy centers is undeniable with a reported nearly 90% of abortion minded women choosing life for their child after seeing their unborn/preborn child with ultrasound. According to Right to Life latest available information January 2012, at least 23 states have laws pending which require an ultrasound be done prior to an abortion.
As a result some abortion centers now offer ultrasound scans for an additional fee unless otherwise dictated by law. However due to the generosity of organizations and individuals many crisis pregnancy centers can now offer free ultrasounds to their clients in order to demonstrate life. In general, registered nurses are trained to perform a very limited 2D (Dimensional) or B – Mode (Brightness Mode) obstetrical scan to determine fetal viability and gestational age.
While the use of ultrasound is medically accepted as having “no known biological effects”, the effects of Doppler use remain undocumented and relatively unknown. The premise is women who hear the audible sound may decide against having an abortion and continue the pregnancy to term.
However, another and much preferred method to demonstrate the fetal heartbeat while demonstrating life to an abortion vulnerable woman remains easily available by utilizing “M-Mode”, or Motion Mode. This clearly shows the beating heart without the potentially adverse side effects of Doppler (which has 7-9 times the energy) on a very small and forming fetal heart. If someone wants to hear a fetal heart beat, the response is “we can do better than that, we can SEE the heart beating!”
So what, if any, difference is there to the unborn baby and mother if Doppler is used in addition to 2D ultrasound? Additionally, what does using Doppler do to our client, both mother and unborn child?
Doppler uses high(er)-intensity sound waves to evaluate blood flow/movement. Adults undergo Doppler medical tests for cardiac irregularities, carotid occlusions, and venous and arterial interrogations where the benefit of medical information outweighs any potential risks. Medical indications for Doppler performed in 3rd trimester of pregnancy are for high risk patients, mothers with high blood pressure, diabetes, renal problems, or any other conditions which may affect the fetal growth to diagnose potential complications affecting fetal outcome. The Doppler is focused on the umbilical cord between the uterus and placenta, and not on the forming heart. In fact, specifically mentioned is the unlikelihood of any fetal safety implication as long as the embryo/fetus lies outside the Doppler beam, in this instance referring to Doppler use in 3rd trimester.
All resources state there are “no known biological effects” using ultrasound prenatally, in other words there are no documented reports of adverse fetal outcomes. The American Institute of Ultrasound in Medicine and the American Congress of Obstetrician and Gynecologists state ultrasound should be done in a “prudent manner”. And another AUIM release states bioeffects may result from inappropriate Doppler use or excessive thermal ore mechanical index setting.
In the pregnancy centers, Doppler is sometimes used to hear blood flow through the heart, and this is usually done in very early first trimester. However, an AIUM Statement approved April 18th, 2011, states the use of Doppler in the first trimester should be viewed with great caution and only when any benefit outweighs any potential risk. Further, it recommended Doppler should not be performed routinely.
Doppler uses considerably more energy, which is directed at the fetal heart during attempts to obtain fetal heart sounds the first trimester. Intensity is the quantitative factor to determine instrumentation output, and while exposure is somewhat difficult to quantify, scan length and other technical factors are important to consider. Also, variation in tissue properties influence dose in an unpredictable manner.
Please refer to the table below which clearly demonstrates a substantial increase in power when using Doppler:
Average Value Intensity Range(Spatial Peak, Temporal Average)
A basic principal practiced in ultrasound is As Low As Reasonably Achievable, ALARA, using the lowest possible energy while producing a diagnostic image. As the above chart demonstrates, using Doppler increases the power significantly a contradiction to ALARA.
Another factor affected by ALARA is transducer/probe movement. Keeping the transducer/probe in one position without movement will increased tissue temperature (Thermal Index) and cavitation will occur in the structures within the beam’s focus. Thus, the transducer/probe should not be held in a fixed or stationary position any longer than necessary to obtain a diagnostic image. The transducer/probe should be either lifted off the patient and/or the image frozen when there is no need for additional image acquisition. (Cine loop can be accessed for continual observation.) Doppler is acquired by maintaining constant placement of the transducer/probe, in this case on the very small embryonic or fetal heart, further increasing Temporal Intensity.
This is especially significant with endo-cavity, or in the PCs transvaginal, scanning where the surrounding tissue is approximately 37°C/98.6°F rather than room temperature as in Transabdominal scanning. When Doppler is used and the fetal heart beat is audibly being heard, the transducer is held in one location and moved around.
For more, see http://ult.rsmjournals.com/content/18/2/52.full.
As long as any possibility of injury to the fetal heart remains, performing Doppler on these forming and early heart cells is not recommended, especially in Pregnancy Centers where nurse sonographers have limited training and sonography skills. Instead, the sonographer can visually demonstrate-show- the fetal cardiac activity, “A Picture is Worth a Thousand Words”. The lack of proper training and experience to acquire a fetal heart beat on M-mode does not necessitate the use of Doppler. Instead, continual development as assessment of scanning skills utilizing depth/size, manufacture specific enhancements, etc. will produce a visual and real-time fetal heart beat to the abortion vulnerable woman.
It is in the presentation of the medical personnel to the client/patient how seeing the fetal heart beat will eliminate the need to use Doppler. Then replay this clip on a continuous cine-loop for continual observation of the fetal heart and fetal activity while completing the patient/client’s appointment. It is also important to note that OB is the most litigious medical field, and there remains a potential medical liability to Pregnancy Centers so standard practices are highly recommended, and Doppler use to hear the fetal heart beat is not a standard practice in the Medical Imaging field.
It has also been suggested by some that in dire instances where the client/patient is determined to end the pregnancy with an abortion, Doppler should be done in a “Hail Mary” attempt. If this is the recommendation/order by your medical director, armed with the above information, one must proceed with great caution recognizing that the unborn/preborn life may be saved from abortion but with the knowledge of potential risk of cardiac issues.Outside of the Pregnancy Center and in clinical practices, Doppler is not done routinely by Registered Diagnostic Medical Sonographers, not even in 1st trimester to determine fetal cardiac activity. If a heartbeat is visualized but not able to be measured, a note will be on the report that cardiac activity was demonstrated.
It is important to note that an ultrasound scan is critically dependent on the operator and his/her education and experience. While safe, even for the developing fetus, ultrasound and especially Doppler should only be done by fully trained personnel in its safe and proper operation, and who thoroughly understand the physics involved. With all of this knowledge, in limited OB training for pregnancy center nurses, Doppler is not recommended for use on pregnant models generously volunteering their preborn child.
by Audrey Stout, RN, RDMS, SoundView Imaging Partners
In over ten years of educating abortion-vulnerable women on fetal development and abortion, I had seen many of these women experience a change of heart. Yet, for years, I also believed that if a woman was able to see her unborn child through ultrasound, many more would choose life. From the very beginning, we knew transvaginal ultrasound to be the best means of imaging a pregnancy in the early stages.
One objection we may not have anticipated was this: “We don’t want to do that, do we? What if the girls have not had a bath before coming?” Our medical team appropriately determined that we must “do that,” and then learned to perform both abdominal and transvaginal ultrasounds in order to provide pregnant women with services equal to the standard of care in the broader medical community.
Even with more than 600 pregnancy medical clinics offering medically indicated limited OB ultrasounds, there is still a lack of a common understanding for the necessity of transvaginal ultrasound in the pregnancy medical clinics, which bears itself out in resistance or hesitance to utilize this valuable resource. But transvaginal sonograms are absolutely necessary for pregnancy medical clinics.
For early pregnancies, as well as women with a retroverted uterus or obesity, the use of transvaginal sonography is critical to determine the location of the pregnancy, since the child is tiny, and often not visible when scanning abdominally.
During a recent training involving around 60 scans, there were two patients for whom it was impossible to determine if there was a true gestational sac or pseudo sac of an ectopic pregnancy in the uterus by scanning abdominally. When the transvaginal probe was used, however, both ultrasounds revealed tiny embryos with beating hearts, measuring from 2-3 mm (25 mm=1 inch) in length alongside a yolk sac—diagnostic for an intrauterine pregnancy.
Apart from using the transvaginal probe in each of these cases, the patients would have needed both ectopic and miscarriage precautions, due to an inconclusive ultrasound. This would have required a follow-up scan, either at the PMC or with another physician, for serial hCG levels, in addition to another sonogram to rule out an ectopic pregnancy. This would have caused needless stress and concern, when the answers were available with a transvaginal scan. When a woman seriously considering abortion comes into a pregnancy clinic, we may only have one opportunity to see her and provide a life-affirming sonogram.
The three medical indications, for performing a limited OB sonogram in most PMCs according to the American Institution for Ultrasound in Medicine:
Every woman considering abortion needs this information to make a truly informed choice regarding her pregnancy. Using transvaginal sonography during the first trimester, one is much more likely to be able to answer the three questions listed above, and enable a woman to see the life of her unborn child in order to refute the idea that her child is just a mass of tissue.
PMCs typically see women in early pregnancy when they are most likely to have ectopic pregnancies, as most show symptoms between 7-8 weeks LMP. Since a ruptured ectopic pregnancy is life-threatening due to massive hemorrhage, every early sonogram must attempt to determine the location of the pregnancy. Ectopic pregnancy is the leading cause of first trimester maternal death, even though less than 9% of ectopics are actually visualized with a fetal pole on sonography because they are notoriously difficult to diagnose.
Skill in both transabdominal scanning and transvaginal scanning are necessary, as some ectopics or associated findings are visible with abdominal scanning, while most can only be visualized using transvaginal scanning. Transvaginal sonography also can uncover a rare condition known as “heterotopic pregnancy,” which is both intrauterine and ectopic, occurring at a rate of 1/30,000 in natural reproduction.
A recent article from MedPage Today discusses ectopic pregnancies and highlights the need for using transvaginal sonography. The article states:
Ectopic pregnancy occurs in up to 2.6% of all pregnancies and is the chief cause of first-trimester pregnancy-related mortality, accounting for up to 6% of maternal deaths. However, less than half of women with ectopic pregnancy have characteristic symptoms of abdominal pain and vaginal bleeding, which are more likely to indicate miscarriage.i
Further, ectopic pregnancy has been on the increase since 1970, when the Center for Disease Control began tracking this condition.
As those performing ultrasound services in the PMCs, adequate training is critical in order to gain skills in imaging the maternal anatomy, demonstrating with every sonogram that the pregnancy is intrauterine (IUP). If one does not possess these skills, it puts not only the woman who comes to you at-risk for losing her life, it also puts your PMC at legal risk of liability for harm. Thankfully, many women have been protected from life-threatening ectopic ruptures, due to the careful and skillful scanning of nurses and other medical personnel in PMCs.
Here are five tips to protect all involved by safely performing sonograms to the highest standard of medical care in your PMC:
So, are transvaginal sonograms necessary in your PMC? Yes, yes, and yes.
Transvaginal sonograms safely provide sonography services and protect those served. In fact, sonographers with adequate training often happily admit, once they have acquired the skills, they very much prefer transvaginal scans because of the superior resolution and the fact that women are able to clearly see the image of their unborn child. ________________________________________Audrey Stout, RN, RDMS, has a passion for the cause of life and began involvement with pregnancy centers in 1987. In 2000, she began instructing with NIFLA’s Limited OB Ultrasound Course and serves as National Nurse Manager Consultant for NIFLA as well. She has provided hands on trainings in sonography for PMCs medical personnel throughout the US, and is a founding partner with SoundView Imaging (SoundViewImaging.org). Audrey lives in Lexington, VA with her husband, Dave. They have three grown adopted children and one grandson.
i. Boyles, S. Transvaginal Ultrasound Best to Find Ectopic Pregnancy. April 23, 2013. Medpage Today. Accessed June 25, 2013 from: http://www.medpagetoday.com/OBGYN/Pregnancy/38638.
ii. Bourgon, D., Lin, E., Ectopic Pregnancy Imaging. April 12, 2011. Medscape. Accessed June 28, 2013 from: http://emedicine.medscape.com/article/403062-overview.
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