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Suspect Diagnoses Come with Biophysical Profiling

by Gloria Lemay

[Editor’s note: This article first appeared in Midwifery Today Issue 69, Spring 2004.]

Many North American women are being told at the very end of their pregnancies to go to an ultrasound clinic and have a biophysical profile done. Most are impressed by the thoroughness of their practitioner and have no idea what this test involves or what sort of harm could follow from consenting to this diagnostic procedure. They will probably not be told that there is no scientific basis for having faith in the test results and that no improvement in health has been proved from large numbers of fetuses being “profiled.” Certainly, no one will mention that the only benefits of the procedure are: 1) the ultrasound clinic will earn $275; and 2) the medical practitioner will be able to cover themselves legally in the very rare instance that a baby might die in utero.

Until recently, physicians and midwives would tell women who were carrying their babies beyond 41 weeks gestational age to do “kick counts.” If the baby has 10 distinct movements between the hours of 9 a.m. and 3 p.m., it is widely accepted that the baby is thriving under the mother’s heart. In a culture that loves technology and with the push to expand the commercial use of ultrasound, it was inevitable that someone would come up with a more complex strategy to provide reassurance of the baby’s wellbeing in late pregnancy. Thus the biophysical profile (BPP) was born. Here is the content of the testing, as it appears on the Family Practice Notebook Web site (www.fpnotebook.com/OB44.htm):

  1. Cost: $275
  2. Criteria (2 points for each)
    1. Fetal Breathing
      1. Thirty seconds sustained breathing in 30 minutes
    2. Fetal Tone
      1. Episode extremity extension and flexion
    3. Body Movement
      1. Three episodes body movement over 30 minutes
    4. Amniotic Fluid Volume
      1. More than 1 pocket amniotic fluid 2 cm in depth
    5. Non-Stress Test
      1. Reactive
  3. Scoring
    1. Give 2 points for each positive above
  4. Interpretation
    1. Biophysical Profile: 8-10
      1. Low risk or Normal result
      2. Repeat Biophysical Profile weekly
      3. Indications to repeat Biophysical Profile biweekly
        1. Gestational Diabetes
        2. Gestational age 42 weeks
    2. Biophysical Profile: 8
      1. Delivery Indications: Oligohydramnios
    3. Biophysical Profile: 6
      1. Suspect asphyxia
      2. Repeat Biophysical Profile in 24 hours
      3. Delivery Indications
        1. Repeat Biophysical Profile less than or equal to 6
    4. Biophysical Profile: 4
      1. Suspect asphyxia
      2. Delivery Indications
        1. Gestational age 36 weeks
        2. Lung Maturity Tests positive (L/S Ratio 2)
    5. Biophysical Profile: 0-2
      1. Likely asphyxia
      2. Continue monitoring for 2 hours
      3. Delivery Indications
        1. Biophysical Profile ‹ 4

“Breathing” above refers to movements in the lungs that show activity of the lungs in preparation for life outside the womb. The baby’s oxygen supply in utero comes via the placenta and umbilical cord while in the mother’s womb.

In the past year, I have had a number of letters and phone calls from doulas, midwives and childbirth educators about a flaw in this testing method. An unusually large number of diagnoses seem to be made that “there is not enough amniotic fluid.” This seems to be the factor in this outline that is most often used as an excuse for induction. It is important for parents to know that this is likely an inaccurate assessment. What the ultrasound technician is doing could be compared to viewing an adult in a see-through plexiglass bathtub from below the tub. In such a scenario, it would be difficult to assess how much water is in the tub above the body that is resting on the bottom of the tub. You might be able to get an idea of the water volume by measuring how much water was showing below the elbows and around the knees, but if the elbows were down at the bottom of the tub, too, you might think there was very little water. This is what the technician is trying to do in late pregnancy—find pockets of amniotic fluid in little spaces around the relatively large body of an 8 lb. baby who is stuffed tightly into an organ that is about the size of a watermelon (the uterus). If most of the amniotic fluid is near the side of the uterus closest to the woman’s spine, it can not be seen or measured. This diagnosis of low amniotic fluid frightens the parents-to-be into acquiescing to an induction of labour. Even though the official BPP guidelines do not require immediate induction for a finding of low amniotic fluid, in practise, the parents are pressured to induce. Stories abound of mothers who are induced for this indication and then report having abundant fluid when the membranes released in the birth process. The risks of induction, which can be catastrophic, and the resulting increase in the need for pain relief medication and cesarean section are usually not discussed with the parents prior to embarking on induction of the birth. Be warned that this latest suspect diagnosis using ultrasound is increasing in frequency and causing increased harm to mothers and unborn babies through aggressive use of induction.

Gloria Lemay has been attending births in Vancouver, B.C., for 25 years. She is an advisory board member of the International Cesarean Awareness Network (ICAN), as well as a contributing editor for Midwifery Today and contributing expert for the Birthlove Web site. Visit her Web site at www.glorialemay.com.


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October 12th, 2008 by Judith Lothian

The Milbank Report, Evidence-Based Maternity Care: What It Is and What It Can Achieve, was released on October 8. This report should shake the world of maternity care to its very core!

The authors of Evidence-Based Maternity Care, Carol Sakala and Maureen Corry, have a  long involvement with evidence-based maternity care including planning and leading Childbirth Connection’s national program to promote such care over the past decade.

Childbirth Connection, the Reforming States Group and the Milbank Memorial Fund collaborated in planning, developing and issuing the report, including formulating policy recommendations.

The Millbank Memorial Fund is a foundation that works to improve health by helping decision makers in the public and private sectors acquire and use best available evidence to inform health policy. The Reforming States Group, organized in 1992, is a voluntary association of leaders in health policy from all 50 states, Canada, England, Scotland and Australia. Childbirth Connection (formerly the Maternity Center Association), founded in 1918, is a national not for profit organization that works to improve the quality of maternity care through research, education, advocacy and policy.

Many national policy, quality and maternity care leaders provided detailed feedback on report drafts and further strengthened the report.

In a nutshell, the report finds that despite the good intentions of health care providers and huge  expenditures (by Medicaid, private insurers and women themselves) the quality of US maternity care is poor. Evidence-based care practices are underused and poor quality practices, like procedures, tests, and medications that are not needed, are overused. The report highlights best evidence that, if widely implemented, would have a positive impact on many mothers and babies and would improve value for payers.

USA Today quotes University of Wisconsin’s Douglas Laube, a former president of the American College of Obstetricians and Gynecologists, who blames “very significant external forces” for the overuse of expensive technologies in maternity care.

“I don’t like to admit it, but there are economic incentives” for doctors and hospitals to use the procedures, says Laube, who reviewed the new report before its release. Dr. Laube goes on to say that some doctors might get bonuses for performing more labor inductions, which adds costs and increases the risk of C-sections, which, in turn, increase hospital profits because they require longer stays. Some doctors order unnecessary tests because of fear of litigation.

Consumer Reports had this to say: “When it’s time to bring a new baby into the world, there’s a lot to be said for letting nature take the lead. The normal, hormone-driven changes in the body that naturally occur during delivery can optimize infant health and encourage the easy establishment and continuation of breastfeeding and mother-baby attachment. Childbirth without technical intervention can succeed in leading to a good outcome for mother and child, according to a new study.” We couldn’t agree more!

The full report plus ongoing press coverage can be found at Childbirth Connection. Every women in America needs to read this report. Every insurance provider needs to read this report. Every health care provider and hospital needs to read this report. Making the changes necessary to improve outcomes and make birth safer for mothers and babies is a collaborative responsibility. Evidence-Based Maternity Care is a call to action, for all of us.

By GERADINE SIMKINS
Posted: July 17, 2008

One wonders what process the American Medical Association House of Delegates used to determine that its resolution on home deliveries was prudent and reasonable.

AMA resolution 205 attempts to outlaw a woman’s choice to give birth at home or in a freestanding birth center by calling for legislation to establish hospitals and hospital-based birth centers as the safest place for labor, delivery and postpartum recovery. Further, it seeks to establish that hospital-based midwives who work under the control of physicians are the only safe midwifery practitioners.

The Midwives Alliance of North America, which has represented midwives since 1982 and whose members are specialists in homebirth, finds the resolution arrogant, patronizing and self-serving.

We have three major objections. First, the resolution patently ignores the vast body of scientific evidence that has documented home birth to be a safe, cost-effective and satisfying option for women who prefer it. Second, it is seriously out of step with the ethical concept of patient autonomy, encompassing both informed consent and informed refusal. Third, it distracts from other critical issues, including increasing access to care, improving perinatal outcomes, reducing health disparities and fostering client satisfaction. The resolution is anti-home birth, anti-midwife, anti-choice and is unsupported by scientific evidence.

Why is the AMA not asking real questions instead of trying to debunk existing evidence on the safety and efficacy of homebirth and attempting to corner the market on maternity care? For example, why are midwife-attended births far more likely to have fewer interventions, fewer postpartum infections, more successful breast-feeding rates and healthy infant weight gain and to result in more satisfied, empowered mothers? Why are so many women left emotionally traumatized by childbirth experiences in hospitals and consequently why do rates of postpartum depression, anxiety and post-traumatic stress continue to escalate?

It is ironic that the AMA should have a quarrel with a known safe birth option while the epidemic rise in coerced or elective Caesarean sections puts healthy mothers and infants at greater risk and strains our health care system. The rate of Caesarean sections in the United States is unacceptable — one in three pregnancies end in major abdominal surgery — and the decline in availability of vaginal birth after Caesarean is deplorable. It is past time that the AMA and the American College of Obstetricians and Gynecologists realize that women and their partners are choosing home birth and freestanding birth centers to avoid ethically unsupported obstetric interventions.

In almost all areas of modern medicine except obstetrics, control in decision-making rests firmly with the patient and not with the medical provider. Informed consent has appropriately become the gold standard.

Why then do the AMA and ACOG believe that they can promote legislative efforts to deny women choices in maternity care providers and childbirth settings?

All maternity care providers should band together to reduce the rates of maternal and infant mortality and morbidity in the United States, increase access to maternity care for all women, reduce unnecessary Caesarean sections, encourage vaginal birth (including after c-section) for healthy women, reduce health disparities of women and infants in minority populations and promote breast-feeding. These would improve the health of mothers and babies far more than reducing the rates of home birth.

The Midwives Alliance joins the other individuals and organizations, including individual AMA and ACOG members, who have grave concerns about the stance articulated in this resolution, and calls for the AMA to abandon this resolution. Midwives everywhere honor and respect the numerous friendly physicians with whom we already partner and look to the day when midwives and obstetricians consistently will work collaboratively to support women’s choices in childbirth and provide the best and most appropriate range of services.

Geradine Simkins is president of the Midwives Alliance of North America.

http://www.jsonline.com/story/index.aspx?id=773731

Ok, here we go again. This is the second Britax car seat I have had to replace this year. The first was in an accident when Ethan’s father’s car was totaled. Yesterday, a car hit Matt’s BMW in a parking lot, rendering our BRAND NEW BRITAX BOULEVARD unsafe for use.

So…after getting off the phone with the insurance company WITHOUT ONE WORD FROM THEM ABOUT OUR CAR SEAT, I have realized that most people do not know that car seats MUST be replaced in cases of accidents, even accidents that most people would refer to as “minor”. Actually, most car seat manufacturers recommend replacement of car seats after ANY accident. Britax, however, follows the NHSTA guidelines for what constitutes a “severe” accident warranting replacement of a car seat.

As you can see below, NHTSA does NOT consider our accident to be “minor”. The criteria for a “minor” accident are the following:

  • Minor crashes are those that meet ALL of the following criteria:
    • The vehicle was able to be driven away from the crash site;
    • The vehicle door nearest the safety seat was undamaged;
    • There were no injuries to any of the vehicle occupants;
    • The air bags (if present) did not deploy; AND
    • There is no visible damage to the safety seat

Both my door and Ethan’s door (which was behind me) were hit. 😦

Here is what NHTSA says (from http://www.nhtsa.dot.gov/people/injury/childps/ChildRestraints/ReUse/RestraintReUse.htm)

NHTSA Logo - This page is 508 compliant


Child Restraint Re-use After Minor Crashes

NHTSA Position

  • NHTSA recommends that child safety seats be replaced following a moderate or severe crash in order to ensure a continued high level of crash protection for child passengers.
  • NHTSA recommends that child safety seats do not automatically need to be replaced following a minor crash.
  • Minor crashes are those that meet ALL of the following criteria:
    • The vehicle was able to be driven away from the crash site;
    • The vehicle door nearest the safety seat was undamaged;
    • There were no injuries to any of the vehicle occupants;
    • The air bags (if present) did not deploy; AND
    • There is no visible damage to the safety seat
  • Clarifying the need for child seat replacement will reduce the number of children unnecessarily riding without a child safety seat while a replacement seat is being acquired, and the number of children who will have to ride without a child seat if a seat were discarded and not replaced. The clarification will also reduce the financial burden of unnecessary replacement.

Background

  • Recent studies demonstrate that child safety seats can withstand minor crash impacts without any documented degradation in subsequent performance.
  • The Insurance Corporation of British Columbia ( ICBC ) subjected nine new and used child seats restraining 3-year-old dummies to a series of 50 consecutive 15 km/h sled tests into a 40% offset barrier. Three seats were inspected visually; no damage was apparent as a result of the impacts. Three seats underwent x-ray inspection; no damage was detected. Three seats were tested in accordance with Canadian federal standards (CMVSS 213) and were found to be in compliance with all standards.
  • ICBC performed four vehicle crash tests at 48 and 64 km/h, with two child seats restraining 3-year-old dummies in each vehicle. Each seat was subjected to multiple impacts and visually inspected. Defects were noted and the seats were re-tested. Seats always performed as well in subsequent tests as they did in the first test.
  • The Insurance Institute for Highway Safety (IIHS) performed 30 mph vehicle crash tests with dummies from six months to three years in a variety of child restraint systems (CRSs). Most seats sustained minor damage (e.g., frayed webbing, small cracks in the hard plastic shell, strain-whitening on the plastic shell or chest clip) but all dummies remained well secured by the restraints. Four of the damaged seats were subjected to three additional 30 mph crash tests. Although additional minor damage was observed in subsequent tests, the seats met all federal standards.
  • The agency searched for, but was unable to find any cases in which a child safety seats were damaged in a minor crash (as defined in NHTSA Position).

Note:

The agency is committed to maintaining policies that are science-based and data-driven. Stakeholders with data that address post crash re-use of child safety seats are encouraged to provide this information to the agency.

Parenting Books

I finally got a list together of my Parenting Books.

Without further ado:

GENERAL HEALTH:

  1. How to Raise a Healthy Child…In Spite of Your Doctor, Robert S. Mendelsohn
  2. Wise Woman Herbal Childbearing Year, Susan Weed
  3. The Healthiest Kid in the Neighborhood, Sears & Sears
  4. A Mother’s Guide to Raising Healthy Children Naturally, Sue Frederick
  5. Feeding Your Child for Lifelong Health, Susan B. Roberts & Melvin B. Heyman
  6. Homeopathy for Pregnancy, Birth & Your Baby’s First Year, Miranda Castro

BABY BOOKS:

  1. The Baby Sleep Book, Sears & Sears
  2. The Baby Book, Sears & Sears
  3. The No-Cry Sleep Solution, Elizabeth Pantley
  4. Sleepless in America, Mary Sheedy Kurcinka

DISCIPLINE BOOKS:

  1. Positive Discipline, The First Three Years, Jane Nelsen, Cheryl Erwin & Roslyn Duffy
  2. The Discipline Book, Everything You Need to Know to Have a Better-Behaved Child – From Birth to Age Ten, Sears & Sears
  3. Unconditional Parenting, Alfie Kohn (hardcover and paperback)
  4. Easy to Love, Difficult to Discipline, The 7 Basic Skills Turning Conflict into Cooperation, Becky A. Bailey
  5. The Happiest Toddler on the Block, Harvey Karp
  6. Raising Your Spirited Child, Mary Sheedy Kurcinka (I have 2 copies; one 1998 and one 2006)
  7. Liberated Parents, Liberated Children, Your Guide to A Happier Family, Adele Faber & Elaine Mazlish
  8. How to Talk So Kids Will Listen & Listen So Kids Will Talk, Adele Faber & Elaine Mazlish
  9. How to Talk So Teens Will Listen & Listen So Teens Will Talk, Adele Faber & Elaine Mazlish
  10. Siblings Without Rivalry, Adele Faber & Elaine Mazlish
  11. Whole Child/Whole Parent, Polly Berrien Berends
  12. Common Sense Discipline, Dr. Roger Allen & Ron Rose
  13. Kids are Worth It! Barbara Coloroso
  14. Playful Parenting, Lawrence J. Cohen
  15. Parenting Your Out-Of-Control Teenager, Scott P. Sells
  16. Ten Most Troublesom Teen-age Problems and How to Solve Them, Lawrence Bauman
  17. Now I Know Why Tigers Eat Their Young, Dr. Peter Marshall
  18. Raising a Thinking Preteen, Myrna B. Shure
  19. Get Out of My Life, but first could you drive me and Cheryl to the mall? Anthony E. Wolf
  20. Between Parent & Child, Dr. Haim G. Ginott
  21. Active Parenting of Teens, Michael Popkin
  22. Parent Efffectiveness Training, Dr. Thomas Gordon

GENERAL PARENTING:

  1. The 7 Habits of Highly Effective Families, Stephen R. Covey
  2. Last Child in the Woods, Saving Our children from Nature-Deficit Disorder, Ricahrd Louv
  3. Attachment, John Bowlby
  4. Real Boys, William Pollack
  5. Driven to Distraction, Edward M. hallowell & John J. Ratey
  6. Baby Days, Barbara Rowley

CHILD DEVELOPMENT:

  1. Bright Start; Understand and Stimulate your child’s development from birth to 5 years, Dr. Richard C. Woolfson
  2. No Contest, The Case Against Competition, Alfie Kohn

SPEECH

  1. Late Talking Children, Thomas Sowell
  2. The Einstein Syndrome, Tomas Sowell

HOMESCHOOLING RELATED:

  1. The Unprocessed child, Living Without School, Valerie Fitzenreiter
  2. The Complete Idiot’s Guide to Homeschooling, Marsha Ransom
  3. Slow & Steady Get Me Ready, June R. Oberlander
  4. A Parent’s Guide to Montessori Play & Learn, Lesley Britton
  5. The How and Why of Homeschooling, Ray E. Ballmann

Pregnancy Related Books

I finally finished compiling my list of parenting, pregnancy, etc. related books. So, I thought I would share the list with whomever reads my blog. Feel free to recommend additional books…I do love books

Those related to Natural Child Birth and Pregnancy (in no particular order):

  1. Aromatherapy During Your Pregnancy, Fances R. Cliffford
  2. Unassisted Homebirth, An Act of Love, Lynn M. Griesemer
  3. The Thinking Woman’s Guide to a Better Birth, Henci Goer
  4. Birth Over Thirty-Five, Sheila Kitzinger
  5. The Natural Childbirth Book, Joyce Milburn & Lynnette Smith
  6. A Good Birth, A Safe Birth, Diane Korte & Roberta Scaer
  7. The Birth Partner, Penny Simkin
  8. Unassisted Childbirth, Laura Kaplan Shanley
  9. Water Birth Unplugged,Proceedings of the First International Water Birth Conference, Edited by Beverley A. Lawrence Beech
  10. Pushed,, Jennifer Block
  11. Taking Charge of Your Fertility, Toni Weschler
  12. Birthing From Within, Pam England & Rob Horowitz
  13. Hypnobirthing: A Celebration of Life, Marie F. Mongan (2 copies)
  14. Hypnobirthing, Marie Mongan
  15. Heart & Hands, A Midwife’s Guide to Pregnancy & Birth, Elizabeth Davis
  16. Ina May’s Guide to Childbirrth, Ina May Gaskin
  17. Emergency Childbirth, A Manual, Gregory J. White
  18. Birthing From Within, Pam England & Rob Horowitz

(from insidevaccines.com; http://insidevaccines.com/wordpress/2008/02/24/secondary-transmission-%ef%bb%bfthe-short-and-sweet-about-live-virus-vaccine-shedding/#more-96)

A child gets vaccinated and is from that moment on protected from the vaccine virus, correct? We all realize that vaccines are not 100% failproof, but is that the only concern?

If it only were that simple. The fact is that once a child is injected with a live virus vaccine (and let’s assume that this child is immune as a result of it) there are still other things to consider which most parents do not know about and most pediatricians fail to warn about – which is shedding!

Shedding is when the live virus that is injected via vaccine, moves through the human body and comes back out in the feces, droplets from the nose, or saliva from the mouth. Anyone who takes care of the child could potentially contract the disease for some time after that child has received certain live vaccines. This was a huge problem with the oral polio vaccine, and was one of the reasons why it was taken off the market in the US.

The OPV is still used in developing counties.

Secondary transmission happens fairly often with some of the live virus vaccines. Influenza, varicella, and Oral Polio Vaccine (OPV) are the most common. On the other hand it may happen very seldom or not ever with the measles and mumps vaccine viruses.

Here are the vaccines that shed or have been known to result in secondary transmission:

Measles Vaccine – Although secondary transmission of the vaccine virus has never been documented, measles virus RNA has been detected in the urine of the vaccinees as early as 1 day or as late as 14 days after vaccination. (1)

In France, measles virus was isolated in a throat swab of a recently vaccinated child 4 days after fever onset. The virus was then further genetically characterised as a vaccine-type virus. (2)

Rubella Vaccine – Excretion of small amounts of live attenuated rubella virus from the nose and throat has occurred in the majority of susceptible individuals 7-28 days after vaccination. Transmission of the vaccine virus via breast milk has been documented. (3)

Chicken Pox Vaccine – Vaccine-strain chickenpox has been found replicating in the lung (4) and documented as transmtting via zoster (shingles sores) (5) as well as “classic” chickenpox (6) rash post-vaccination.

Oral Polio Vaccine (OPV) – In areas of the world where OPV is still used, children who have been vaccinated with it pass the virus into the water supply through the oral/feces route. Other children who then play in or drink that water pick up the vaccine viruses, which can pass from person to person and spark new outbreaks of polio. (7)

FluMist Vaccine – The mist contains live attenuated influenza viruses that must infect and replicate in cells lining the nasopharynx of the recipient to induce immunity. Vaccine viruses capable of infection and replication can be cultured from nasal secretions obtained from vaccine recipients.

Transmission of a vaccine virus from a FluMist recipient to a contact was documented in a pre-licensing trial. The contact had a mild symptomatic Type B virus infection confirmed as a FluMist vaccine virus. (8)

Rotavirus Vaccine (RotaTeq) – There is a possibility that one strain of rotavirus which is presently circulating may be an “escaped” vaccine strain, from an old Finnish rotavirus vaccine. (9)

Following are excerpts from the discussion by the FDA Advisory Committee on RotaTeq vaccine shedding: (10)

Page 50:

The latest shedding that we saw was 15 days from dose one.

We had no subjects that shed after dose two, and only one subject shed after dose three. He shed four days from dose three.

Page 51:

A: The quantities were low, similar to what we saw in phase 2 studies, as well.

We also had two placebo recipients that shed, and of course, this raised a red flag for us.

B: Could this have been transmission of vaccine virus from vaccine recipients to placebo recipients?

A: We did a very thorough investigation looking for opportunities for a vaccine transmission to occur and did not find anything. These children were not siblings of a vaccine recipient. They didn’t attend day care with vaccine recipients. They didn’t have a common caretaker with the vaccine recipient, and in the office and clinic in which they were vaccinated, they were not exposed to vaccine recipients.

So going on then to summarize general safety, Rotateq was well tolerated….

Page 70:
Question and answer section –

Then with respect to the possibilities of how these children ended up with vaccine strains in their stool, we really could not find the answer for that. We even went so far as to look and see like on the day that that child was in the clinic, were other children getting vaccine, you know, right before or after them?

And that was not the case. So it has been a puzzle, and we don’t have an answer as to why these children had vaccine strains in their stool.

(One has to ask: Could the reason have been that someone mixed up the placebo with the actual vaccine vials and consequently some kids of the control group got the real vaccine?)

Source:
(1) Detection of Measles RNA
(2) Detection of measles vaccine in the throat of a vaccinated child.
(3) MMR II
(4) Vaccine Oka Varicella-Zoster Virus
(5) Chickenpox Attributable to a Vaccine Virus
(6) Genetic Profile of an Oka Varicella Vaccine Virus
(7) Polio Outbreak in Nigeria
(8) Flumist
(9) Human and Bovine Serotype G8 Rotaviruses
(10) Products Advisory Committee