Things that F*ck Up your Birth Plan, A Series

Things that F*ck Up your Birth Plan

LATE PREGNANCY ULTRASOUNDS

Ultrasounds are a ‘normal’ part of pregnancy if you ask any American woman—BUT if we look at the science behind them, you might be surprised at what you find…

While you may enjoy seeing your baby, it’s worth discussing the risks before saying ‘yes’ to any and all ultrasounds and scans. Pregnant people routinely go through a number of ultrasounds during pregnancy. 

Most commonly:

• - 11-14 weeks to confirm pregnancy
• - 18-22 weeks to confirm anatomy is looking normal
• - 35-38 weeks which is known as the growth scan (we check the ‘size of baby’ and baby’s position)

I put ’size of baby’ in quotations because the accuracy of ultrasounds is so laughable that it’s ridiculous to lead anyone to ever believe we could accurately predict the size of a baby that way. Ultrasounds also get less and less accurate as the baby grows. However, there are risks with late-pregnancy ultrasounds and some are severe like misdiagnosis, unnecessary inductions, and unnecessary c-sections. There is a fine line between intervening and monitoring—sometimes, checking in actually hinders the process. 

The Science

This 2015 Cochrane Review of Late Pregnancy Ultrasounds (after 24-weeks) found, ‘there were no differences between groups in the rates of women having additional scans, antenatal admissions, preterm delivery, induction of labour, or instrumental deliveries although the rate of caesarean section increased slightly with screening. For babies, birthweight, condition at birth, interventions such as resuscitation, and admission to special care were similar between groups. Infant survival, with or without congenital abnormalities, was no different with and without routine screening, and childhood development at eight to nine years was similar in the three trials that measured it. None of the trials reported on psychological effects for mothers of routine ultrasound in late pregnancy.’ You can also find the 2008 original version of this paper here.

During the 1970’s a few major key players in maternity care changed —for better or worse (feels like worse). First, Electronic Fetal Monitoring was introduced and promised to reduce infant mortality which it has not done, but it has increased c-sections and maternal complications astronomically. Coincidentally, this is also the time that we saw c-section rates go from 5% (1970) to nearly 25% by 1988! 

The Benefit

There are other functions of this third trimester ultrasound like checking for baby’s position, placenta position, evaluates (not with great accuracy) amniotic fluid levels, and can detect any late term abnormalities (cardiac complications, abnormalitites in kidneys or urinary systems or central nervous systems). Isabel Monier, a French Researcher, has long said, ‘Neonatal outcomes were not better for SGA infants if FGR was suspected.’

The F*ck Up 

The Global View You know I love looking at other countries and this 2013 Journal of Obstetrics and Gynecology Canada article shares, “In women without risk factors for intrauterine growth restriction, comprehensive third trimester ultrasound examination including biophysical profile, fetal biometry, amniotic fluid volume, and umbilical artery Doppler studies is not recommended. (II-2D).” Based on existing evidence, routine late pregnancy ultrasound in low risk or unselected populations does not confer benefit on mother or baby. There is no evidence that it should be recommended routinely in late pregnancy, yet this is the standard practice across the United States.

The Small Baby There is ‘the difficulty in distinguishing between those SGA that truly have an FGR problem and those constitutional SGA which entails a high false positive rate.’ Another study found that even with risk factors identified, it was still challenging to get accurate results. The artihttps://pubmed.ncbi.nlm.nih.gov/26488771/cle states, ‘However, despite the presence of these factors, 60% of SGA and 40% of severely SGA infants, respectively, were not suspected of FGR.’

The Provider Bias Your provider’s bias can be more influential than the actual screening results! Customizing fetal size for maternal height, weight and ethnicity, has been shown to improve the identification of babies who are small because of FGR, rather than constitutional reasons.

The Manipulation The issue with constant monitoring —besides how inaccurate the results are— is that it opens up the conversation for scary, fear-based manipulation. Expecting every body and every baby to do exactly the same exact thing is unrealistic. Obstetricians, and some midwives, will give care from a place of ‘looking for a problem’ rather than ‘responding to whatever the body shares.’ Looking for a problem says ‘go for a ‘just in case scan’ even though you’re not yet in the range that I’d be concerned,’ whereas responding says ‘you’re in the normal range but let’s watch it.’

The Gender Bias There is also one last bias that we should all expect at this point—but female gendered fetuses are more likely to be suspected of FGR. https://pubmed.ncbi.nlm.nih.gov/26488771/

So since this routine practice doesn’t improve outcomes and leads to higher rates of stress and unnecessary worry for pregnant people—why are we still recommending this across the board? 

Late pregnancy ultrasounds should be something you have to ‘risk’ into meaning that we don’t give them to everyone as the current US medical system does. Only folks who have risk factors or individual factors that lead us to believe they may have increased risk that we may be able to mitigate if we catch it via a 3rd trimester ultrasound. But, these complications are so rare and that’s why not everyone needs them. 

The Risk

Unless you need one, they are unnecessary interventions that have the major potential to disrupt your birth plan by causing unnecessary drama or courses of action. Consenting to extra ultrasounds after 24-weeks should be a very calculated decision in which you understand the risk of just how inaccurate the results can be plus the risk of opening the door to pressure and manipulation from medical staff. If you understand the risk and feel comfortable navigating that — I support you.

Are there risks to having Small For Gestational Age babies?

Yes, there are risks to everything. This article shares clearly the risks associated with small for gestational age. One thing that people always forget to look at are your own genetics.

• - What did you weight at birth?
• - What about the baby’s other parent?
• - How big of a human are you now?
• - What about the baby’s other parent?

If this baby is made by two relatively small people, why would we expect your body to grow a 11lb baby! I am a very petite person at 5’4” and 100lbs. My partner is not a large guy, either with a height of just 5’6”. We have no reason to believe the two of us would make a ginormous baby. So genetics matter. Small people make small babies and that’s okay. It almost feels like that’s how nature intended it to be. 

More so than the risks to your baby, thisis about making sure that you need the initial scans in the first place. When we intervene (with anything—even as little and seemingly harmless as an ultrasound), we must understand the risks associated with it and not just the physical ones! We must also think about the rate of false-positives (where you believe you or your baby has something bad, but you/they don’t) and false-negatives (where you falsely believe you and your baby are safe/in the clear and you are not). This is one stat that providers fail to mention with almost ALL care—with how much certainty can they give you this answer? With ultrasounds—it’s not very certain!

You can see how using a notoriously inaccurate tool, like ultrasound, to diagnose such a hard thing to distinguish to begin with (SGA vs FGR) can lead to a few twists and turns in your labor story. 

The Birth Lounge will help prepare you for all of those twists and turns so you know exactly what your options are at each step of the way. You’ll also learn the pro’s and con’s plus the appropriate timing of each intervention and how they might interact with other interventions along the way!

All of the content is accessible via an app that conveniently goes into the birth room with you so you can have lounge support from start to finish!