Pregnancy Before and After Sonography in Lebanon!
Presented by Reem Naji, Eliana Al-Taki and Zainab Kamar
Table of Contents
- Literature Review
- Research Question
The history of sonography in obstetrics and gynecology can be traced back to Ian Donald and his Glasgow team’s classic 1968 Lancet paper. More than fifty years later, it is impossible to imagine practicing obstetrics and gynecology without one of the many types of ultrasound that are now available, since it helps in creating an image of a developing baby, the mother’s placenta, and the uterus using high-frequency sound waves. As the use of ultrasound scans in pregnancy is increasing over the time, the huge difference between the past and now are increasingly appearing, while its various kinds, including 3D, 4D and Doppler imaging, and many others, are spreading and becoming more accurate and precise.
This study is divided into two parts: the first is a literature review that highlights ideas from journal articles and research studies; the second is primary research interviewing five people on the topic from various backgrounds and pregnancies. A qualitative study based on the five interviews was conducted to assess and weigh the potential powers and benefits of this technique along its development path, noting from each interview his/her experience with the technology and his/her point of view on it. Relying on and respecting the ethical standards and practices of qualitative research by taking from each participant a consent form to share thoughts and record the interview where accepted, the views of participants in this study were respected by assuring free, prior, informed, and voluntary consent for all signatures to these forms.
Interviewing professionals and specialists including a midwife, a nurse, a medical student, as well as women who had experienced this method like the grandmother, as well as the current pregnant women who has knowledgeable many deliveries and pregnancies, proved to be a very fruitful way of demonstrating ultrasonography’s positive impacts and improvements in Lebanon. All the participants agreed on the idea that ultrasound images are now very effective procedures and need to be improved and spread in every region and area of Lebanon. While its importance in Lebanese rural areas cannot be overstated, especially during these difficult times and the crisis that all Lebanese citizens are experiencing, there are still many challenges that women face to get an ultrasound for their child. Sometimes due to these challenges, women who should always have access to regular check-ups during pregnancy cannot because these programs tend not to exist in rural areas, transportation can be hard to come by, or can be expensive due to fuel prices. For these reasons and others, it is recommended and suggested to improve those ultrasound medical programs in rural and small Lebanese regions, besides providing them with high efficient machines and technologies, for the pregnancy to be all on track.
The results from our study demonstrate that the technique has an effect on pregnant women, allowing her to check her own health as a mother, and positive effects on the health of the baby in preventing issues and problems as the ultrasound images can provide vital diagnostic information about a developing baby. Some of this vital information provided about the baby from the ultrasound include: confirming pregnancy and gestational age; checking for multiple pregnancies, detecting congenital anomalies, and/or placental problems; monitoring fetal position, growth, and amniotic fluid level; and assisting in other tests.
Keywords: sonography, ultrasound, Ian Donald, 3D ultrasound, 4D ultrasound, Doppler, fetal biometry, fetal abnormalities, preterm birth.
In an ultrasound test, often known as a sonogram, sound waves are used to create a picture of the developing child inside the uterus (womb). It also aids the medical professional in monitoring the infant’s wellbeing and growth.
Through the late 1960s and into the 1970s, sonography equipment and procedures advanced. With the adaptation and replacement of diverse approaches, techniques to assess fetal biometry and anomalies kept improving (Ultrasound School, 2021).
Ultrasounds show how to make the work of all medical professionals, particularly gynecologists, easier. The qualities, benefits, and drawbacks of sonography are unique, just like those of every other technology. This study aims to address how the absence of medical equipment has impacted births from a historical viewpoint, particularly one related to the adverse health consequences for women denied access to the technology.
Sonography is a noninvasive, painless procedure. It uses high-frequency sound waves, called ultrasound waves, to produce images of organs, soft tissues, blood vessels, and blood flow from inside the body, which can then be used for medical analysis. Ultrasound imaging technology has been used in medicine. The use of ultrasound in medicine began during and shortly after the 2nd World War in various centers around the world. The work of Dr. Karl Theodore Dussik in Austria in 1942 on transmission ultrasound investigation of the brain provides the first published work on medical ultrasonic (Dussik, 1942). The technology has been available since the 1950s after being introduced by Dr. Donald, an obstetrician who pioneered ultrasonography diagnostics in Europe during the twentieth century. Dr. Donald introduced ultrasonography to the field of gynecology medicine where the technology underwent significant transformation. One of these transformations occurred in 1966 when Dennis Watkins, John Reid, and Don Baker developed pulse Doppler ultrasound technology: a noninvasive diagnostic that uses high-frequency sound waves (ultrasound) to measure blood flow via blood arteries by bouncing them off circulating red blood cells (Donald, 1966).
The transformation that has occurred in ultrasound usage into visual information since then allowed for accurate dating of a pregnancy by comparing fetal size to charts of normal growth trajectories, which allowed for more precise medical management of the patient and more precise timing of biochemical tests, such as amniocentesis, a concurrently emerging technology (Michelle et. Amber, 2021).
In addition, clinical researchers have seized technological advances such as solid-state circuitry, real time imaging, color and power Doppler, trans-vaginal sonography, and 3/4D imaging to improve patient investigation and management in areas as diverse as assessment of fetal growth and wellbeing, screening for fetal anomalies, prediction of preeclampsia and preterm birth, detection of ectopic gestation, evaluation of pelvic masses, and screening for ovarian cancer (Lancet, 1976).
By the time several inventions were made, especially in the devices of ultrasound field, a large number of static scanning machines had come into existence. These machines were initially built in research centers where it was essential always to have dedicated physicists on hand in these were pretransistor or days when the equipment was prone to develop electronic faults. Compared to today’s sleek, real-time digital scanning machines, one of the first versions of ultrasound technology was the Diasonograph, an 8 ft tall device which occupied about one-third of a scanning room. The gantry that housed the probe was also very large and had to be physically shifted with no small effort to alter the scanning plane. Many people, especially the Americans, unflatteringly called it the “Dinosaurograph” for its large weight and size. It did, however, have positive features which allowed users to take a lead in the early ultrasound biometry. Of these, the diasonograph had by far the best image resolution compared to its rivals.
A prenatal ultrasound shows an image of a baby within the womb using sound waves and a computer screen. Doctors can use ultrasounds to see how a baby is growing and developing. Ultrasounds may also be used by a provider to determine whether additional testing is required to assess a baby’s health, unlike in the past where accessing technique posed big challenges for pregnant women and healthcare providers.
Using the ultrasound technology, sound waves travel into the area being examined until they hit a boundary between tissues, such as between fluid and soft tissue or soft tissue and bone. At these boundaries, some of the sound waves are reflected back to the probe, while others travel further until they reach another boundary and are reflected back. Since the speed, direction, and distance sound waves travel differ depending on the boundary they run into, a computer can interpret this information as a two-dimensional image on a screen. It can provide a detailed picture of the embryo and the uterus (MayFair, 2020). The image produced is called an ‘ultrasound image’.
Ultrasound imaging has many benefits: One of the main benefits of using it during pregnancy is that it can confirm if you are in fact pregnant or not. Obstetrical ultrasounds can be performed at any time during pregnancy, but the earliest that an embryo is usually visible with a heartbeat is at about six weeks of gestation. Also known as sonography, ultrasound imaging uses a small transducer (probe) to both transmit sound waves into the body and record the waves that echo back (American College of Obstetricians and Gynecologists, 2020).
Another main benefit of the ultrasound is that it provides the best opportunity to discover fetal defects and assist in prenatal care management, also reducing the number of ultrasound tests required to complete the fetal anatomy survey in the second trimester (Society of Obstetricians and Gynecologists of Canada, 2009).
In Lebanon, a cross-sectional study was done to assess cases and consider the possible impact of an obstetrical ultrasonography screening intervention on pregnant patients in a refugee-dense area of Lebanon. Patients were offered monthly second-trimester obstetrical ultrasound imaging. The findings of the study indicated the need for a prenatal ultrasound screening program in Lebanon’s rural areas where refugees have settled. In these areas, the lack of proper ultrasound screening poses serious risks that can jeopardize any pregnancy (Snaifer, 2021).
As the ultrasound may possibly have a future role in molecular imaging which enables it to produce micro-scale visualization, and the technology is distinguishable for its real-time, non-invasive scanning, convenience of administration, and the absence of ionizing radiation, the ultrasonography is an interesting alternative in educational settings for understanding topographic anatomy and maybe improving future clinical practice for vocational students (Varsou, 2019).
What difference does the presence of ultrasound technology during pregnancy make for the health of women and babies in Lebanon compared to historical times when the technology was not yet created?
A qualitative method, based on different oral interviews was chosen to build this research. Open-ended questions were asked of interviewees in this research to explore access and experience with ultrasounds.
Starting with an interview with an old woman aged 78 years old, we asked this woman four main questions. The aim of these questions was to know how difficult the pregnancy and delivery process was, as it was not possible during this elder woman’s lifetime to use ultrasound to check for pregnancy or assess a fetus’s health condition.
Interviewing a current pregnant woman was important also in order to understand from a recent pregnancy how the technology is or is not useful today. Asking this woman about the month of her pregnancy and her fetus’s ongoing health, the aim of this interview was to get more information on how a pregnant woman today can assure the continued health of her baby. The pregnant woman was also asked for her opinion on the technology and how comfortable she felt when doing the ultrasound image each time she was pregnant to assess the level of comfort and confidentiality of these assessments.
An interview was conducted with a Lebanese medical student to understand the importance of implementing ultrasonography mainly in rural areas and to explain reasons for the ultrasound based on his/her information and experiences in this field. In addition, the medical student was asked for his expectations on how ultrasonography and Doppler imaging are benefiting pregnant women who test positive for severe acute respiratory syndrome due to Covid-19.
Interviewing, finally, a nurse, we posed questions about the types of ultrasound that exist, asking the nurse to please also explain briefly the different types of ultrasound which exist, including a practical emphasis on the fetal ultrasound. Questions about the ultrasound history and reasons of using it were also asked to the nurse. The last questions posed to the nurse probed into the working process of using the ultrasound and about the risks when using the technology.
Last but not least, a couple of questions were posed to an experienced midwife about the ultrasound transformation a visual image and the relationship of this image with the delivery in a precise date. We asked the experienced midwife to speak briefly about her experience measuring the flow of pregnant women via blood arteries, through many layers of the heart of the baby. Based on her scientific perspectives and valuable experience, the last two questions were also posed to the experienced midwife based on her scientific view and valuable experience: “How can we know if the fetus has any genetic problem or which month/stage of pregnancy the woman is in?; What will be the advantages from the ultrasound scanning during the first trimester?”
After conducting the five oral interviews with the identified participants, information about ultrasound sonography, its advantages and its importance compared to the time without the technology was assessed and analyzed into this study findings. Those findings are presented in the following section.
After interviewing the identified participants, particularly with regard to receiving the written, free, prior, and informed consent of all participants we identified the importance of the ultrasound for the health of pregnant women and their babies.
From the medical student’s interview, where he provided thoughtful answers to each question, the critical importance of putting such initiatives into action, particularly in light of the severe economic crisis Lebanon is currently experiencing was emphasized. Rural areas constantly need to grow and become more productive, as well as rich in such resources and programs (Walid, 2022).
Additionally, a sonogram is a crucial treatment to monitor the fetus’ and pregnant woman’s growth. The medical student (Walid, 2022) concurred that numerous studies had demonstrated the value of ultrasound imaging in assessing, among other things, glands, breast tumors, joint issues, and bone illnesses. Thus, an ultrasound reading is similar to a complete examination for the baby’s health, including any issues or abnormalities, and it is a type of image that allows the mother feel more at ease and comfortable. It is also completely painless and safe. Regarding the final query, which concerns the benefits of Doppler imaging and ultrasonography for females who have tested positive for Covid-19, numerous studies have found no differences in abnormal fetal ultrasonography or Doppler results between pregnant women and those who tested positive for Covid-19, but they have also found that preterm births (less than 35 weeks) were more frequent in those who had the test compared to those who did not (Walid, 2022).
The interview with the grandmother sought to know more about the issues regarding her check-ups each month, the presence of any genetic problem or some difficulties in getting pregnant, and where the birth had taken place in the past. A wide gap appeared between the past and the current health care services, opening the door for a variety of further questions regarding the availability of medical supplies and essential medicines and machines, to if the staff were well prepared for the usage of those techniques and if the health services were affordable for all pregnant women. The grandmother mentioned that during her pregnancy years ago, the presence of gynecologist to check up on her health was not possible because of the unavailability of transportation for rural regions. Medicines were not affordable for all in the past. She also reported that it was very difficult to track in which month her pregnancy was. Mainly, the delivery process was done in their current state “at home” by the women. This kind of pregnancy was known as “Dayah” in the past. The women interviewed was also experienced in the delivery of babies using these traditional methods which could be useful in the delivery of other women children during those 9 months.
In a third interview, we interviewed a women in her seventh month of her current pregnancy. She and her fetus were in good health. This women told us about her previous pregnancy experience as well. In this experience, she directly explained to us the importance of the presence of the audio image and how it preserved the life of her fetus. She said that she was about to give birth and in a visit to the doctor the doctor performed an ultrasound of the fetus and was shocked that the fetus was in a serious condition due to the wrapping of the umbilical cord around the fetus’s neck. The sound image was an essential tool to protect the child from death. The woman further explained the comfort and reassurance that she feels whenever she takes the sound image, hearing the child’s pulse, following its growth, and seeing its movements and organs when visiting through sonography. The woman told us that she believed that medical development is a very important matter which has the advantage of increasing human life and health. Moreover, the pregnant woman gave us a picture of her fetus (see Figure 1), and she explained to us about the details of the organs of her fetus that appear in the picture, expressing the extent of her comfort and reassurance about the fetus whenever she performed the ultrasound. Joy appeared on the woman’s face whenever she looked at the picture of her fetus. For that reason, we have kept this ultrasound image as illustrative material to support our research.
From the interview done with the midwife, we discovered that an important use of the ultrasound is date checking the fetus and mother’s health throughout pregnancy. The midwife focused on the way and the how we should do the scan for the pregnant women and the usage of the machines during scanning. She also stressed to us the importance of timing for the ultrasound, sharing with us that this information in the first trimester and then 18-22 weeks for normal cases, were important times for checking the health of the child and mother. All of these factors can make the difference in the ideal pregnancy ways and plans, which will be reflected in the good health of the fetus and his mother.
Through another interview with a nurse, we learned various information about the audio image, including that there are different types of ultrasounds, like abdominal ultrasound, pelvic ultrasound imaging, trans-abdominal and fetal echocardiography, etc. The ultrasound scan isn’t 100 percent accurate, but the advantages of the test are that it’s non-invasive, painless, and safe for both the mother and the unborn baby.
The specific ultrasound called a sonogram is used during pregnancy to check the baby’s development, the presence of a multiple pregnancies, and to help pick up any abnormalities. The gynecologist interviewed told us about the development of the sound image which went through several stages since 1940. Ultrasound technology has continued to advance since the first 3D ultrasound technology was introduced in the 1980s. Then the 4D ultrasound technology, which shows movement, made its debut. The nurse added that between 1970 and 1980 the ultrasound entered Lebanon specifically. Gradually, the development of this machine took place also.
The nurse indicated that ultrasound imaging or sonography is often used in medicine. In the non-destructive testing of products and structures, ultrasound is used to detect invisible flaws. Industrially, the ultrasound is used for cleaning, mixing, and accelerating chemical processes. In addition to these, the nurse identified the ultrasound as useful also for the following reasons: view the uterus and ovaries during pregnancy and to monitor the developing baby’s health, diagnose gallbladder disease, and to evaluate blood flow.
Moreover, the nurse interviewed explained how pregnant women can use sonography, telling us that typically pregnant woman would be asked to lie on her back and reveal her stomach for this procedure. The sonographer would then put ultrasound gel on her stomach, which makes sure there is good contact between the machine and the skin. Finally, the sonographer then passes a probe over the woman’s stomach and a picture of the baby will appear on the ultrasound screen.
Regarding the work of ultrasound (sonography) the nurse indicated that sonography or ultrasound imaging uses a small transducer (probe) to both transmit sound waves into the body and record the waves that echo back. Sound waves travel into the area being examined until they hit a boundary between tissues, such as between fluid and soft tissue, or soft tissue and bone. Doctors commonly use ultrasound to study a developing fetus (unborn baby), a person’s abdominal and pelvic organs, muscles and tendons, or their heart and blood vessels. The midwife interviewed added that an ultrasound is safe for the pregnant and her baby when done by the health care provider. Because ultrasound uses sound waves instead of radiation, it is also safer than X-rays. Providers have used ultrasound technology for more than 30 years and they have not found any dangerous risks in all of this time.
The answers to the questions in our interviews indicate that the ultrasound image has a significant impact on maintaining the health of the pregnant woman and her fetus. The interview with the Lebanese grandmother explained to us the difficulty that pregnant women felt in the old days before the existence of the sound image, and the grandmother was a model for the women of her time as she lost a son due to poor medical technology. In her case, the medical failures as a result of an inability to see the fetus well left the fetus in a position that he was unable to survive from. From our interview with the pregnant woman, it became clear to us how significant was the difference between using and not using the ultrasound. We were able to gather how important the ultrasound can be for making the mothers feel comfortable with the health of their babies before birth. By taking a picture of a child with the doctor, it is possible to check on the fetus and know from this image if any abnormality is developing, correcting it through treatment before any further issue develop.
The comparison between a model of pregnant women before using the sonogram in Lebanon and a model of women after the presence of this development, the extent and impact of this development on the psychological and physical health of women became clear. In addition to its impact on the protection of the fetus, the technology also reassured the mother through reports provided by the ultrasound on the health of the child in the womb.
All of this was also confirmed from the medical perspective in an interview with the nurse who explained the importance of using the ultrasound image of pregnant women for maintaining the safety of the pregnant woman and her son and facilitating the doctor’s work. The findings were similar between the nurse and the midwife, who emphasized the importance of this medical development on the health of the pregnant woman and early detection of any danger to the fetus. Both agreed that the use of a sonography image is safe and has no side effects at all.
We enriched our study by interviewing the student in the scientific field in order to know the extent to which the students know about this development and to learn about any new developments in this field based on scientific studies or research. Our findings from this interview indicate that the types of sound image, its ramifications, and the different roles it plays in treatment have also evolved as the devices and sound images have become more accessible and more clear over time.
All findings showed us the role of the sonogram machine for preserving the life of the pregnant woman and the fetus, and that the technology greatly facilitates the work of the midwife and the doctor. On the other hand, we have also learned of the difficulties women had previously for those who were not able to access the technology (sonography).
Ultrasonography is becoming a valuable diagnostic tool for healthcare providers working in resource-constrained settings. To date, much research supports the use of this technology to guide management plans and procedures. It is possible to draw conclusions about the long-term sustainability of ultrasound programs in Lebanon, particularly in rural areas, and with reference to target populations who may benefit the most from ultrasound services, as well as further expand the indications for its use, particularly as conducted in this study, where the benefits and huge positive consequences of this technique are highlighted. Our findings confirm the need for a prenatal ultrasound screening program to be implemented in rural areas of Lebanon, noting that the lack of adequate ultrasound screening in these areas poses serious risks that can jeopardize the health of mother or child in any pregnancy.
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