Protective eye on the unborn child

TODAY's ultrasounds are a boon to prenatal care and parental bonding.

Unborn child

ON my phone there is a lovely picture of my third child. The baby has a furrowed brow, perhaps an unfortunate inheritance from its father. With eyes shut tight, it's impossible to tell whether mum's waterpool eyes have been passed on. We will have to wait for that information. You see, our baby is yet to be born.

A wonderfully clear and intimate ultrasound image of our unborn baby's face, taken two months before the due date, is just one example of how medical technology has transformed the pregnancy experience during the past decades. And it is perhaps the least important because, crucially, technology has improved treatments and reduced risks for mothers and babies.

Ultrasound has been the gamechanger, and refinements in this technology and its diagnostic applications continue apace. These developments not only have improved the quality of information available to doctors, midwives and parents, but also made the technology more affordable and portable so the benefits are shared more widely.

For me, having first become a father 20 years ago, this shock of the new has been a uniquely amazing experience. When my first two children were born in the late 1980s and early 90s, good quality care involved one ultrasound scan about midway through the pregnancy. These grainy images enabled medical staff to check basic physical attributes and spot any obvious abnormalities. It was exciting and reassuring but perhaps the best way to convey the lack of detail is to recall that our doctor refused to identify the sex because it couldn't be done with sufficient certainty.

Fast forward two decades and since before the halfway point of this pregnancy we have had to remind the obstetrician and sonographers (ultrasound operators) that we don't want to know the sex of our child - so they must carefully skirt around the groin, lest they spoil our surprise.

Our first scan last year was at seven weeks, when the pregnancy was yet to make itself felt. To see the embryo and, astonishingly, to hear the heartbeat was perhaps as moving an experience as I have had as a parent. That life-affirming sound of a healthy heartbeat almost had my heart breaking through the ribcage.

Leading specialist in obstetric imaging and prenatal diagnosis Andrew McLennan says the way technology binds men into the experience of pregnancy has been a revelation. "In terms of bonding and the connection there is nothing like it," he says. "In the past men have tended to be completely divorced from the process; a pregnancy is something that happens to the woman, and they get on with it until men can perhaps feel the kicks and movements much later on, but now men can see a recognisable embyro very early on and hear a heartbeat.

"It really involves the father in the pregnancy. We would rarely see scans here now without a partner; the connection is excellent."

Few women have the opportunity to experience directly the improvements in obstetric technology across two decades, except of course, through their daughters. McLennan says it is common for mothers to accompany their daughters for scans. "These women will have had their babies in the 70s and 80s when ultrasound was just starting to get going," he explains. "Ultrasound might only have been available at the major teaching hospitals and would often only be used late in pregnancy for women who were experiencing problems.

"Now virtually every woman in Australia will have at least one ultrasound during their pregnancy, so what the mothers see is a dramatic change and it completely blows them away. The first thing is just how exceptional the visualisation has become, particularly in 3-D, which truly makes it real for everyone."

Natasha D'Ambrosio gave birth to her third child, Matilda, this month and says she feels "blessed" by the role ultrasound has had in her pregnancies. "It is an amazing experience in itself; being able to see your baby on a screen at seven weeks ... is daunting and wonderful at the same time," she says. "You eventually see all the baby's growth and recognise the delicate features such as eyes, nose and lips."

But apart from embracing the opportunity to view the development of her children in utero, D'Ambrosio has experienced significant medical benefits. In two of her pregnancies the ultrasound confirmed breech positions, so early decisions could be made to have caesarean section deliveries. Also, potential difficulties were pinpointed. In Matilda's case doctors noticed fluid around the heart, leading to further tests to rule out major abnormalities and examination by a foetal cardiologist. "The cardiologist was absolutely amazing," D'Ambrosio says. "He viewed the heart at 26 weeks, when it was the size of an adult thumbnail, yet he could tell me all about the valves, the ventricles and how they had developed normally." D'Ambrosio's mother, Marie, accompanied her to some scans and was amazed by the experience; when she had Natasha 36 years ago, her doctor did not even permit her to see the screen during her only ultrasound.

Ultrasound machines that were once cumbersome and imprecise now process millions of pieces of information per second and give detailed 3-D imagery in real time, showing movement and blood flow. Some of this technological development, including the key breakthrough to greyscale imaging - which enabled the distinction between fluids, bone and muscle - occurred in Australia. Typically the machines are the size of a filing cabinet but laptop size machines are available for portability. Most obstetricians have ultrasound machines and scan patients at most visits.

The knowledge this provides minimises risks in childbirth, whether from increasingly detailed information or more basic knowledge such as the positioning of the placenta. "You don't have to wait for problems in labour before you realise something is wrong," McLennan says. "You can plan for many of these things, particularly when we have abnormal placenta attachment, so we have blood transfusions and surgeons ready; all of these things make it just so much safer."

Typically ultrasound is used for detailed screening for abnormalities early in the pregnancy. This happens at 19 weeks now but advances in technology aim to bring it forward to 12 weeks. Picking up problems early is crucial. For instance, about four in every 1000 babies has a cardiac defect that requires early surgery and identifying problems before birth is a tremendous advantage.

"We get much better outcomes because we can direct the traffic in terms of the care they receive," McLennan says. "The parents know about the problem and we can decide where the best care is available for the delivery. They get a chance before the baby is born to talk to all the relevant specialists, they get to visit the intensive care unit - all this preparation is gold dust - so that when the baby is born it all happens calmly. They know what to expect; they are still anxious of course, but it's not nearly so traumatic as when a baby collapses at six hours of age and suddenly gets air-lifted to another hospital.

"So it is making a difference in terms of where people are delivered, how they are delivered, and increasingly we hope we are going to be better able to predict those who are going to have high-risk pregnancies."

Ultrasound has also made possible diagnostic and treatment advances for infertility and gynaecological disorders, including cancers.

The one downside is that sometimes the knowledge raises anxiety. Problems spotted early in pregnancy, such as a low placenta, often sort themselves out. So women may worry about issues that go away. But this seems a small price for the overall benefits.

While a key focus of early screening is identifying abnormalities that force some parents into difficult decisions about termination, McLennan says the advances in scanning can also create unrealistic expectations.

"It has built up expectations that every abnormality will be identified and every baby will be perfect; and that is never going to be the case. Some disorders don't develop until later and some are difficult to detect; in the early days of ultrasound we picked up about 20 per cent of abnormalities, now in good institutions it is up to about 85 to 90 per cent."

McLennan says premature births create most health crises, expense and need for infrastructure in obstetrics. Extremely premature babies have much improved survival rates compared with years gone by, but often suffer long-term health issues.

So, increasingly the research is focused on finding ways to predict pre-term deliveries and some of the associated pregnancy complications, such as maternal hypertension and gestational diabetes. Given the advances in technology, diagnostics and treatment that prenatal care has seen in the past few decades, our expectations are entitled to be high.

With three healthy children, D'Ambrosio says despite the anxieties caused during ultrasound assessments, the results speak for themselves. "I am eternally thankful that the technology enabled us to discover these issues, and helped us to make plans for resolving problems, in case they didn't resolve themselves during the pregnancy."

Since this piece was filed, Chris Kenny's wife, Sunita, has given birth to a healthy boy, Isaac. Technology proved crucial, with ultrasound detecting the baby's dangerous posterior position, allowing a calm and timely decision to deliver via caesarean section.