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Sunday, October 17, 2010

Low amniotic fluid is NOT an emergency

Hey, guess what time it is? It's been a good while since I busted my last OB myth, but I think it's time to get that ball rolling again.

This time I am tackling the myth of "low amniotic fluid." It seems that the more silly excuses OBs give for induction get shot down, the more they like to come up with. What baffles me is how they can justify doing so, knowing all the literature out there that does NOT support active management in most cases...but they do anyway. And since the average pregnant woman in America has neither the time nor the inclination to go read a bunch of research articles, I have dedicated my precious time to doing it for you. Let's look at the issue:

Disclaimer: This post is discussing the merits, or lack thereof, of inducing labor for low AFI levels, at term, and in the absence of any other risk factors. I do not address preterm labor, preterm premature rupture of membranes, or congenital defects. If any of these things apply to you, then this post does not.

This website describes the basics of low amniotic fluid (oligohydramnios), or low AFI. The level of amniotic fluid is determined by measuring, by ultrasound, an estimate of the various pockets of fluid around the baby. This is important because too much or too much fluid might indicate some sort of problem. A fluid level of between 5 and 18 cm. is considered normal. The level of fluid cycles, and so can fluctuate daily, or even hourly. You may begin to see for yourself the margins for error with this diagnostic tool.

First of all, what's the big deal with low AFI anyway? Extremely low, and/or persistent low AFI can be associated with various congenital defects, such as uteroplacental insufficiency, congenital anomalies, viral diseases, idiopathic fetal growth restriction (FGR), premature rupture of the fetal membranes, fetal hypoxia, meconium-stained fluid, and/ or postmaturity syndrome. It can also contribute to malpresentations, umbilical cord compression, and difficult or failed external cephalic version. (ref) For these reasons, doctors have typically associated low AFIs with poor fetal outcomes. However, as Leeman and Almond discuss, "A number of studies over the past 15 years have shown an association between oligohydramnios and poor fetal outcomes. These were predominantly retrospective studies, which failed to control for the presence of factors known to be associated with oligohydramnios such as intrauterine growth restriction (IUGR) and urogenital malformations."

In other words, though low AFI might be associated with some of these conditions, it doesn't necessarily mean the baby is in any immediate danger with a low AFI, with no other indicators. That is, low AFI by itself doesn't really mean much. In addition, there have been several studies which also show no correlation between low AFI and poor outcomes. (here, here, here, here, among others)

Knowing this, it would make sense if doctors chose not to actively manage low AFI in the absence of any other factors, as it doesn't usually mean negative outcomes, but this is not the case. According to this survey, submitted to perinatologists across the nation, ninety-two percent of respondents consider isolated low AFI (IO) to be a risk factor for various adverse outcomes. With a favourable cervix, 82% would consider inducing labour without documented lung maturity prior to 39 weeks. When asked whether induction of labour in cases of IO reduces perinatal morbidity, 45% were unsure and 21.4% thought it would not. Only 33% believe induction could decrease adverse outcomes. So most of the respondents considered low AFI to be a risk factor of some sort (it can be), and a full 78% either didn't know or thought induction would result in improved outcomes (it doesn't). This is pretty consistent with my own (anecdotal) experience with different mothers I have come in contact with in my own personal life. In every case of mothers that I have personally known being induced for low AFI, there was not a single other supporting factor. In both this and this blog post, I have mentioned before that I believe that low AFI is more likely to be used as a convenient "medical" reason to induce a woman who is postdates, especially if she refuses an induction for convenience.

Questionable motivations aside, let's assume for a moment that low AFI by itself can mean serious problems for the baby. How does one determine a dangerously low AFI? It is assessed by using ultrasound to measure the levels of fluid around the baby. Naturally, this is not an exact science. Gloria LeMay, in her article, "Low Amniotic Fluid....I don't think so," she describes the process like this:

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.
That is to say, it can easily be inaccurate. In the above referenced article from gynob.com, it is even admitted that ultrasound measurements can be wrong:

If there were to turn out to be a normal amount of fluid with rupture of membranes during an induction, then the low AFI that prompted the induction was either temporary or wrong. It happens, but ultrasound's the best thing we have to go by, even with its inherent error. (emph. added)
This article quotes a 1998 study, which concludes, "that indexing amniotic fluid by measuring the pockets of amniotic fluid...is 'a poor screening test' to identify infants at risk." In this article, several studies and factors can explain the inaccuracies inherent in this method of measurement:

Although the AFI is widely accepted as the standard to diagnose oligohydramnios in the United States,[1] many studies have found it to be an inaccurate method for assessing the actual amount of amniotic fluid, especially in the lower or higher ranges.[3,4,6-9] Rutherford et al.[10] point that poor intra- and interobserver reliability may account for some of the low positive predictive value. Serial measurements have shown mean differences of 1 cm of amniotic fluid volume when conducted by the same ultrasound operator, and 2 cm variance in measures of volume when conducted by multiple operators. Variation can exist because of subjectivity of the ultrasonographer, the amount of pressure applied to the abdomen, and fetal position or movement.[4] Additional variables that may alter AFI summation of the 4 uterine quadrants of amniotic fluid is the influence of the environmental temperature, altitude, maternal glucose control in diabetes, maternal hydration, and the status of the amniotic membranes.[6] (original linked references in article)

Many factors can influence the measurement of the AFI, not the least of which involve subjectivity on the part of the sonographer(s). Observing and approximating measurements through a solid surface, around a moving object, under constantly changing conditions, is a guess, at best.

So if induction for low AFI does nothing to improve fetal outcomes, what does it accomplish? In short, a higher risk of induction complications, including c-section.

"Although small and insufficiently powered, these studies suggest that isolated oligohydramnios does not appear to be associated with adverse outcomes, but it may cause fetal intolerance of labor, which does result in higher cesarean rates." (ref)

"In a case-control study by Conway, 183 low-risk, term parturients with oligohydramnios were matched to 183 women of similar gestational age and parity who presented in spontaneous labor. The patients with isolated oligohydramnios were induced and showed an increased cesarean delivery rate. The increased rate of cesarean delivery was not due to nonreassuring fetal surveillance and was attributed to the induction process (LOE: 2).25" (ref)

"CONCLUSION: Active induction of labor in term low risk gestations with isolated oligohydramnios translated into higher labor induction, operative vaginal delivery and cesarean section rates. This led to increased maternal risk and an increase in costs with no differences in neonatal outcome." (ref)

"CONCLUSION: Isolated oligohydramnios is not associated with adverse perinatal outcomes. However, it increases the risk for labour induction and Caesarean section." (ref)

One other interesting note. In this article, the question is asked, " Is the increase in cesarean section secondary to fetal intolerance of labor from low AFI or the induction process itself?" I would submit that the question is moot. If the fetus is experiencing stress related to low AFI, would it make sense to add more stress by inducing? In either case, it is clear that induction is a strong contributor to another completely unnecessary c-section, and therefore, that induction for a diagnosis of low AFI is yet another unsubstantiated OB myth.


For more technical information and analysis of various studies and factors related to the assessment of oligohydramnios, check out these two articles: 1 and 2

31 comments:

Amber said...

During my 2nd pregnancy, as I neared term I talked to my midwives about what would happen if I went past my due date. They explained that at 41 weeks or so I would need to have an ultrasound to assess how the fetus was doing. Then they told me how to make sure that there would be ample amniotic fluid by drinking lots of water for 48 hours in advance, so that I could avoid induction.

If you're able to cheat on a medical test, it doesn't seem like it's a very good test in the first place. You know?

In any case, I delivered at 39w5d on my own, so luckily I didn't even have to go there.

Carla said...

Thanks for posting. I keep going back and forth on the usefulness of ultrasounds. If I have kids, I just don't know how much poking and prodding I'm willing to submit myself and my baby to for a 1 in a million chance of risk or disease.

Emily said...

Good point, Amber. If one can "fool" a medical test, then there's obviously nothing so wrong that would require "emergency" intervention.

Anonymous said...

I have a lot of problems with this post. Being a mother that had very severe low amniotic fluid at 28 weeks (4.6 cm) I have learned a lot about it from doctors rather than looking up what could turn out to be a bunch of crap online.
All of my information comes from multiple conversations with doctors and nurses, some of the best in our country.

First off, some of your facts are incorrect. Normal amniotic fluid range is 8 cm to 25 cm. And low amniotic fluid, under 8 cm, is a very high risk to your baby. If your amniotic fluid is below 5 cm the doctors become very concerned because the baby can put pressure on their own umbilical cord, cut off their oxygen supply, and die.

Secondly, I know a mother that this happened to, she was at 36 weeks, so keeping track of afl is very important.

Thirdly,yes, the levels fluctuate, and you can cheat on your exams by drinking fluids. But, if your levels are low drinking all the water in the world will not help, I know from personal experience. Luckily, my amniotic fluid has since balanced itself and returned to about 8 cm, but it took me weeks upon weeks of resting to get the levels back up into a some what normal range. My doctor explained that it is rest and not drinking water that will help the most for women with low af.

So, in the future, post all you want, but please get your facts straight. There is a good reason why doctors monitor some pregnant woman so closely. And to be honest woman should trust their doctors. If you don't trust your doctor to make good choices for you and are scared they will fabricate excuses to visit with you then maybe you should find a new doctor. Please don't make generalizations about all doctors based on stories you have heard from your friends though and what you read on the internet. I would cry if a baby died as a result of a woman reading this post and refusing care who does have low amniotic fluid.

Emily said...

Anonymous -

1. Read the disclaimer. This post does not apply to your situation.

2. My "internet facts" are actually referenced clearly, and include such resources as OBGYN.com (which I consider faily trustworthy in terms of OBGYN info), and various studies. I didn't pull these facts off Wikipedia, these are peer-reviewed, publicly published scientific facts.

3. Nowhere in this post did I malign doctors or state that low AFI is no problem.

I suggest you go back and actually read my article.

Kimberly said...

I know a woman where I live who has had 3 births. All started out as homebirths with a midwife, but for the first two she transferred to hospital for induction for ridiculous reasons-one of which was low amniotic fluid. After the second birth she said NEVER again would she transfer for such reasons. There was no need. It's so hard to go against your caregiver, often you want to give in to keep the relationship as positive as you can. Knowledge is power, but it takes courage to actually exercise it.

Elizabeth said...

I had a classic "case" of low amniotic fluid. I dropped off the cm measuring my belly at like 38 weeks, and had to have an ultrasound, which revealed LOW amnitotic fluid. BUT, that was the ONLY indicator. I had a fabulous pregnancy, and my baby measured perfectly on the Non-stress tests they had me do because of this. It was a good thing it was thanksgiving time and I couldn't get in for an ultrasound for a week. If it was so "urgent" to check you think they would have pushed it through - that should have been my first red flag. Anyway, my fluid was low, but my dr was gracious enough to disobey hospital policy to let me have the weekend to drink a lot of fluid to try to get the levels up. I totally agree with the other comment- if a medical test can be cheated then it's not a very good test. My fluid was still low, and they sent me in to be induced right there. I had a not so great induction and reacted to the cytotec. Anyway- the induction was not good, but at least my pushing phase went well, baby was stable and I was able to take my time pushing. But, the whole induction process was unfavorable to me and my body and my baby- when I had a perfectly healthy baby and pregnancy. It's hard to think back on "what if...." But I learned and grew from the experience.
I appreciate your information, and it helped me think- OH yeah- There WAS plenty of amniotic fluid when my bag of waters was broken as a started pushing- something I hadn't put together before! AH! The very cause I was in there, really was not a good one- because turns out I had plenty of fluid for my baby!

kelly @kellynaturally said...

It's interesting to read your article, and I do believe I fall under the "disclaimer". but wanted to share my story anyhow; because I think low fluid is not often talked about, and when it IS discussed it is done so with urgency, by a specialist, later in pregnancy, and all of these things do add up to increased stress for the mother (and hence, the baby). So I appreciate reading something more in-depth than just low fluid = bad.

In my 35th week I was preparing to go for an ultrasound to check my baby's position - I & my doulas believed he was still breech in spite of everything we'd tried to turn him. I understood that he could turn last minute, as my daughter had (who was also persistantly breech), but I wanted to be appropriately armed with information, so I asked for an ultrasound to verify position. It was entirely my choice.

That evening I received several panicked phone calls from my doctor - all of which I missed because my phone was off. She continued to call into the next day, asking me to please return to the hospital ASAP to re-check the fluid levels. The number they'd found was ~6.

Now, I believe I had a slow leak for several weeks prior to that. However, after reassuring myself online, that as long as everything felt okay, and I wasn't gushing fluid, and baby was still kicking around, and I kept my drinking water and vitamin C and garlic - I was worried that if I went in, I'd be scheduled for a section and baby would be born way too early, so I waited & kept to myself. Not sure, in retrospect, this was the best decision. But after my first birth experience I was wary of intervetion.

I went in the next day for a repeat ultrasound, and the level was ~5. The doctor on duty felt that was not too frightening b/c coupled with the non stress test, while I was contracting, baby was not showing too many signs of stress. He recommended I go home, rest, drink a lot of fluids, and come back in 2 days - as long as nothing changed. I did. Levels continued to drop at the next u/s - they were unable to find even one 2cm pocket of fluid. I asked for a different ultra sound tech and the test was repeated a few hours later, and still no pocket. The doctor noticed some serious calcification of my placenta, and the fact that my levels were continuing to drop, combined with my own personal sense of unwellness (in yoga class the day before, I had gotten a forboding type of feeling - and had actually packed a hospital bag), and baby's NST decels, doc was concerned about cord compression.

Because I'd had a previous c-section, AND because baby was frank breeck, AND because of the significantly low fluid, a c-section was the only option.

I was put on intravenous fluid for several hours in an effort to increase the levels one more time - in the hopes perhaps we could do an ECV or baby would turn with the contractions, but his heart rate continued to drop, and my fluid levels never increased. He was born soon after. Small, but healthy, and my placenta by all accounts looked like it was at least 42 weeks, not 36 (though my dates, putting me at 36 weeks, were 100% right on, I can tell you).

So. (continued)

kelly @kellynaturally said...

(cont. from previous)

Even in the presence of very low fluid, and other risk factors, we were able to take some time, try some other things, have various techs take & retake the tests, and different docs analyze the results. It was treated like an urgent situation, but not an emergency. As the fluid got very low, and baby started showing signs of stress, then yes, it was treted with more urgency, but low fluid is just a tool - another measurement to check on the health
of the baby and should be treated as such.

Sometimes I wonder if I never made the choice for the initial ultrasound. Or what if we'd just said no thanks & left the hospital after the first or the second or the third or the fourth test... if I went on with my home laboring & VBAC experience... what could have happened. Would baby have been okay? Would he have turned? Would his already compressed cord been further compressed in an effort to turn, and with my increasing contractions... there's so many what ifs.
Did I have an infection from the weeks of leaking?
I don't know. I'm glad for the test, but will always wonder what if. I had planned and prepared so hard for this VBAC & it didn't work out as planned.

Emily said...

Kelly - thanks for sharing your story. It seems that everything that could have been done was done. The low AFI index is only a tool, and an inaccurate one at best, but can still be useful in the presence of other compounding issues, such as yours. I do not consider breech to be an indication for c-section, so the fact that the baby was breech had very little, if anything, to do with the urgency of the situation. But the dropping levels, over several days and with your own increased fluid intake, and increasingly non-reassuring signs from the baby, and the placenta calcification, it seems getting the baby out was a good decision.

KellyNaturally said...

>>I do not consider breech to be an indication for c-section, so the fact that the baby was breech had very little, if anything, to do with the urgency of the situation.

I would agree with you as an issue standing on it's own. Particularly if I'd had a care provider familiar with breech delivery. Unfortunately NJ is definitely NOT natural-birth friendly - have you seen the latest c-sec rates? Scary. I was not able to find a midwife who would see me outside of an OB practice or who was willing to deliver in a non-hospital setting due to my previous C-sec history.

So, with the previous C in the picture, it did add some complications - had DS been heads down, I would perhaps have opted for other induction methods (as pit was off the table due to previous C and baby's decels from my mild contractions), had there been a breech-delivery-experienced doc available, I perhaps would have waited it out - doc did give us the option to stay longer in the hospital, on fluids to see if he would turn on his own (the ECV also being off the table due to the low fluid levels & decels AND my own reservations from having had 2 failed and very painful ECVs with my 1st pregnancy - I was loathe to try it again).

I do agree, breech on its own is not an emergency. But in my situation it unfortunately added to the complexity of the decision-making.

I appreciate you hearing me out, and again, I really appreciate the facts being out there on low fluid because I agree with you - it does seem to be an ever-increasing reason being given for C-sections. And, I wasn't highly informed about it at the time (thank you mothering.com & my doula for quick-thinking & lots of links).

Anonymous said...

When I startedd going to my ob I I ased more than once about a vbac delivery, he state he would allow me to go 41 weeks. Fast foward to GD testing period test; by text book results I had past by one point, by his I fell by one point. So I retested with 4 hour test( passed), but he was already stressiung c-section if I had GD. I am measuring bigger and was concerned about big sized baby.Now I am 38 weeks with AF level of 8cm(even though this is considered normal level) and stressing the dangers of low fluid levels and placed me on stress testing but baby is fine . So because of low AFI of 8cm, he has csection scheduled 3/8. I would like to think and trust his decicion as a medical professional but at the same time I feel like he really was not being truthful about being a vbac doctor...just my gut feeling.

Emily said...

Anonymous - I'm sorry I was unable to post and reply to your comment before now; I've been traveling. I hope you didn't end up with that c-section. I would say your instincts are right - this OB sounds like he's looking for any reason to get you into surgery and avoid VBAC altogether. If you managed to ignore the pressure and are still pregnant, kudos to you! If you ended up with a second, unnecessary c-section, I hope you can get more involved with ICAN and other cesarean awareness groups, and learn how to advocate for yourself for next time. Good luck!

WannabeMama said...

Sitting here at 41+2, I'm relieved to have today said no to the 2nd recommendation of induction this week, with my midwife's support, to spend some time researching this 'low liquor' label I've been diagnosed with. The more I read the more confident I am with this decision to wait for labour to start on it's own. 3.7cm was the measurement given with the deepest pocket at 2.2cm. All other movement/activity/breathing/umbilical flow etc is showing fine.

I was so upset when the Dr on staff pushed induction again. Not really knowing the ramifications of low AFI, all I could do was cry when faced with a possible decision to make (yet again) on induction.

I now have the faith in myself & the health of my baby in resisting & waiting for him to come in his own time.

Thanks :)

Vanessa said...

Thank you for writing about this! I was induced at 40 weeks for "low fluid." I didn't know any better and didn't question the doctor's decision. When my water broke during my induced labor, my midwife commented on how much it was. I ended up with a c-section. I felt very cheated when I found out that "low fluid", in an otherwise healthy term pregnancy, is not an indication for induction. I am much more informed now and with my next pregnancy will definitely be trying for a VBAC. You might be interested in this article I found about isolated oligohydramnios at term: http://www.jfponline.com/pages.asp?aid=1847

Hannah said...

Very interesting. Just read a birth story of a friend's baby. Her AFI dropped to 8 (no other risk factors that I know of, and the birth story was fairly detailed), so her midwives induced her that evening with Cytotec. Couldn't she at least have gone home and got a good night's rest? I couldn't believe that midwives would do that!

Alexandra said...

The disclaimer does apply to me, however, i think that it is important to be aware of the other side of the story. I wish, it would have been wonderful, if my pregnancies would have been normal and pleasant. However, other then having low amniotic fluid and hernia with both of them, there were other complications. With my first daughter, the 6 months ultrasound showed low amniotic fluid. Very low. Weekly ultrasounds started. At 35 weeks my baby stopped growing and stared showing signs of distress. I ended up being induced (after few emergency trips to hospital because i could not feel the baby moving) at 37 weeks. My daughter barely weighted 2.4 kg. With my second daughter, on top on very low levels of amniotic fluid, there was only 1 blood vessel (instead of 3) in the umbilical cord. Weekly trips to ultrasound starting with 5 months of pregnancy. My daughter stopped growing at36 weeks and was induced at 38. Sometimes induced labors are a necessity and i think every woman should take it seriously... Just my opinion...

Emily said...

Alexandra - thanks for your comments, and I'm glad your daughters are happy and healthy (from what I gather)! Your story illustrates perfectly what I was getting at in my post. Your issues, including low AFI were diagnosed early on, and there were other contributing factors. It sounds like the doctors did a wonderful job at monitoring the situation, keeping the babies in as long as possible, then getting the babies out when necessary.

The main part of non-emergent cases of induction for low AFI are triggered by post-dates exams, and are generally a way to get women to induce who would not do so otherwise. As I mentioned in this post, if a woman has had a complication-free pregnancy to that point, and has no other risk factors, there doesn't seem to be any immediate danger.

Anonymous said...

While I understand that you have a disclaimer for this, I have a problem with you calling low amniotic fluid a "myth" and stating that it's not an emergency. It may not ALWAYS be an emergency, but it's something that needs to be taken very seriously. My daughter (my first child) had low amniotic fluid; this led to cord compression. She died in my womb at 37 weeks. My second child also had low fluid, and I was induced at 37 weeks to prevent an accident. I'm pregnant with my 3rd child, have low fluid again, and am being induced this week. Low fluid is not a "myth," and, while I appreciate your opinion, not all doctors induce just for the hell of it.

Emily said...

Anonymous - thanks for your comment. Your situation fits the disclaimer perfectly, and you're right - not all doctors induce solely for convenience. Certainly you had other risk factors which warranted prompt action. The point of this article was directed toward induction around or after the EDD with no other complicating factors.

Anonymous said...

During my first pregnancy at 39 weeks I was waiting in the doctor's office and realized my baby hadn't moved more than a couple times all day. This was strange cause she was a little dancer, even with such little space. My doctor did a quick ultrasound and thought my amniotic fluid looked low and wanted me to go get a more accurate ultrasound. I did and I was measuring at a 2.

They immediately had me check into the hospital to be induced with my only symptom being low amniotic fluids. I wasn't worried at all. Once I was hooked up I gave birth in 12 hours and luckily they did induce me because they broke my water and nothing came out. It turns out I wasn't producing enough fluid and what little I had, she was breathing in but not breathing out. Had I not been induced that day, my baby could have had some serious issues. When she was born they had to drain her lungs because of the amniotic fluid she had breathed in and were debating about taking her to the NICU for observation. Her color and breathing came back strong and she didn't end up going to the NICU.

I trust my doctors because we want the same result, a happy and safe delivery. And I rather them be overly cautious and have a healthy baby, than wait and hope for the best.

Anonymous said...

This is my sixth pregnancy and I am advanced maternal age at age 41. I will be 42 When the baby arrives. At 19 weeks, I was diagnosed with low amniotic fluid on the normal side from a gender ultrasound place that offers 4-D ultrasounds. I informed my doctors and after awful remarks about the accuracy of such places they sent me straight to the hospital to get an ultrasound. Where the 4-D ultrasound place was encouraging and informative and shared all information about My baby located in MY body, my docs and the hospital really wouldn't tell me any more information on what they found. The tech stated she wasn't allowed to say. I am considering firing this doctors office and moving to a fresh start elsewhere. Im not very sure that I have much stock in ultrasounds, but as long as I am informed and allowed to make my own decisions as to his health, I am ok. At this point, I don't know how low the level is, what the deepest pocket is, what the next step is etc. All I know is the information I have found out from research. Thanks for a great article!

Emily said...

Anonymous - thanks for your comment. Your instinct is right on. Regardless of whether your pregnancy ends up being routine or high maintenance, you already know you're not going to get respectful, informed care from this provider.

As far as amniotic fluid goes, if you have a concern, you should request at least two separate tests by difference technicians, at different times of the day. That will give you a clearer picture of what's going on.

Anonymous said...

I am a sonographer at a very busy ob/gyn office. I find your article very interesting and informative and you are correct with the info stating AFI volumes are normal if they are at least 5 cm, depending on gestational age of course. I would however like to make a comment regarding some negative feedback about ultrasound techs. We have a VERY important, skillful job we do. We are NOT allowed to give any pertinent information to patients ( techs that do so, need to change their profession), as that is the physician's job to do so. I have been doing ultrasound now for 10 years, I love what I do but I get aggravated when patients see ultrasound as a "entertaining" purpose v/s a medical, diagnostic test. Sorry for getting on my soap box.

Emily said...

Anonymous - Thank you for your comments. I'm glad to hear there's some great ones out there.

Anonymous said...

Thank you so very much for using your intelligence to talk about something so very important.

I had a wonderful, healthy pregnancy with my first only to go for an ultrasound on my due date(since I've found out I tend to go to 42 weeks) and be scared into an induction based on low amniotic fluid. After that birth, I totally understand how the term "birth rape" would be coined.

Thanks to the GOOD Lord and some Christian women in Arkansas who were praying for me, I made it out of that hospital without a c-section.

Hospitals are now producing super bugs, people are having to be dismembered, horrors. Birth at home is so much safer in every way.

Keya said...

At 40 weeks I asked my OB to do an ultrasound to check fluids. She said "hmm it looks low", then changed to "no I think its fine" and said I was ok for now. I never trusted that particular OB in the practice, so I went to a different OB for my next visit at 40 weeks 4 days. She did an NST, then immediately did an U/S. I think she saw something on the NST which prompted her to do do the U/S. I had AFI less than 5 and she said I was better off being induced. Pitocin induction it was, but all through labor baby kept pressing down on the cord due to not having enough fluid, leading to significant decelerations. They let me labor on, did not do a c section and I had a vaginal delivery. BUT my baby was born with a condition called persistent pulmonary hypertension (PPHN) causing severe respiratory distress. PPHN is rare (1 in 1000 births or so) and can be caused due to low fluids, in addition to some other factors. My baby almost died!! She made it finally, after going through a very invasive surgery called ECMO, where she was hooked up to a heart lung bypass machine. I had a perfect pregnancy (read low risk), she was perfectly formed, but the low fluids almost took her away from us. So in my thought, low fluid is a true emergency. Ask a mother who has lost a child or almost lost a child. I know its easy to say "statistics are low" but my heart always stops to look at even that "one in" in a 1/1000 births because I have been that one. I just wanted to put this here so people are also aware of stories such as mine.

Keya said...

I left a long comment but for some reason stupid google messed it up. Going to try again: My daughter was born with severe respiratory distress caused by a condition called PPHN. It was probably caused due to low fluids. I was induced at 40 weeks 4 days due to low fluids and a not so great looking NST. Baby had significant decelerations throughout labor because she was pressing down on the cord due to the low fluids. I had to labor entirely on one side (painful oh so painful) because any change in position and her heart rate would go down. I did have a vaginal delivery. But she got so sick soon after that she had to be transported to a bigger hospital, and was placed on a heart lung bypass machine called ECMO, that ultimately saved her life. I had a perfectly healthy pregnancy (read low risk), she was perfectly formed, but the low fluids caused her to almost die. PPHN is rare (1 in 1000 births or so), but it happened to us. So I never ignore that "one" in 1000, because my baby was the "one". Talk to a mother who has lost a baby, or whose baby was born, and she will probably say that low AFI can be a true emergency, such as in cases like mine. Just wanted to share this to make people aware of PPHN and low fluids.

Anonymous said...

my wife has just completed 41 weeks.when she went for check up she was told to go for c section.Reasons told1) passed the expected date by one week.2) low amniotic fluid.But she is feeling very healthy with good baby movements.Therefore I gave a second thought and not go for c section atleast for coming 6-7 days. please suggest.

Anonymous said...

On my due date I lost the 'plug' and began to feel little 'squirts' internally here and there, very subtle. I was past 40 weeks, so I saw my midwive(s) at the birth clinic (next to the hospital) twice a week. I expressed concern over leaking fluid at every check up over the next 2 weeks, as well as calling in twice when I felt especially worried that that 'squirt' I just felt was not normal. I was worried but trusted the midwives, especially after they had all given me the same answer... 'you are not leaking, we are not at all concerned'. They were more worried that I was fast approaching 42 weeks, the cut off for a birth outside of the hospital (Alaska).

See, I chose to go to the birth center because I valued all I had learned about natural birth and avoiding intervention. Because the most important thing to me was ending up with a healthy baby. Ignoring a serious development like dropping fluid levels ultimately forced me into an emergency birthing situation. When I finally did go into labor the day before 42 weeks, I was progressing slowly. I went to the birth center and was sent home to rest. I labored at home all night and came back the next morning. I mentioned my concern about the fluid again, as my water still hadn't broken. The head midwife brushed it off again. She then decided it was time to break my water, to speed things up in effort to avoid the mandatory hospital birth. She couldn't, because the fluid was so low that the baby's head was very tight against the sac. She suddenly flipped out and rushed us next door to the hospital. I again mentioned my concern about the leaking to the nurse, who looked horrified. The doctor came in and succeeded in breaking the sac, releasing a 'scant' amount of fluid. The baby's heart was decelerating and I ended up with an emergency C section. Furthermore, the doctor made a surgical error and I internally bled for 8 hours before being rushed into a second corrective surgery. I nearly lost my uterus or worse. I lost over 3 liters of blood. My baby was ok, but the rushed transfer to the hospital coupled with the late term pregnancy led to a messy, last minute (I was fully dialated and pushing) surgery.

The 'watch out for the interventionists at the hospital' fever that you are perpetrating here with this article nearly killed me. Then again, its the doctor at the hospital who committed the surgical error. All who witnessed my case agree that I was terribly mishandled by both parties.

My placenta was extremely calcified, and the baby was indeed 42 weeks. My midwife had been insisting she must be just a bit younger than we expected. She was wrong. The fluid had been leaking and it lead to a very traumatic birth experience.

While low fluid itself is not always cause for alarm, spreading the rumor that it is not dangerous late in pregnancy is wildly irresponsible. If you suspect it, ignore anyone who tries to tell you its normal and go get an ultrasound and see a doctor.

It's better to come to terms with induction, drugs, or a C section after a tell tale ultra sound than to brush off the warning signs and have your baby yanked out last minute as she is entering the birth canal, causing internal tearing and bleeding for mom.

Low fluid level will not cause surgical complications, but the emergency situation that ignoring such signs leads to can force your birth experience into a corner, where big decisions are being made last minute, unnecisarily.

Don Howser said...

I am a board certified on/gyn. This blogger is absolutely spot on. The real problem is that in spite of out specialty understanding low afi as Emily stated so well it is continues to be a "medical" indication for induction when in fact it is not! Most inductions are for convenience of the doc and some are patient driven without resistance from the doctor...... Why? Complicated answer but it has nothing to do with evidence based medicine......,...unfortunately