Within a Woman

Circumcision (Infant Male)

Until recently, only public health and religious views were taken into consideration in the debate over infant male circumcision. However, our understanding of medical practice must change as research findings become available. The College is issuing this guide for physicians regarding routine infant male circumcision in light of evidence]based medicine and contemporary principles in ethics, law and human rights.
Infant male circumcision was once considered a preventive health measure and was therefore adopted extensively in Western countries. Current understanding of the benefits, risks and potential harm of this procedure, however, no longer supports this practice for prophylactic health benefit. Routine infant male circumcision performed on a healthy infant is now considered a non]therapeutic and medically unnecessary intervention. From a religious standpoint, infant male circumcision is acknowledged to be an important ritual and an integral part of Jewish and Islamic religions. Male circumcision is also practiced in other parts of the world as a rite of puberty.

A wider societal discussion on infant male circumcision is warranted based on a current understanding of bioethics that takes into account the non]therapeutic nature of the procedure as well as the high importance it plays in religious and traditional customs. This paper provides a discussion on current medical perspectives as well as relevant legal, human rights, and ethical considerations. Medical Perspectives
Circumcision removes the prepuce that covers and protects the head or the glans of the penis. The prepuce is composed of an outer skin and an inner mucosa that is rich in specialized sensory nerve endings and erogenous tissue. Circumcision is painful, and puts the patient at risk for complications ranging from minor, as in mild local infections, to more serious such as injury to the penis, meatal stenosis, urinary retention, urinary tract infection and, rarely, even haemorrhage leading to death. The benefits of infant male circumcision that have been promoted over time include the prevention of urinary tract infections and sexually transmitted diseases, and the reduction in risk of penile and cervical cancer. Current consensus of medical opinion, including that of the Canadian and American Paediatric Societies and the American Urological Society, is that there is insufficient evidence that these benefits outweigh the potential risks. That is, routine infant male circumcision, i.e. routine removal of normal tissue in a healthy infant, is not recommended.
Legal Considerations To date, the legality of infant male circumcision has not been tested in the Courts. It is thus assumed to be legal if it is performed competently, in the childfs best interest, and after valid consent has been obtained.

At all times the physician must perform the procedure with competence and at all times, the parent and physician must act in the best interests of the child. Signed parental consent for any treatment is assumed to be valid if the parent understands the nature of the procedure and its associated risks and benefits. However, proxy consent by parents is now being questioned. Many believe it should be limited to consent for diagnosis and treatment of medical conditions, and that it is not relevant for non]therapeutic procedures. Human Rights Considerations

The matter of infant male circumcision is particularly difficult in regards to human rights, as it involves consideration of the rights of the infant as well as the rights of the parents.
Under the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights, an infant has rights that include security of person, life, freedom and bodily integrity. Routine infant male circumcision is an unnecessary and irreversible procedure. Therefore, many consider it to be gunwarranted mutilating surgeryh.

Many adult men are increasingly concerned about whether their parents had the right to give consent for infant male circumcision. They claim that an infantfs rights should take priority over any parental rights to make such a decision. This procedure should be delayed to a later date when the child can make his own informed decision. Parental preference alone does not justify a non]therapeutic procedure.

Others argue that this stance violates the parentsf right to religious or cultural expression, and that adherence to their religious and cultural practices would be in the best interests of the infant. Ethical Considerations
Ethical considerations regarding infant male circumcision centre on the welfare (or gbest interestsh) of the infant and the potential benefit and harm associated with the procedure. Ethics points us to corrective vision, i.e. to question practices that have become routine, or which we take for granted.

Therefore, each request for the procedure should be carefully evaluated, and an agreement to perform the procedure should take into consideration the ethical principles of beneficence (duty to benefit); non]maleficence (do no harm); veracity (accurate information); autonomy (consent); and justice (fairness).
These principles are articulated in specific responsibility statements in the CMA Code of Ethics. Also included below are items relating to physicians rights and care of the patient.
Resource Manual . Circumcision (Infant Male) 2

CMA Code of Ethics
Beneficence (duty to benefit)
1. Consider first the well]being of the patient.
14. Recommend only those diagnostic and therapeutic procedures that you consider to be beneficial to your patient and not othersc.
For Consideration: Medical evidence is that the benefits of routine infant male circumcision do not outweigh the risks of complications from the procedure. Best interests also take into account the infantfs social circumstances.
Non]maleficence (do no harm)
33. Refuse to participate in or support practices that violate basic human rights.
For Consideration: Routine infant male circumcision does cause pain and permanent loss of healthy tissue.
Veracity (adequate information)
13. Make every reasonable effort to communicate with your patients in such way that information exchanged is understood.

For Consideration: Discussion should include the new understanding that there is a lack of evidence of a real medical benefit in routine infant male circumcision, that it is non]therapeutic, and that only in rare situations is there any clinical indication for the procedure. Specifics of potential risks and complications should also be explained. It is important to ensure a meaningful discussion between physician and parents, and that the information provided is understood.
Autonomy (informed consent)

12. Provide your patients with the information they need to make informed decisions about their medical care, and answer their questions to the best of your ability.
For Consideration: Parents must be given accurate and impartial information to assist them in making an informed decision. The infant, the actual patient, is unable to give consent. Proxy consent by parents for a non]therapeutic procedure is debatable.
Justice (fairness)

29. Recognize that community, society and the environment are important factors in the health of individual patients.
For Consideration: Physicians should understand the basis for the request and consider the infantfs social and cultural circumstances and what might be in the infantfs best interest.
Resource Manual . Circumcision (Infant Male) 3
Physicianfs Rights

8. Inform your patient when your personal morality would influence the recommendation or practice of any medical procedure that the patient needs or wants.
For Consideration: If your personal beliefs dictate against infant male circumcision, this should be made known to your patients, with an offer of referral to another physician competent in performing the procedure.
Care of the Patient

3. Provide for appropriate care for your patient, including physical comfort and spiritual and psychosocial support.
4. Practice the art and science of medicine competently and without impairment.
6. Recognize your limitations and the competence of others, and, when indicated, recommend that additional opinions and services be sought.
For Consideration: As with any medical procedure, if for religious or cultural reasons you decide to perform an infant male circumcision, ensure that your skills are current. Expertise can be maintained only if a sufficient number of such circumcisions are performed.
Recommendation: Best medical practice includes the following standards of practice for doctors who are asked to circumcise male infants:
. Keep up]to]date on the issues surrounding infant male circumcision, including the therapeutic medical indications and legal and ethical issues.
.
Advise parents that the current medical consensus is that routine infant male circumcision is not a recommended procedure; it is non]therapeutic and has no medical prophylactic basis; it is a cosmetic surgical procedure; current evidence indicates that previously]thought prophylactic public health benefits do not out]weigh the potential risks.
.
Provide objective medical information about the risk of complications and potential harm in infant male circumcision.
.
Discuss the new ethical considerations of infantfs rights and proxy consent in a non]therapeutic procedure.
.
Listen to parents and consider the basis of their request, which may be based on religious or cultural practices.
This paper is intended to help physicians use their professional judgement when a request is made for routine infant male circumcision. While parental preference is important, factors like the best available evidence regarding potential benefits and complications, alternatives to this intervention, the infantfs best interest, and current understanding of bioethics should be taken into consideration.
You are not obliged to act upon a request to circumcise an infant, but you must discuss the medical evidence and the current thoughts in bioethics that dissuade you from performing this procedure. You must also inform the parents that they have the right to see another doctor.
Resource Manual . Circumcision (Infant Male) 4
If you decide to perform the procedure for religious, cultural or other reasons:
. Ensure that you have the necessary skills and experience, or ensure that the parents and child are referred to a physician who has these skills.
.
Obtain valid consent from both parents and ensure that both parents sign a consent form.
.
Provide the procedure under hygienic conditions with appropriate analgesia and aftercare.
R
esources cited:
American Academy of Pediatrics. Task force on Circumcision. Circumcision Policy Statement. Pediatrics 1999; 103: 686]693
British Medical Association Committee on Medical Ethics: The Law and Ethics of Male Circumcision .guidance for doctors, March 2003
Canadian Medical Association. Code of Ethics. Can Med Assoc J 1996; 155: 1176A]B
Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996: 154(6): 769]780
College of Physicians and Surgeons of BC. Code of Ethics. Policy Manual.
College of Physicians and Surgeons of Manitoba. Neonatal Circumcision. Winnipeg: College of Physicians and Surgeons of Manitoba 1997
College of Physicians and Surgeons of Saskatchewan. Caution against Circumcision of Newborn Male Infants. Feb 2002
Christakis DA, Harvey E, Zerr DM et al. A Trade]off Analysis of Routine Newborn Circumcision. Pediatrics 2000. 105: 246]249
Goodman J. Jewish Circumcision: an alternative perspective. BJU International 1999. 83: Suppl. 1, 22]27
Paton M. The Ethics of Circumcising Male Babies. The Bioethics Bulletin (June 1992). Edmonton, University of Alberta.
Richards D. Male Circumcision: Medical or Ritual? Journal of Law and Medicine 1996. 3:371]376
Somerville M. Altering Baby Boysf Bodies: the ethics of male circumcision. The Ethical Canary: Science, Society and Human Spirit. Toronto: Viking, 2000:202]219
Szaz T. Routine Neonatal Circumcision: Symbol of the Birth of the Therapeutic State. Journal of Medicine and Philosophy 1996:21:137]148
Patient resources:
We are trying to decide whether or not to circumcise our baby boy. What should we know?
Canadian Health Network. Canadian Paediatric Society. www.canadian]health]network.ca
The Circumcision Decision: Pros and Cons. Schmidt, BD. University of Michigan Health System. Pediatric Health Topics. www.med.umich.edu Resource Manual . Circumcision (Infant Male) 5
Resource Manual . Circumcision (Infant Male) 6
Answers to your questions about the Bioethics of Infant Circumcision. National Organization of Circumcision Information Resource Centers. Publications. www.nocirc.org
The circumcision decision. Mayo Foundation for Medical Education and Research. Mayo Clinic Health Information. www.mayoclinic.com
Circumcision. How do I decide about circumcision? American Academy of Family Physicians. www.familydoctor.org
Updated September 2009

Circumcision: Information for parents

Circumcision of baby boys is a surgical procedure to remove the layer of skin (called the foreskin or the prepuce) that covers the head (glans) of the penis and part of the shaft. It is most often done during the first few days after birth.

Circumcision is a “non-therapeutic” procedure, which means it is not medically necessary. Parents who decide to circumcise their newborns often do so for religious, social or cultural reasons. To help make the decision about circumcision, parents should have information about risks and benefits. It is helpful to speak with your baby’s doctor.
After reviewing the scientific evidence for and against circumcision, the CPS does not recommend routine circumcision for newborn boys. Many paediatricians no longer perform circumcisions.

Risks and benefits of circumcision

Problems from the surgery are usually minor. Although serious complications are rare, they do occur. Newborn circumcision has been associated with surgical mistakes, such as having too much skin removed.

Of every 1,000 boys who are circumcised:

•20 to 30 will have a surgical complication, such as too much bleeding or infection in the area.

•2 to 3 will have a more serious complication that needs more treatment. Examples include having too much skin removed or more serious bleeding.

•2 will be admitted to hospital for a urinary tract infection (UTI) before they are one year old.

•About 10 babies may need to have the circumcision done again because of a poor result.
In rare cases, pain relief methods and medicines can cause side effects and complications. You should talk to your baby’s doctor about the possible risks.

Of every 1,000 boys who are not circumcised:

•7 will be admitted to hospital for a UTI before they are one year old.

•10 will have a circumcision later in life for medical reasons, such as a condition called phimosis. Phimosis is when the opening of the foreskin is scarred and narrow because of infections in the area that keep coming back. Older children who are circumcised may need a general anesthetic, and may have more complications than newborns.
Circumcision slightly lowers the risk of developing cancer of the penis in later life. However, this form of cancer is very rare. One of every one million men who are circumcised will develop cancer of the penis each year. By comparison, 3 of every one million men who are not circumcised will develop penile cancer each year.

Caring for an uncircumcised penis

The foreskin covers the shaft and head (glans) of a boy’s penis. During the early years of a boy’s life, the foreskin separates from the glans. This is a natural process that occurs over time. You do not need to do anything to make it happen.

When the foreskin separates, it is said to be “retractable,” meaning it can be pulled back.

An uncircumcised penis is easy to keep clean and requires no special care:

•Keep your baby’s penis clean by gently washing the area during his bath. Do not try to pull back the foreskin. Usually, it is not fully retractable until a boy is 3 to 5 years old, or even until after puberty. Never force it.

•When your son is old enough, teach him to keep his penis clean as you’re teaching him how to keep the rest of his body clean.

•When the foreskin separates, skin cells will be shed and new ones will develop to replace them. These dead skin cells will work their way down the penis through the tip of the foreskin and may look like white, cheesy lumps. These are called smegma. If you see them under the skin, you don’t need to force them out. Just wipe them away once they come out.

•When the foreskin is fully retractable, teach your son to wash underneath it each day.
If you decide to have your baby boy circumcised

It is helpful to talk to your baby’s doctor about the issues involved in circumcision:

•Cost: Circumcisions for non-medical reasons are not covered by all provincial and territorial health plans.

•Possible complications, such as the ones described above.

•Pain relief:
◦Newborn babies do feel pain. Without pain relief, circumcision is painful. Acetaminophen (such as Tempra or Tylenol) or EMLA cream, which numbs the skin, won’t be enough.

◦There is more than one way to do a circumcision. Studies show that the amount of pain depends on what method is used. The Mogen clamp seems to cause less pain than the Plastibell or Gomco technique.

◦Your baby will need a local anesthetic (dorsal penile nerve block or subpubic block technique), given by a needle in the area where the circumcision is done. EMLA cream should also be used to reduce the pain of giving the needle for the anesthetic.

◦Anesthetics do carry risks, and the needle can cause bruising or swelling.

◦Sucking on a pacifier or gauze soaked with a sugar solution may help relieve the pain.

◦Your baby should receive acetaminophen when the local anesthetic wears off. It should be given for 48 hours, or longer if he is still uncomfortable.
Caring for the circumcised penis
•After the circumcision, you can help comfort your baby by holding him and nursing him often.

•The penis will take 7 to 10 days to heal. The area may be red for a few days and you may see some yellow discharge, which should decrease as it heals. Talk to your baby’s doctor about what to expect.

•Keep the area as clean as possible. Wash gently with mild soap and water, and be sure to clean away any bits of stool. If there is a bandage, change it each time you change your baby’s diaper. Use petroleum jelly (Vaseline) to keep the bandage from sticking.

•Call your doctor if:
◦You see more than a few drops of blood at any time during the healing process.

◦The redness and swelling around the circumcision do not start to go down in 48 hours.

◦Your baby develops a fever (rectal temperature of 38.0° C or higher).

◦Your baby seems to be sick.

Article Reproduced from Caring for Kids

Please go to http://www.caringforkids.cps.ca/pregnancybabies/Circumcision.htm for more information

Knowledge about the short-term and long-term benefits of ‘delayed cord clamping’ is finally making it into practice. Midwives and in some cases obstetricians are realising the importance of allowing the placenta to finish circulating blood before intervening. I personally don’t like the term ‘delayed cord clamping’ and prefer the term ‘premature clamping’ to describe the alternative practice. However, whatever you choose to call it, the good news is that babies are benefitting from the practice. The main physiological benefits are summed up in a Cochrane review:

“The suggested neonatal benefits associated with this increased placental transfusion include higher haemoglobin levels (Prendiville 1989), additional iron stores and less anaemia later in infancy (Chaparro 2006; WHO 1998b), higher red blood cell flow to vital organs, better cardiopulmonary adaptation, and increased duration of early breastfeeding (Mercer 2001; Mercer 2006). There is growing evidence that delaying cord clamping confers improved iron status in infants up to six months post birth (Chaparro 2006; Mercer 2006; van Rheenen 2004).”

The review also notes that ‘delayed clamping’ is associated with an increased risk of jaundice in the newborn. In contrast Mercer and Skovgaard (2002) cite research findings that dispute this link. I also wonder whether giving an injection of syntocinon/syntometrine while the placenta is still circulating blood to the baby may influence the risk of jaundice. IV syntocinon/pitocin in labour has been linked to jaundice since the 1974s (do a google search for more research). All the studies in the Cochrane review were carried out in hospitals where the vast majority of women have an oxytocic injection for management of the third stage. I very rarely come across anything more than mild jaundice following a physiological birth. Anyone need a research topic?

Resuscitation and premature cord clamping

This post explores the the practice of premature clamping when a baby is perceived to need resuscitation. I often hear birth stories which include “They (or I) had to cut the cord because the baby needed resuscitation”. In hospital-based neonatal resuscitation workshops practitioners are taught to 1. assess the baby, 2. summon help 3. clamp and the cut cord, 4. take the baby to resuscitaire, etc. For obvious reasons resuscitating a baby is stressful, and I understand the benefits for midwives and doctors of doing it on a nice neat, ‘clean’ area without worried parents watching and/or asking questions. However, this approach makes no sense if you consider the physiology of transition to extrauterine life, or the importance of the mother in the baby’s transition and any necessary resuscitation.

The physiology of newborn transition
This is extremely complex and probably very boring for those not interested in science/physiology. So, if you want a full scientific version please see the article by Mercer and Skovgaard (2002). Here’s the simple version…

The baby/placenta has a separate blood system from the mother. The placenta does the job of the lungs by exchanging gas (oxygen and carbon dioxide) via the intervillous space between the baby’s and the mother’s blood system. Before birth, a third of the baby/placenta blood volume is in the placenta at any given time to facilitate this gas exchange.

After birth this ‘placental’ blood volume is transferred through the pulsing cord into the baby increasing the baby’s circulating blood volume. This has two major effects:

1.Provides the extra blood volume needed for the heart to direct 50% of it’s output to the lungs (8% before birth). This extra blood fills the capillaries in the lungs making them expand to provide support for the alveoli to open. It also aids lung fluid clearance from the alveoli. These changes allow the baby to breath effectively.
2.Increases the number of circulating red blood cells which carry oxygen. This increases the baby’s capacity to send oxygen around the body.
This transfer of blood volume from placenta to lungs takes place over a number of minutes following birth. Textbooks will tell you 3-7 minutes, but I have felt cords pulse for a lot longer than that. While these changes take place, oxygen continues to be provided by the placenta until the baby is ready to begin breathing.

Most babies will initiate breathing quickly after birth and premature clamping of the cord will not have any immediately noticeably effects. The baby’s circulation will adjust to direct the smaller blood volume to the important organs. The effects of a reduced blood volume will be subtle but present (see the above Cochrane review).

The need for resuscitation

There are two reasons that caregivers decide to abandon ‘delayed cord clamping’ and clamp/cut a cord in order to resuscitate a baby. In both cases this action creates difficulties for the baby. In the first it can actually create the need to resuscitate.

1. Lack knowledge, patience (and a bit of panic)

This often happens when a baby is slower to initiate breathing. The baby is still being oxygenated by the placenta but is chilling out while the effects of an increased blood volume kick in. This is particularly common with waterbirth babies. These babies have good tone and slowly turn from blue to pink. It can be difficult to even notice them begin to breathe. Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. Unfortunately the usual response to this situation is to clamp and cut the cord in order to resuscitate the baby. The outcome will be that baby responds to the interruption of placental flow and the stressful journey away from mother by crying. A worse outcome is that without the placental circulation the baby is unable to complete their transition and becomes a compromised baby requiring resuscitation (see below).

This film is of an outdoor birth (the mother didn’t make it to her birth tent). The baby makes an unhurried transition supported by placenta circulation:

Whereas this baby is being hurried to cry (also see birth from the baby’s perspective)

2. A compromised baby

This is a baby who has had a rough time during birth and might appreciate a little external support to make the transition. This situation is often a result of interventions during birth such as directed pushing, artificial rupture of membranes, syntocinon/pitocin. It may also be a result of a tight nuchal cord reducing blood flow just before birth (a loose one does not do this). A compromised baby is floppy and heading from a blue colour to a white colour. They may also have passed meconium during the birth, and their heart rate is slow and/or dropping. This baby could probably do with a bit of help, but most importantly they need their placental circulation. While the cord is intact the baby is still receiving some oxygen which is better than none. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets into the lungs via external methods of resuscitation.

The importance of the mother and family in resuscitation

It is important that the mother, father or any other significant person is involved in the resuscitation of a compromised baby.

For baby

A baby has spent months inside his mother and learned her voice and smell. She has also learned the voice of her father and/or other family members. To be held close, spoken to and stroked is often enough to initiate breathing. Even if further measures are needed being held by her mother skin to skin, rather than being put on a flat resuscitaire has got to be nicer.

For mother, father and/or other family members

Being able to see and touch your baby is probably less stressful than having her ‘worked on’ over the other side of the room. Being involved in assisting the baby’s transition reinforces the power of the parents. Fathers are often very proud to be the one who encourages baby’s first breath by blowing gently in her face. In addition mothers often instinctively know how to help their baby. I remember one mother telling me she felt her baby needed to be in a certain position on her chest. When she moved him his breathing regulated perfectly.

Here is a film of an unassisted birth where a mother resuscitates her own baby:

Suggestions

■Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
■Do not clamp or cut the cord.
■Give the baby time to transition – if the cord is pulsing the placenta is providing oxygen… relax and reassure the mother if she needs reassurance.
■Do not clamp or cut the cord.
■If the baby requires assistance, start small – gentle stimulation, talking, blowing in his face (all can be done by a parent).
■Do not clamp or cut the cord.
■If further measures are needed, take the resuscitation equipment to the baby and resuscitate him in his mother’s arms.
■Did I mention – Do not clamp or cut the cord.
Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate).
You can find some amazing photos of a baby being resuscitated in his mother’s arms here.

Summary

Babies are born with their own resuscitation equipment. The placenta not only helps the baby to transition, but assists with resuscitation if needed. There is no reason to clamp and cut the cord of a baby who needs help. Doing so will create more problems for the baby and mother. Anything that needs to be done can be done with back-up from the placenta, and the involvement of the mother.

Further readings

Mercer, Skovgaard and Erickson-Owens (2008) have written a great chapter about the transition from placental circulation to breathing in this book. More information about the third stage of labour and ‘delayed cord clamping’ can be found in an online article by Sarah Buckley.

circumcision%20decision.pdf“>circumcision%20decision.pdf

The pushing stage the second phase of labor, begins once you’ve dilated to 10 centimeters. This will end with the much-anticipated birth of the baby. This stage can last a few minutes or several hours. In a natural birth, the pushing phase is typically much shorter than in a medicated one. Contrary to any rumors you may have heard, such as the “ring of fire”, this is probably the most empowering part of the experience and can be the most motivating and comfortable. You know you will be holding that baby in just a short time and that thought is all the motivation you need.

Pushing is usually much more manageable than transition. The pushing contractions are of a different variety than those you have previously experienced. You will feel your body pushing independent of any extra effort on your part. Remember, this is exactly what is supposed to happen. Your body will birth your baby best when you let it. True “pushing” is rarely required. The best course of action is to let your body be your guide. Don’t push until you feel the urge to do so. Just because you’re 10 cm dilated doesn’t mean you have to push. It will be a waste of time and effort. That is also how complications start, including fetal distress, malpositioning, pulled ligaments and shoulder dystocia. If you find that you have a lull in contractions, feel free to let the baby drift down on its own. This saves energy for you and the baby. It also makes for a slow, controlled delivery with less chance of tearing and can eliminate the “ring of fire” that means your body is stretching very quickly.

Within A Woman Doula Care offers professional Birth and Postpartum Doula Services, Infant Massage Classes, Breastfeeding Support and Childbirth Education for BC’s Interior Women. By joining our facepage you will received postings on different activities that are being hosted in the community.

I have listed many great resources for BC’s Interior Women on this site. I also offer the opportunity for questions and comments. You can find me at Within A Woman Doula Care.
Lets start a network of mothers supporting mothers and show your support for doula service in our rural communities.

Kindly,
Casie

I rent my Sonotrax 3mHz Doppler for $10.00 per day
You are welcome to send me an email to arrange pick up and drop off locations for the rental unit

Helpful Tips Using a Doppler
Using a fetal doppler for the first time can sometimes take a bit of getting used to, especially in the early months. Please follow the tips below to ensure your success!

In the early months a full bladder may help to lift the uterus out of the pelvic area. The further along you are (after 12 weeks) the less important it is.

Lying down on your back seems to be the easiest and most comfortable way to find the baby’s heartbeat.

Generally its common practice to start from the belly button and move down towards the pubic bone, then move side to side. The earlier along in pregnancy the lower in the abdomen you will hear the heartbeat. Early in the pregnancy (8-12 weeks) you will likely hear the heartbeat just above your pubic bone and may benefit from angling the doppler down towards your tail bone.

Move the doppler wand SLOWLY, very SLOWLY. Often people miss the heartbeat because they are moving around the abdomen too fast.

You will probably hear your own heartbeat a number of times before you pick up your baby’s. We have found that the baby’s heartbeat is often just behind your own heartbeat. Locate your own heartbeat and then just move the doppler ever so slowly, it’s likely you will hear a more faint and faster heartbeat near to where you found your own, that’s the baby’s heartbeat!!!

How early can the Sonotrax fetal doppler detect a fetal heartbeat?
Our dopplers are the same medical grade dopplers that your doctor uses and are able to detect a fetal heartrate as early as 8-10 weeks. However, due to factors such as, the position of the fetus, size and shape of mother’s uterus, size of the mother’s body some people may not be able to hear the heartbeat until closer to 10-12 weeks (very tall and/or overweight people may have more difficulties hearing the heartbeat before 10 or 12 weeks). Typically, most of our customers have reported hearing the heartbeat between 10-14 weeks.

Are Sonotrax fetal dopplers safe to use?

Doppler ultrasound is regulated by Health Canada the FDA. Years of studies have shown no harmful effects on the fetus. The Mayo Clinic states “In 30 years of regular use, no adverse effects have ever been demonstrated from ultrasound testing. Research has been done investigating both the noise produced in utero and the heat produced by ultrasound, and no problems have ever been detected from its use in exposed babies. There is no reason to feel uncomfortable about the use of ultrasound during pregnancy and there are great benefits to using it.”

I am having trouble hearing my baby’s heartbeat, does that mean something is wrong?

Not detecting a fetal heartbeat (especially in the first trimester) is NOT an indication that something is wrong with your baby. Sometimes it takes a few tries to get used to using a fetal doppler, especially in the first trimester. Make sure that you are using a good amount of gel and place the probe directly on top of the gel (the gel acts as the transducing agent).

The Sonotrax fetal doppler should not be used in any way for diagnostic or medical purposes by anyone other than a medical professional.

• The Sonotrax fetal doppler should not be used as a substitute for regular prenatal care by a medical practitioner. Any concerns about your pregnancy should be addressed to your care provider.
• Fetal heartbeat is not the only indicator of fetal well being, if you have any concerns please consult with your care provider.

I have run out of gel what should I use?

You may either purchase more from us here or your local medical supplies store should be able to help you. Aloe vera gel works well, is gentle enough for your skin and wont damage the probe. Hand cream or vaseline will also work although there is some speculation that it may cause damage to the probe.

What is the difference between a 3 Mhz and a 2 Mhz probe?

A 3 Mhz probe has a wider beam so it is more sensitive than a 2 Mhz probe and can pick up baby’s heartbeat as early as 8-10 weeks gestation. A 2Mhz probe tends to work best after 10-12 weeks and on overweight or very tall women. Typically though, a 3 Mhz probe work better early on and throughout the rest of pregnancy.

What do your dopplers come with?

All of our dopplers come with digital display with which you are able to see your baby’s heartrate (the number of beats per minute). Our dopplers come complete with a convenient carrying case and one tube of doppler gel and easy to follow instructions.

What is your return policy?

We offer a 7 day money back guarantee and 1 year warranty on all of our dopplers. If for any reason you are unsatisfied with your doppler, simply call or email us within 7 days and we will offer you a full refund, less the shipping charges.

I am hearing two heartbeats, does this mean I am having twins?

No, not necessarily. It is very possible to hear the heartbeat in more than one place especially later on in pregnancy. If you are picking up a heartbeat in two locations at roughly the same rate (within 10 bpm or so) then assume its just a single baby’s heartbeat in two places. However, if you are picking up a heartbeat in two locations at drastically differnent beats per minute (ei: one is 130 and one is 160) then that may be more of an indication of twins. The only way to be sure if you are having twins though, is through an ultrasound.

What is considered to be normal for a fetal heart rate?

A normal fetal heart rate is usually between 120 and 180 beats per minute and vary according to fetal age and activity level at the time.

How much gel should I use?

You need to use about a quarter sized blob at first, do not rub it into your skin but rather place the probe directly on top of the gel. The gel acts as a conducting agent and will help to give you an accurate heart rate display and good clear sound.

Quick Reference Card for Recording a Fetal Heartbeat

1) Using a double ended male mini jack audio cable, insert one plug into the audio input (usually microphone input)socket of the PC, the other plug into the earphone socket of the Doppler.

2) Turn on the PC, startup the sound recorder (Click “Start”→ “Programs” → “Accessories” →
“Entertainment” → “Sound Recorder”).

3) Click Start to start recording. You can record 60 seconds every time, when time is up,
click Start again to keep on recording.

4) Click Stop to stop recording.

5) Click “File” → “Save”, input the file name and click Save. The recorded sounds are saved as a waveform (.wav) file in your computer.

6) To start a new recording, click “File” → “New”. To play the recording, click Play in
Sound Recorder, or play it in any other program that supports waveform (.wav) files.

7) The waveform files saved in your PC are normal audio data files. You can save them to CDs, or e-mail to whomever you want.

Birth Plan for Twins and some Triplet sets
The following format may help expectant parents create a birth plan for full-term or close to term twin or triplet pregnancies. Expectant parents may adapt all aspects of this plan by adding or deleting information. When higher-order multiples are expected or a surgical birth is planned, several aspects of the plan, especially those listed with/after Surgical (Cesarean) Birth still may be possible to implement.

Once you develop a birth plan, review and agree upon the information in advance with your spouse, healthcare provider and labor support person(s). Ask your OB care provider to attach a copy to your in-office records and send another copy to the hospital obstetrical unit. Also, provide your spouse/partner and any labor support person or doula with a copy. Plan to take extra copies with you for your labor and delivery chart.

Letter:
Birth Plan for (insert your name and your husband’s/partner’s name)
Due Date (insert full-term due date)
Client/Patient of (insert the name[s] of your obstetric care provider[s])
To give birth at (insert name of hospital/birth site, and list a second hospital name if you plan to give birth a higher-level obstetrical care site if preterm labor or birth occurs)
(Insert today’s date)
Dear Dr. (insert name[s]) and the staff of (insert birth site):
My husband (partner) and I are looking forward to sharing the birth of our twins (triplets or more) with you. The following birth plan describes our preferences for care during various aspects of the labor, birth and postpartum experience. It includes our preferences whether the babies’ birth is “by the book” or involves complications. We have been preparing for our babies’ birth by reading books, attending (multiples-related) childbirth classes, and arranging for someone (doula or other) to support us during labor and birth.
I have been doing everything I can to have the healthiest possible pregnancy and minimize the risks associated with multiple pregnancy. However, my husband (partner) and I recognize that multiple pregnancy, labor and birth entail more risk than single-infant pregnancy and birth. We understand the need for flexibility during labor, birth and postpartum, and we know that a healthy outcome for the babies and myself is the main goal.
Birth Team
No matter what situation arises during labor, birth or postpartum, my husband (partner) and I expect to be an important part of the decision-making team. We expect to take part in any discussion of, and to give permission for, any type of medical intervention being considered. If any of our birth plan preferences are not possible, or become impossible later, we expect to be provided with a research-based rationale, including the benefits, risks, possible consequences or other options for any recommended intervention.
Personal Wishes
 For issues of personal privacy, we request that the minimum number of staff necessary for an optimal outcome be included on the birth team.
 We would like to photograph or record the babies’ birth on videotape.
Labor and Birth
Baby A (Check any/all that you prefer): We prefer as little intervention as possible if labor is progressing normally:
 I want my husband (partner) and/or labor support person (doula) to stay with me at all times, including during admission, examinations or any medical procedures.
 I prefer intermittent fetal monitor during labor to allow for mobility.
 I would like to walk during early labor.
 I would like to labor in water during active labor.
 I would like to determine optional positions for active labor.
 I prefer a heparin lock (hep lock) insertion to a standard intravenous (IV) line.
 I would like to sip water or other clear liquids during labor.
 I prefer that vaginal exams be kept to a minimum.
 I prefer that labor progress without augmentation. If it becomes necessary, I prefer time to adjust to changes in contractions with any increase in dose.
 I would prefer that the baby’s membranes be allowed to rupture spontaneously.
 I prefer the use of nonpharmaceutical pain control techniques.
 I am an adult and able to request medication if desired. I do NOT want medication offered prior to my request.
 I prefer (insert type) anesthetic for each birth. (I understand that a general anesthetic may be necessary if a complication arises during the birth of Baby B [or C] if I choose to deliver Baby A spontaneously or with only a local anesthetic. (Some healthcare providers are willing to insert epidural tubing, but use it for analgesia/anesthesia only if a complication arises.)
 I prefer to push and deliver Baby A in whatever position feels best at the time.
 I would like to hold Baby A until labor begins for Baby B.
 I do not wish to hold Baby A until after giving birth to Baby B (and/or C).
Each birth
Assuming there are no complications:
 I prefer not to have an episiotomy, unless absolutely necessary.
 I would like each baby to be placed on my abdomen immediately after birth.
 My husband (partner) would like to cut each baby’s cord.
 We prefer that treatment of the babies’ eyes with drops or ointment be postponed until an hour or two after birth, so they can see clearly during early interaction. (Option if certain of parent health history: We do not want our babies treated with eye drops or ointment.)
Labor and Birth (Baby B or C)
 Once Baby B (or C) is engaged in a normal position in my pelvis and the fetal monitor is in place, I prefer to push and deliver that baby in whatever position feels best at the time.
 If an emergency vaginal or surgical birth is necessary and I have had no anesthetic or only local anesthetic, I would prefer a regional anesthetic if there is time.
 If general anesthesia is necessary for the birth, I would prefer the type and dosage be given in a way that allows me to regain consciousness as quickly as possible.
Surgical (Cesarean) Birth
 I would prefer a regional anesthetic (epidural, spinal block, etc.) if there is time.
 If general anesthesia is necessary, I would prefer the type and dosage be given in a way that allows me to regain consciousness as quickly as possible.
 I would prefer to be catheterized after receiving an anesthetic.
 I would like my husband/partner present at all times for emotional support.
 I would like to see and touch each baby after an initial examination determines each is in stable condition.
 I prefer post-operative analgesic (pain) medication that allows me to remain alert and able to interact with my babies, such as epidural morphine (Duramorph) if I have had an epidural or intramuscular (IM) or IV ketolac (Tordal).
Post-birth Recovery (4th Stage)
 I prefer that each baby remain with me in the birth and recovery room(s), unless a particular baby requires special care due to its medical status.
 I prefer a private room, such as a labor or LDR (labor-delivery-recovery) room for the recovery period.
 Breastfeeding:
 I expect to breastfeed any stable, healthy twin (triplet) as soon as the infant(s) exhibits feeding cues, which is usually within an hour of birth.
 If any or all babies require NICU care, I would like to initiate breast-milk expression (pumping) within 3 hours of birth.
 I would like the staff’s help to breastfeed or pump within several hours of birth if I experience a complication that interferes with immediate breastfeeding or milk expression. (If necessary, I would like the staff to actually pump my breasts or teach my support person to do it until I am able.)
Postpartum
 Rooming-in/non-separation: To care for multiple infants, I would prefer a private room. I expect to keep any stable, healthy twin (triplet) stay in my room with me as soon as possible. (I understand that the degree of rooming-in depends on both the babies’ and my conditions after birth.)
 We prefer that any physical examinations, tests, etc. of the babies take place in my room.
 We prefer no artificial infant formula, bottles of any kind or pacifiers be given to any baby, unless found medically necessary and after consultation with us.
 Support person(s): I would like to have my husband (partner) or another support person remain in my room around-the-clock.
 Medication: I prefer medication options that allow me to remain clear-headed and able to interact with my babies and support persons.
 Circumcision: We prefer a local anesthetic be used for circumcision.
 We do not want our son[s] circumcised.
NICU
 No matter what situation arises during any baby’s NICU stay, we expect to be part of any discussion of, and to give permission for, any medical intervention being considered for our child(ren).
 Breastfeeding/lactation: We want our babies to receive as much of my colostrum and milk as possible. Further, I would like help to initiate breastfeeding as soon as any baby shows signs of interest or begins to coordinate sucking and swallowing.
 Kangaroo Care: We would like to initiate skin-to-skin care as soon as possible, as supported by research evidence and implemented at high-level NICU centers.
 Co-bedding: If two or more of our babies require NICU care, we would like them to be co-bedded in a single crib as soon as two are medically stable.
 If co-bedding is not yet possible, we would like their cribs/isolettes to be placed side-by-side. If not implemented, we expect to receive an evidence-based explanation immediately.
Thank you for respecting our wishes to the extent that is safely possible for the best outcome for all involved and for providing the evidence-based rationale when any of our preferences cannot be met.

Sincerely,
(Your signature)