by Laura Strietmann, Associate Director, Pregnancy Center East, Cincinnati, Ohio
When I began serving clients in crisis at Pregnancy Center East in Cincinnati, Ohio over 7 years ago, I noticed that besides time, love, and an ultrasound, there was another powerful tool in assisting a woman in the choice of life for her unborn baby.
This was an outdated grainy VHS tape, entitled Abortion Techniques. Non-graphic in content, but real and compassionate, each
time this tape was viewed by a client considering abortion, she left with a different mindset. The client usually moved from being abortion-vulnerable to choosing life for her baby.
Carol Everett, a former abortion
clinic owner and operator, turned pro-life warrior, had filmed Abortion Techniques in 1993. It was a 25-minute video showing abortion through illustrations, actual tools, and Carol’s personal testimony. Many centers throughout the country use this video in teaching pregnant women the realities of abortion. Today, abortion has been made to seem as if it is equivalent to having a mole removed, as a “necessary” aspect of healthcare. Abortion Techniques showed how far these perceptions are from reality. One day several years ago, while working at PCE, our copy of the video broke. After searching for an updated replacement for this worn tape, I discovered that the industry lacked a current video with the most recent abortion methods sensitively presented in such an effective manner.
I decided to contact Carol Everett, now very busy as an internationally known pro-life author, speaker, and lobbyist for the state of Texas. Had she thought of making a more updated version of the video? Did she realize the number of babies’ lives saved by this tape? Would she see it was time to make a new film? Several months of persistent emails, Facebook inbox messages, and finally a phone conversation before Carol conditionally agreed to the project.
Having never met
in person, only through internet and phone lines, Carol promised that if I could secure funding for the project, she would journey to PCE and make a new video. She would generously assign PCE the rights to the video as a means for fundraising. Through the generosity of the Ruth J. and Robert A. Conway Foundation, PCE was able to secure the funds to film the new version. This was not the answer I thought I would receive in my initial inquiries, but it was an incredible opportunity to affect the lives of the babies at PCE and now throughout the country.
Carol traveled to Cincinnati and Greg Schlueter, a Catholic moviemaker, and staff member for the Diocese of Toledo, OH filmed the video. On the afternoon of February 15, 2013 just as filming was wrapping up at PCE our doorbell rang. With a CLOSED sign on the door, two women still rang our bell desperate for help. As I opened the door and they noticed all of the filming equipment, the client begged for assistance. Stepping inside the Center, the client shared she was already well into her second trimester, but had finally just told her sister, who then found the Center and brought her for help. The situation was sensitive and the expecting mom was also post abortive.
As the young pregnant client and her sister described the crisis, Carol rounded the corner and heard the story. Right there in the lobby of PCE Carol listened to this young client and through a beautiful conversation offered so much understanding and hope. Carol counseled the client with sincerity and love. This client stayed in PCE’s care throughout her pregnancy and a perfect baby was delivered this summer. Mom is overjoyed with how everything has worked out. This was the first miracle of life from the updated video being brought to reality.
An Informed Look at Abortion Techniques is the new 14-minute modern life-saving tool. Using modern colors and graphics Mertz Design Studios completed this version to also include information on Plan B as well as RU-486 abortions. The initial launch of the video took place in April 2013 at the Heartbeat International Conference, selling over 100 copies to centers as far away as Alaska, Africa, Austria, and Germany.
After viewing the video in Dallas at the Conference, Janet Morana, Executive Director of Priests for Life, shared, “Every pregnancy center should be showing this movie to clients.” Reviews from center directors throughout the country are calling it “powerful,” the “best tool next to an ultrasound in reaching hearts and minds in the decision for life.”
On the day I write this article one absolutely abortion determined mom sat in PCE with a volunteer and viewed An Informed Look. The decision for life was made then and there while watching the video, even before the ultrasound. The client was astounded by the reality of abortion procedures. What happens to her body as well as the unborn baby’s was shocking to say the least. Even in a non-graphic manner, seeing how an abortion is performed is devastating enough. When making the biggest decision of her life a woman deserves to have complete information. Carol’s testimony is riveting.
Hearing the sorrow of a post-abortive women provides another enormous window to the reality of abortion. Viewing this film allows a woman, in the words of Carol “To make her decision fully informed.”
We hope to get this tool in the hands
of thousands, including pregnancy resource centers, high school educators, and politicians. We will be distributing the video at future Catholic and pro-life conferences. Please visit us in Washington, D.C. during The March for Life convention. The video will continue to be sold through www.HeritageHouse.com, as well as directly through the Center, at 513-321-3100.
by Susan Dammann RN, Medical Specialist
With a presence in the U.S. and globally, Vitamin Angels assists at-risk pregnant women, new mothers, and children under 5 years old gain access to life-saving and life-changing multivitamins.
Vitamin Angels’ domestic program is coordinated through a network of grassroots organizations, including pregnancy resource centers and national organizations with a network of local operations, such as Feeding America, the National Association of Free Clinics, WIC, and local food banks.
In the U.S., Vitamin Angels is working to reach 70,000 children under the age of five, new mothers, and pregnant women with daily multivitamins in 2013.
Hundreds of thousands of children—right here in America—are undernourished. An undernourished child’s ability to reach his or her full potential is hindered by inconsistent access to healthy and nutritious foods. This food insecurity can result in deficiencies of micronutrients (vitamins and minerals) that are necessary for proper physical and mental development. Without these micronutrients, their lives—and futures—are at risk. These deficiencies can start in the womb, which is why reaching a mother during her pregnancy with these vitamins can be so pivotal.
To learn more about Vitamin Angels click here.
You may review eligibility requirements and apply for a grant at http://www.vitaminangels.org/become-field-partner .
Good question! And one that needs exploring before a center begins offering prenatal vitamins to clients. There are several aspects to consider in finding the answer…
by Susan Dammann RN LAS, Medical Specialist
Recent advances in prenatal testing have afforded physicians and parents the opportunity to screen for abnormalities with a greater degree of accuracy, while identifying a broader range of disorders than ever before.With this additional knowledge come both the opportunities to seek further testing and to better prepare for the birth of a child with a possible birth defect. Tragically, the increased prevalence of these tests does come with a deadly downside, and has already resulted in a higher number of children who are aborted because of a possible birth defect.
Technology today is taking us into even deeper uncharted waters, presenting greater challenges and opportunities as we consult with clients in the pregnancy center setting. Let’s take a look at some of what is currently available as well as what is on the horizon.
Between 15 and 20 weeks of pregnancy, it is common practice for a pregnant woman to be offered the Quad Marker Screen test, as it can only be performed within this certain window of time. The test is optional, and due to uncertainties surrounding the test results, a woman may opt out of the test.
The Quad Marker Screen is a blood test that screens substances in the mother’s blood for problems in the development of the fetus’s brain and spinal cord, called “open neural tube defects”, as well as genetic disorders such as Down syndrome. The Quad Marker Screen can predict approximately 75-80% of open neural tube defects and approximately 75% of Down syndrome cases in women under 35 years old, and over 80% in women age 35 years and older.
The Quad Marker Screen does not diagnose, but rather, predicts the likelihood of a certain problem occurring, determining if a woman is at higher or lower risk of carrying a baby with a birth defect. The test involves no risk to the baby, as a blood sample is taken only from the mother.
Four substances (hence “Quad” Marker Screening) normally found in the baby’s blood, brain, spinal fluid and amniotic fluid are tested:
The normal amounts of these substances in the mother’s bloodstream change during pregnancy. High AFP levels may indicate an open neural tube defect in the baby, or could indicate that the fetus is older than was originally thought. The numbers could also indicate that the woman is having twins.
An increased risk of a baby having Down syndrome is indicated by higher than normal levels of hCG and Inhibin-A, and lower levels of the hormone estriol.
Can normal test results guarantee a healthy baby? No, a normal result is not a guarantee, but it is a strong indication of health, achieving an accuracy rate of over 98 percent, according to WebMD:
Out of 1,000 pregnant women, approximately 50 will have quad marker screen results that indicate an increased risk for having a baby with a birth defect. Of those women, only one or two will actually have a baby with an open neural tube defect. About 40 women will have quad marker screen results that show an increased risk for having a baby with Down syndrome and one or two will actually have a baby with Down syndrome.
Among the general medical community it is recommended that a woman have the test if:
Test results outside the normal range do not necessarily mean there is a problem with the pregnancy. It is a test that only assesses the risk of having a baby with a birth defect, and can be followed up with additional testing, such as amniocentesis or ultrasound.
The Quad Marker Screen has a false positive rate of 20% when a cut of 1:190 is used. When a positive result is obtained, an amniocentesis may be recommended to help confirm or negate the results. Amniocentesis is very accurate in diagnosing Down syndrome, serving as a “gold standard” predictor, though the fetal loss rate from amniocentesis is about 1:200 or 0.5%.
As we encounter women in our centers who have received negative (suggesting a possible problem) quad test results, or who may be considering having the testing done due to risk factors in their history, and who may gravitate towards aborting if a negative prenatal diagnosis is obtained, this information may help to alleviate some of their initial concerns and equip you to knowledgeably offer support during this potentially difficult time.
In 1997, scientists discovered that cell-free fetal DNA could be isolated from maternal blood. Using this technology a screening test was developed to identify 3 trisomies -- trisomy 21 (Down syndrome), trisomy 18 (Edwards syndrome), and trisomy 13 (Patau syndrome). New technology now exists for four prenatal genomic screenings that analyze cell-free fetal DNA circulating in maternal blood, offering an early method for detecting certain fetal chromosomal abnormalities. Chromosomal aberration screening can be done between 8 and 10 weeks.
One common test is the MaternT21. The test takes about 7 days to return results, and is 99.8% accurate. It works by sequencing gene fragments of the fetus that are in the maternal blood system.
"It is pretty darn remarkable that there are 4 simple blood tests capitalizing on the cell-free DNA from the fetus in that 1 tube of maternal blood, from which we can determine chromosomal aberrations and gender as well as a whole lot more in terms of sequencing the fetal genome," writes Dr. Eric Topol, Editor-in-Chief of Medscape.1
Susan Klugman, MD, Director of Reproductive Genetics at Montefiore Medical Center in New York City, writes:
In accordance with the American College of Obstetrics and Gynecology (ACOG) guidelines, it is only recommended for high-risk women at the present time. In New York State, the noninvasive prenatal screening test can only be used according to those guidelines. High-risk women are those with:
For now, noninvasive prenatal screening definitely has a place in prenatal genetic assessment. Women can get reassurance that their unborn babies don't have 1 of the 3 trisomies (13, 18, and 21) or a sex-chromosome disorder, if the screen includes that.2
Cell-free fetal DNA Prenatal Screening is highly sensitive and specific, noninvasive prenatal screening, not a diagnostic test, meaning that if the test is positive for a fetal trisomy, the woman will have to undergo invasive testing if she wants confirmation. According to Klugman, cost varies by laboratory and insurance, in the range of $800 to $3,000, but many laboratories cover most of this cost except for a few hundred dollars.
Screening results do not address the presence or absence of other genetic disorders or diseases that might be present, nor does it assure parents their infant will not have other birth defects. It does not screen for neural tube defects.
Some women may desire to undergo this testing, feeling that obtaining additional information about chromosomal conditions before the birth of the baby will help them feel more prepared. Others may choose this screening with an intent of considering abortion if a chromosomal condition were to be identified.
Katie Stoll, a genetics counselor at Group Health Cooperative in Seattle, has spoken to the issue:
[W]ithout a doubt, some women are making pregnancy termination decisions on the basis of screening results alone. One laboratory presented some preliminary outcomes data at a genetics meeting recently showing that some women were terminating on the basis of noninvasive screening results alone.3
Cell-Free DNA Technology may make Whole Fetal Genome/Exome Sequencing Possible
Since it is now possible to sequence a fetal genome, Dr. Topol identifies the major ethical concern that needs to be addressed as the technology advances and the possibilities multiply:
[T]he question I really want to bring up is, where do we draw the line? Now that we can sequence a fetal genome, when are we going to start doing that and not just screen for big chromosomal aberrations of trisomies and aneuploidy? This is something that will perhaps engender the biggest bioethical issues of the future. (emphasis added) What do we say is an appropriate finding from sequencing -- whether it is an exome of the fetus or whole genome -- that constitutes criteria for early termination of pregnancy?4
Stoll, likewise, raised the issue in her article:
I am concerned that our technology already has outpaced our ability to offer this testing in a way that empowers truly informed decisions and meaningful information for our patients. There are so many genetic variations that we do not know how to interpret even when we find them in pediatric and adult patients. Is a variant of uncertain significance harmful or beneficial? We often do not know.
Having this level of genetic information prenatally, when we understand so little of what it means, is bound to cause confusion, anxiety, and fear. When used in a way that supports individual needs and values, prenatal testing is incredibly powerful. However, as it becomes more routine and, at the same time, more complex, we run the risk of burdening patients with information that may do more harm than good.5
Arthur L. Caplan, Ph.D., NYU Langone Medical Center, sees a huge concern on the horizon:
The ability to draw cells from the mom's blood will quickly become a test that is used on 100% of pregnant women. I would be surprised if it does not become the standard of care… More testing means that more women may find problems with their fetuses. This test can be performed much earlier than amniocentesis, possibly enabling fetal screening at 7 to 9 weeks. Many people worry that this will lead to more pregnancy terminations. Women who would not have had testing before this will undergo testing, and some may discover things about their fetus that they will not accept, be it a birth defect or some other disease risk factor. Because it is earlier, the burden of abortion may seem morally more acceptable to women than having an abortion much later in pregnancy.6
We can only imagine what these developments will mean long-term for the clients who come into your center. It surely seems probable that as more women are tested with these increasingly definitive tests, the pressure from the medical community to abort would increase as we have already seen for children with Down syndrome. More women may also view abortion as their best—or only—choice as they consider the possibility of giving birth to a child with a negative diagnosis.
As our Savior commanded, let us stay alert and watch and pray, and be ready to minister to these women who will so desperately need our support and love.
1. Eric J Topol, MD, "Topol Predicts Genomic Screening Will Replace Amniocentesis," Medscape, November 2013.2. Susan Klugman, MD, "The Pros and Cons of Noninvasive Prenatal Screening," Medscape, November 07, 2013.3. Katie Stoll, MS "Noninvasive Prenatal Screening: A genetics counselor's Perspective" Medscape, November 08, 2013.4. Topal, "Genomic Screening."5. Stoll, "Prenatal Screening."6. Arthur L. Caplan, Ph.D. "Will New Genetic Tests Lead to More and earlier Abortions?" Medscape October 29, 2013.
by Joel Brind, Ph.D.
A new systematic review and meta-analysis of abortion and breast cancer (ABC link) in China, was just published in November, 2013 in the prestigious, peer-reviewed international cancer journal, “Cancer Causes and Control”. It showed that the overall risk of developing breast cancer among women who had one or more induced abortions was significantly increased by 44%. In this meta-analysis (a study of studies in which results from many studies are pooled), Dr. Yubei Huang et al. combined all 36 studies that have been published through 2012 on the ABC link in China.
Also in peer-reviewed journals in 2013, Dr. Ramchandra Kamath et al. reported an odds ratio (a measure of relative risk) of 6.38 and Dr. A.S. Bhadoria et al. reported a relative risk of 5.03, i.e., a 5-fold—or 403%--increased risk of getting breast cancer among Indian women who have had any abortions. Not only are these relative risks much stronger than had been reported anywhere before (e.g., the 1.44 reported by Huang et al. in China and the 1.3 reported by my colleagues and I in our worldwide meta-analysis of 1996), but also in 2013, Dr. S. Jabeen and colleagues reported a relative risk of 20.62 among women in Bangladesh!
These new Asian studies change the game in ABC link research, and should completely abolish any credibility of the "politically correct" dictum of the US National Cancer Institute (NCI; a federal agency like the IRS and the NSA) that the ABC link is nonexistent.
Several reasons for this can be enumerated:
Although no credible evidence for this response bias hypothesis has ever been presented (and plenty of good evidence against it) in ABC link research, the NCI and others have continually cited it as if it were a matter of fact, to deny the reality of the ABC link. The fact is that such response bias is only even plausible when the relative risk is relatively low, such as around 1.5. But such bias becomes extremely implausible when the relative risk is strong—e.g. 5 or 6 or more. Thus, while one might attempt to explain how some women with breast cancer might be more or less inclined to report their history of induced abortion, the numbers from India and Bangladesh are just too overwhelming: In the Jabeen study, 262 breast cancer patients were compared to 262 healthy (control) women. It was found that 231 of the patients (88%) had had any abortions, whereas only 70 out of the 262 healthy women (27%) had had any abortions!
It is important to note that the Jabeen data does raise the question as to why there should be such a strong link in Bangladesh, if abortion should have the same effect on women everywhere The answer is straightforward: In Bangladesh, breast cancer is still rare because a)early marriage and childbearing—the best known protection against breast cancer—is nearly universal; b) breastfeeding (also a protective factor against breast cancer) is also nearly universal, as is c) the lack of alcohol consumption (a known risk factor). Consequently, there's not much in Bangladesh besides abortion to cause breast cancer, so it really stands out.
It is really frightening when you start doing the math on the impact of abortion on a population of over a billion women—in India and China alone: Just a 2% lifetime risk of breast cancer due to abortion—a very conservative estimate—means upwards of 10 million women getting breast cancer, and millions dying from it. Welcome to the real war on women.
Joel Brind, Ph.D. is a Professor of Human Biology and Endocrinology at Baruch College, City University of New York; Co-founder of the Breast Cancer Prevention Institute, Somerville, NJ; and member of the Heartbeat International Medical Advisory Council.
By Connie Ambrecht RDMS, CMB
It was very exciting when your Pregnancy Resource Center (PRC) changed to a Pregnancy Medical Clinic (PMC). I am certain you can recall the enthusiastic atmosphere that filled the center as you reached your goal of changing from having a focus on material assistance to focusing on being able to answer the question; “Am I pregnant?” through medical imaging. Providing confirmation of pregnancy was finally a goal actualized!
Looking back at the steps that were taken, everyone on the team participated in training that was a necessary component to adding medical services. From the Board of Directors, the Executive Director and the Clinic or Nurse Manager, every aspect of the PRC was educated about the change. Our team at Sonography Now participated in the change at over 500 PRC to PMC transitions and our responsibility to you remains. Our role as an education company is to keep ourselves educated and pass that along to you. Our team attends approximately 6-8 conferences per year to keep abreast of trends that impact your clinical setting.
For many of you, that initial investment in getting to know what was needed for a PRC to become a PMC was the start and the finish to your education as it relates to being a clinic. Let’s review what is necessary for the medical personnel in particular to remain strong for the PMC. Then let’s consider: What does each member of the team need to do to remain strong for the PMC we serve?
For those such as NARAL Pro-Choice America who would like to see our doors close, they state things like: “CPCs are a growing threat to women's health. They often lie to women about abortion and birth control. They'll do anything to scare a woman away from choosing legal abortion.” They consider this a challenge to address.
We don’t believe there is a need to feel a panic in addressing such accusations, instead we feel it is wiser to be methodical about how you keep your entire organization educated. We want you to be empowered to discuss how and why you stay strong. In considering a methodical approach to your team’s education, there are a few things to ask… Who needs to be educated? How would we get such education? Where do we get the funding? Where can we go? Do we have to go anywhere? Who decides who needs what? There are so many legitimate things to consider.
This article is to assist you in building a plan for continuing education as it relates to your team, as well as providing talking points to aid in community relations.
As we begin, I’d like to outline a few facts: you provide medical services, sonography and maybe SDI testing, so that’s what makes you a clinic…embrace it. As a clinic, the public has certain expectations…be aware of those expectations. With those expectations comes the responsibility to provide your medical services at a level that meets standards as established by professional organizations.
Do you have an awareness of who those organizations are? Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), American Nurses Association (ANA), and the Society of Diagnostic Medical Sonographers (SDMS)? Each of these organizations has guidelines and/or recommendations for continuing education. Let’s look at each one, create a talking point and build a plan to implement.
• According to AWHONN, the RN who performs sonography “should demonstrate educational and clinical expertise in obstetrics….”
• In the new Code of Ethics for Nurses with Interpretive Statements, the ANA clearly states in Provision 5 that “the nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.” Provision 7 states that “the nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.”
• The SDMS clearly requires all sonographers, registered or unregistered, under Section II, to “maintain continued competence through lifelong learning, which includes continuing education, acquisition of specialty specific credentials and re-credentialing.”
If you take the three professional organizations above and build a talking point you might be ready to state; “As a clinic we find it is a priority to maintain competency, build skills and knowledge, because we value keeping up with medical standards.”
Your approach to building an education plan will vary from clinic to clinic. Annual Conferences such as the Heartbeat International Conference can build your medical team as well as others who attend. As education organizations, Sonography Now and Equip Leaders Now are committed to maintaining a large library of courses for the Pregnancy Medical Clinic that can grow your entire team. We recognize the importance of keeping up on trends, building the team's knowledge base and providing quality care and focus on that aspect of your services.
To quote Maya Angelou, “If we know better we do better”. We know you need continuing education in order to do better. Our obligation to you is to stay informed and pass it along. We look forward to serving you this year in regards to your education needs.
Connie Ambrecht RDMS CMB and her husband Dan founded Sonography Now in 2002. Connie has been published in professional journals, has spoken at national conferences. Sonography Now has provided training to physicians, nurses, physicians assistants, nurse practitioners, midwives, radiologic technologists, as well as cross-training other sonography specialists.
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 Martha L. Teter MS, CRNP
Many states in the United States have laws and rules regarding the use of “standing orders” or protocols for non-prescribers to administer medications. Do you know what the laws in your state are? Heartbeat International strongly recommends that you research your state laws in this area and be sure you are in compliance with them if you are operating in any area according to standing orders for the administration of treatment or medication, such as in the area of STD/STI treatment.
As an example, in the State of Ohio, no medication may be given to any patient without prior assessment of the patient’s condition by a legal prescriber and documentation of the legal prescriber's order on the patient's record.
Legal prescribers in the State of Ohio, include Physicians, and the following Advanced Practice Nurses who also hold Certificates to Prescribe: Certified Nurse Practitioners, Certified Nurse Midwives and Certified Clinical Nurse Specialists. Many Certified Physician Assistants also have Certificates to Prescribe and are legal prescribers.
A standing order or protocol is a definitive set of treatment guidelines that include definitive orders for drugs and their specified doses. These “Standing Orders” have been authorized by a prescriber to be administered by a certified or licensed health care professional, to a patient for a specific condition. This type of “Standing Order” or Protocol may only be utilized by licensed health care professionals in Ohio in the following situations.
The administration of drugs for any reason other than the above exceptions and that are not patient specific or authorized by the prescriber prior to implementation would be the unauthorized practice of medicine, which is a felony in the state of Ohio. The details of how and when the above exceptions may be applied are detailed in Ohio law.
If you would like to learn more about Ohio Law regarding standing orders, click here.
Many other states also have laws regulating standing orders. To learn more about the laws in your state, log onto the professional websites of The State Board of Nursing, The State Board of Medicine or the State Board of Pharmacy. Should you find that your current practices are not in compliance with your state law, Heartbeat International recommends that you place a hold on further treatment until such time as you can assure you are in compliance with your state law.
If you have any further questions please feel free to contact Heartbeat International.
Diagram from EctopicPregnancyFoundation.org
By Susan Dammann, RN, Medical Specialist
Diagram from EctopicPregnancyFoundation.org
Ectopic pregnancies occur in a range of 1 in 40 to 1 in 100 pregnancies. An ectopic pregnancy is any pregnancy that implants somewhere outside of the uterus, most often occurring in one of the fallopian tubes, which is also known as a tubal pregnancy. Other locations for an ectopic pregnancy include the ovary, the cervix, and the abdominal cavity.
Ectopic pregnancies are life-threatening for the mother, and the baby (embryo) cannot survive. Ectopic pregnancies may occur with or without the use of birth control.
Though rare when considered with the overall number of U.S. pregnancies, ectopic pregnancies still occur at a rate of 100,000 per year, according to the Center for Disease Control. The CDC also reports the life-threatening nature of an ectopic pregnancy for a mother: "Ectopic pregnancies are the leading cause of pregnancy related deaths in the first trimester and account for 9% of all pregnancy related deaths in the country."
An ectopic pregnancy can result from any condition blocking or slowing the movement of the embryo through the fallopian tube, where it then becomes lodged. The cause, sometimes unknown in an individual case, may include any of the following:
Initially, an ectopic pregnancy may not cause any symptoms outside of those of a normal pregnancy. A pregnancy test will read positive, but will likely be accompanied by the following symptoms:
If the areas around the ectopic pregnancy rupture and bleed, symptoms may worsen and include:
If an ectopic pregnancy is suspected, the physician may do a pelvic exam to check for pain. Tenderness or a mass in the fallopian tube or ovary may be an indicator. Blood tests and vaginal ultrasound exam help confirm the diagnosis, as does checking hCG blood levels over 1 to 2 days.
Ectopic pregnancy may occur after tubal ligation, even more so if the woman was sterilized before 30 years of age. One study found these women were twice as likely to have a subsequent ectopic pregnancy as those women who undergo tubual ligation after the age of 30. It should never be assumed that a woman’s history of tubal ligation automatically rules out the possibility of an ectopic pregnancy.
In order to prevent the loss of a mother’s life in addition to the loss of her embryo, intervention is required. The pregnancy cannot continue to full-term. If the ectopic pregnancy is diagnosed before symptoms occur, treatment may consist of an injection of methotrexate to stop cell growth. Ectopic pregnancies can be removed through laparoscopic surgery. If the fallopian tube is damaged, it may need to be removed as well.
Emergency medical attention is required if the fallopian tube has ruptured and heavy bleeding is occurring. Emergency surgery (laparotomy) may be required to stop the blood loss, as well as the termination of the pregnancy and possibly removal of the fallopian tube. Because the rupture can lead to shock, the following may be necessary:
While some women do not conceive subsequent to an ectopic pregnancy, approximately one-third do experience a later pregnancy. Of this one-third who do become pregnant following an ectopic pregnancy, approximately one-third will have a repeat ectopic pregnancy.
The best means of avoiding a tubal pregnancy is to avoid anything that would cause infection, or scarring of the fallopian tubes. Early diagnosis and treatment of all STD/STIs is critical. There are, however, no preventative measures to avoid ectopic pregnancy occurring outside the fallopian tubes.
This information is critical for pregnancy center staff to know. With every client who comes in our center with a positive pregnancy test we must be aware that she could potentially have an ectopic pregnancy. Therefore, it is recommended every center have a policy and procedure for advising clients of the signs and symptoms of an ectopic pregnancy.
This could be as simple as giving your client a sheet of instructions and information listing the signs and symptoms of an ectopic pregnancy, along with instruction to contact a health professional immediately if she experiences any of these symptoms.
To find a sample Ectopic Pregnancy Patient Instruction Sheet, reprinted with permission from Pregnancy Decision Health Centers in Columbus, Ohio, click here. Also see PDHC's Miscarriage Patient Instruction Sheet here.
1. http://www.mayoclinic.com/health/ectopic-pregnancy/DS006222. http://www.nlm.nih.gov/medlineplus/ency/article/000895.htm3. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001897/Tubal pregnancy; Cervical pregnancy; Tubal ligation-ectopic pregnancy4. CDC Fact Sheet: Ectopic Pregnancy Risk after Tubal Sterilization[CDC Reproductive Health Information Source, 7/04 http://pregnancy.about.com/cs/ectopicpregnancy/l/bltubalfacts.htm]5. http://health.usnews.com/health-news/news/articles/2012/02/16/illicit-drug-use-may-be-driving-rise-in-ectopic-pregnancies-in-florida
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.
This article was originally written by the Medical Institute for Sexual Health, received July 1, 2013. It is reprinted as written in its entirety with permission.
In May 2013, the CDC released the report Decline in State Teen Birth Rates by Race and Hispanic Origin.1 This report includes four important findings. First, the teen birth rates fell by at least 15% for all but two states during 2007 – 2011. In fact, seven of these states recorded a decrease of about 30% or more.1Second, this decline in teen birth rates was most rapid in Hispanic teenagers who achieved a 34% reduction, followed by non-Hispanic Blacks at 24% and non-Hispanic white teens at 20%.1Third, the recorded long-term difference between teen birth rates for non-Hispanic blacks and Hispanic teenagers had gradually disappeared over five years of follow-up data from 2007 – 2011, and the rates had become virtually identical for both groups in 2011, the most current year for which data is available.1,2Fourth, the rates for Hispanic teens fell about 40% or more in 22 states and the District of Columbia.1 In all, rates for Hispanic teens decreased by at least 30% in 37 states and DC.1Although this decrease has been attributed to an increased use of contraception (long acting reversible contraceptives (LARCs), oral contraceptive pills, and condoms) among teenagers;3 the number of teens who have initiated sexual intercourse or are currently sexually active has been on the decline.4 This trend has also been a contributory factor in decreasing teen pregnancies and consequently teen births. However; the rates of sexually transmitted infections have been on the rise among sexually active teenagers and young adults aged 15 – 24 years.5Even with the record decline among all populations of teens; especially in minority populations, the work is not yet done in making sure this trend is sustained among teens of all ethnic groups. Focusing on sexual health education, character training, and parenting education at the community level are all initiatives that could address different needs of various populations within the US. Currently, the Medical Institute offers training to health educators and community liaisons to teach these topics to parents in a wide range of communities across the US.Surveys continue to show that parents are very influential in the sexual decision making of their children but that parents are frequently unaware of this influence.5 Therefore, it is important for parents to be prepared to discuss these topics with their children. Increasing the involvement of parents in the sexual and character education of their children offers the opportunity to capitalize on the unique position of influence that parents hold and to deliver the message in an individualized, culturally-appropriate way.We cannot underestimate the role of a number of social factors that influence the sexual behavior of teenagers. However, evaluation studies have shown a common thread in the positive effect of parental communication and connectedness in delaying sexual initiation and helping young people make healthy sexual decisions.6The decline in teen birth rates is a welcome development. However, the STI rates among this population have been increasing. Working towards a reduction in the rates of other attendant negative outcomes of early sexual initiation such as sexually transmitted diseases and emotional consequences is also critical. Consequently, a risk avoidance prevention message continues to take priority in achieving this goal. Avoiding all risky behaviors is the most reliable way to prevent the myriad of adverse outcomes associated with such behaviors. By emphasizing risk avoidance messages; parents, parenting adults and educators can guide youth towards making the healthiest decisions and leading productive lives.
About Medical Institute for Sexual HealthThe mission of the Medical Institute for Sexual Health is “To empower safe, healthy living by communicating objective and scientific sexual health information.” MI is focusing on five initiatives: Parent Education, Adolescent and College Education, Sex in Media, Medical Accuracy, and Medical Education. These initiatives will facilitate access to medically accurate, evidence-based sexual health information.” The Medical Institute offers a wealth of information and resources relating to sexual health. For additional information, visit https://www.medinstitute.org/.
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