Low Amniotic Fluid???

Low Amniotic Fluid. . . I don’t think so

Posted on November 28, 2008 by gloria

What will it take to stop the inductions for too little amniotic fluid?  This is largely a wrong diagnosis based on ultrasound.  Women are having their births wrecked by midwives and doctors who believe that Biophysical Profile is a valid testing method.  We need to go back to clinical palpation skills and stop depending on sound wave fuzzy pictures to assess the amount of fluid at full term.

 Here is where the problem begins:

Many North American women are being told at the very end of their pregnancies to go to an ultrasound clinic and have a biophysical profile done. Most are impressed by the thoroughness of their practitioner and have no idea what this test involves or what sort of harm could follow from consenting to this diagnostic procedure. They will probably not be told that there is no scientific basis for having faith in the test results and that no improvement in health has been proved from large numbers of fetuses being “profiled.” Certainly, no one will mention that the only benefits of the procedure are: 1) the ultrasound clinic will earn $275; and 2) the medical practitioner will be able to cover themselves legally in the very rare instance that a baby might die in utero.Until recently, physicians and midwives would tell women who were carrying their babies beyond 41 weeks gestational age to do “kick counts.” If the baby has 10 distinct movements between the hours of 9 a.m. and 3 p.m., it is widely accepted that the baby is thriving under the mother’s heart. In a culture that loves technology and with the push to expand the commercial use of ultrasound, it was inevitable that someone would come up with a more complex strategy to provide reassurance of the baby’s wellbeing in late pregnancy. Thus the biophysical profile (BPP) was born. Here is the content of the testing, as it appears on the Family Practice Notebook Web site (www.fpnotebook.com/OB44.htm):

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

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

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

After I published the above explanation in Midwifery Today Magazine in 2004, I received  posts from women who had experienced being induced for this diagnosis. Here’s an example:

Thanks for writing this article, Gloria.  It was the one that made me fully realize that my induction (at 41w1d – due to “low” amniotic fluid) & subsequent c/s due to failed induction were almost certainly unnecessary when I first read it in 2004.  Everything you wrote happened to me.  The BPP was perfect besides the fluid measurements.  And then I did have “abundant fluid when the membranes released in the birth process”.

Cathleen in MA

——————

DS 5/03

DD 2/06 (HBAC!)

Here are some medical studies that confirm my alarm over using Amniotic Fluid Index as the reason to do an induction:

Low Levels of Amniotic Fluid No Risk To Normal Birth (2004)

Doctors may not have to deliver a baby early if it has low levels of amniotic fluid surrounding it, Johns Hopkins obstetricians report.

In a study to be presented Feb. 7 at the annual meeting of the Society for Maternal-Fetal Medicine in San Francisco, researchers show that babies born under such conditions fared similarly to those born to women whose wombs held normal amounts of amniotic fluid. No significant differences were found in the babies’ birth weights, levels of acid in the umbilical cord blood, or lengths of stay in the hospital.

Typically, doctors have been concerned about women with low levels of amniotic fluid during the third trimester – a condition called oligohydramnios – because too little fluid can be associated with incomplete development of the lungs, poor fetal growth and complications with delivery. Amniotic fluid is measured by depth in centimeters. Normal amounts range from 5 to 25 centimeters; any amount less than 5 centimeters is considered low.

“These study results are very surprising – they go against the conventional wisdom,” says Ernest M. Graham, M.D., senior author of the study and assistant professor of gynecology and obstetrics. “Amniotic fluid stems from the baby’s urine, and the urine results from good blood flow, so if we see low fluid we assume there probably is not good blood flow and the fetus is compromised. This study shows the fluid test is not as good as we thought, and there is most likely no reason to deliver the baby early if other tests are normal.”

The researchers studied 262 women (131 with oligohydramnios and 131 with normal amounts of amniotic fluid) who gave birth at The Johns Hopkins Hospital between November 1999 and July 2002, comparing the babies’ health at birth. Patients with oligohydramnios were delivered sooner, but were less likely to need Caesarian sections. Babies born to moms with isolated low amniotic fluid were normal size and were at no increased risk of respiratory problems, immature intestines or brain disorders.

Study co-authors were Rita Driggers, Karin Blakemore and Cynthia Holcroft.

Abstract # 318: Driggers, R. et al,

“Are Neonatal Outcomes Worse in Deliveries Prompted by Oligohydramnios?”

Related Web sites: Related Web sites:

http://www.nature.com/jp/journal/v24/n2/abs/7211034a.html
Journal of Perinatology (2004) 24, 72–76. doi:10.1038/sj.jp.7211034 Published online 22 January 2004

An Amniotic Fluid Index 5 cm Within 7 Days of Delivery in the Third Trimester Is Not Associated with Decreasing Umbilical Arterial pH and Base Excess

Rita W Driggers MD¹, Cynthia J Holcroft MD¹, Karin J Blakemore MD¹ and Ernest M Graham MD¹¹Division of Maternal-Fetal Medicine, Department of Gyn-Ob, Johns Hopkins University School of Medicine, Baltimore, MD, USA.Correspondence: Ernest M. Graham, MD, Johns Hopkins Hospital, Department of Gyn-Ob, Phipps 228, 600 N. Wolfe Street, Baltimore, MD 21287-1228, USA.

You Can Eat and Drink During Labor

By Megan Brooks

NEW YORK | Wed Jan 20, 2010 11:18am EST

(Reuters Health) - There is no reason why pregnant women at low risk for complications during delivery should be denied fluids and food during labor, a new Cochrane research review concludes.

"Women should be free to eat and drink in labor, or not, as they wish," the authors of the review wrote in the Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research.

Dr. Jennifer Milosavljevic, a specialist in obstetrics and gynecology at Henry Ford Health System, Detroit, who was not involved in the Cochrane Review, agrees that pregnant women should be allowed to eat and/or drink during labor.

"In my experience," she told Reuters Health in an email, "most pregnant patients at Henry Ford are placed on a clear liquid diet during labor which includes water, apple juice, cranberry juice, broth, and jello. If a patient is brought in for a prolonged induction of labor, she will typically be permitted to eat a regular diet and order anything off the menu in between different induction modalities."

Milosavlievic has "not seen any adverse outcomes by allowing women the option of liquids and/or a regular diet in labor."

Standard hospital policy for many decades has been to allow only tiny sips of water or ice chips for pregnant women in labor if they were thirsty. Why? It was feared, and some studies in the 1940s showed, that if a woman needed to undergo general anesthesia for a cesarean delivery, she might inhale regurgitated liquids or food particles that could lead to pneumonia and other lung damage.

But anesthesia practices have changed and improved since the 1940s, with more use of regional anesthesia and safer general anesthesia.

And recently, attitudes on food and drink during labor have begun to relax. Last September, the American College of Obstetricians and Gynecologists (ACOG) released a "Committee Opinion" advising doctors that women with a normal, uncomplicated labor may drink modest amounts of clear liquids such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, and sports drinks. They fell short of saying food was okay, however, advising that women should avoid fluids with solid particles, such as soup.

"As for the continued restriction on food, the reality is that eating is the last thing most women are going to want to do since nausea and vomiting during labor is quite common," Dr. William H. Barth, Jr., chair of ACOGs Committee on Obstetric Practice, noted in a written statement at the time.

But based on the evidence, Mandisa Singata of the East London Hospital Complex in East London, South Africa, an author on the new Cochrane Review, says "women should be able to make their own decisions about whether they want to eat or drink during labor, or not."

Singata and colleagues systematically reviewed five studies involving more than 3100 pregnant that looked at the evidence for restricting food and drink in women who were considered unlikely to need anesthesia. One study looked at complete restriction versus giving women the freedom to eat and drink at will; two studies looked at water only versus giving women specific fluids and foods and two studies looked at water only versus giving women carbohydrate drinks.

The evidence showed no benefits or harms of restricting foods and fluids during labor in women at low risk of needing anesthesia.

Singata and colleagues acknowledge that many women may not feel like eating or drinking during labor. However, research has shown that some women find the food and drink restriction unpleasant. Poor nutritional balance may be also associated with longer and more painful labors. Drinking clear liquids in limited quantities has been found to bring comfort to women in labor and does not increase labor complications.

The researchers emphasize that they did not find any studies that assessed the risks of eating and drinking for women with a higher risk of needing anesthesia and so further research is need before specific recommendations can be made for this group.

SOURCE: Cochrane Library, 2010.

10 Commandments for Expectant Fathers

1. You Shall Be Sympathetic to Morning Sickness....All Day....

I don't know who decided to call it morning sickness, but the name is misleading. Morning sickness can happen all day long, from the moment she wakes up until the moment she sleeps. You must be sympathetic and offer to hold her hair while she pukes. She'll probably yell at you to get the heck out of the bathroom, but your offer will go a long way.

2.  You Shall Not Ask her to "Hold It"

Don't ever ask her if she can hold it. She can't. Get her to a restroom immediately. Be very concerned. She may ask you to pull the car over so she can pee on the side of the road. Do it. Don't question her or you will have a problem on your hands. In fact, never question a pregnant woman who has to pee; you're just asking for trouble. (I, personally, have wet myself on several occasions and it's not pleasant. )

3. You Shall Not Take Her Hunger Lightly

A hungry pregnant woman is more threatening than stumbling across a bear cub in the woods and then seeing his mama 10 feet away eyeballing you. Get her some food now, you fool! And then go get her more food while she's eating that food. I don't care if it's three in the morning; you can't go wrong with food. I cannot stress the importance of keeping a pregnant woman full. It could save your marriage. Oh, you thought I was kidding, didn't you? That's cute. I’m not.

4. You Shall Not Covet Cologne

Pregnant women develop super powers - they can puke like a fire hose and they can smell better than a bloodhound on the hunt. That cologne that used to be so sexy on you now sucks, so stop wearing it. And that spray deodorant is making her feel murderous and you would be the first victim. It's not her fault she can smell you three hours after you leave for work, it's yourfault (just play along with this for now).

5. Honor Mood Changes

Don't even think about blaming it on hormones unless you're looking to get hurt. You don't know what a pregnant woman is capable of doing. She probably doesn't know either, but do you really want to find out? Just keep in mind that in conjunction with these mood changes it will take your lady a fraction of the time to get upset compared to the good old days, which means your escape window is now significantly smaller. (Remember this in case you break a commandment.)

6. You Shall Not Bear False Witness Against Female Anatomy

Most everything seems to change! Things expand, change color, stretch out, and leak. Listen dude, you won't look at women the same way, but you must smile and nod and try to look sympathetic to all these bodily changes. Think about how sad it was when Apollo Creed died at the end of Rocky IV. If you keep that image in mind while the ladies talk private parts, you will appear compassionate and everyone will love that none of this grosses you out in the slightest.

7.  Remember, She Will Get Freaked Out

All these articles she is reading online are driving her mad. It’s your job to find another article that debunks the first article, print it out and highlight it. You must also rage at the author of the first article, ‘Blank is an idiot! He/she doesn't know what they're talking about!'

8. Do Not Expect her to Maintain her Pre-Pregnancy Activity Levels

She tires easily and won't be able to keep up with her normal activities, so you will have to take on more. This may include doing the dishes, laundry, vacuuming and possibly some light dusting. Do it, don't complain. If you complain, immediately reread commandment number 5. Get out of the house now, you are in danger. Don't come home until you bring food.

9. You Shall Not Take the Word Pee in Vain

If she says she has to pee again, she does. Yes, she just went 10 minutes ago, but she has to go again. Seriously.

10. She is the One, The Only One

You will do well to smile and nod and pretend that she’s always right because as horrible as you think it is to bow to your goddess right now, it is twenty times more horrible being pregnant and then pushing a human being out of very sensitive lady parts. But guess what? It's all worth it. Just wait until you hold your son or daughter for the very first time — you will look at your wife and know that yes, she is in fact, a goddess. And that goddess will look at you with the same awe.

Doulas: Easing Birth

Doulas: Easing Birth

Labor Coaches

By Star Lawrence
WebMD Feature

Reviewed by Charlotte E. Grayson Mathis, MD

When Barbara and Christopher Lawton were planning for the birth of their son almost two years ago, the midwife practice they were using in Pittsburgh asked them if they were going to use a doula during childbirth. "I didn't even know what that was," says Barbara.

A doula, Lawton found out, is a private labor assistant ... not a doctor, not a nurse, not a midwife. Indeed, a doula (a Greek word meaning "women supporting women") is not a medical professional at all. Rather, she provides support and encouragement throughout labor and delivery, and often, after the baby is born, as well.

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Doulas are a centuries-old tradition, but have become popular again in the U.S. in the past 15 or so years. "Having another woman's presence during childbirth is very helpful," says Pam Lesser, RNC, MS, manager of women's support services at Barnes-Jewish Hospital in St. Louis, Mo. While many labor-delivery nurses would like to provide the encouragement that delivering moms need, the fact is that because of the time constraints nurses face in today's hospitals, it's not likely that one nurse will be able to provide the support that most women need during this time.

Doulas do not take the place of a woman's partner. "The mother's partner is an integral part of the experience and an extremely supportive one," Lesser says. "But it's unreasonable to expect the partner -- who is as emotionally involved as the expectant mom -- to provide all the support."

Continuous Support

According to the organization, DONA (Doulas of North America), doulas are women who are trained and experienced in childbirth, whether or not they have actually given birth themselves. The doula provides physical, emotional, and informational support to women and their partners during labor and birth. She offers help and advice on such measures as breathing, relaxation, movement, and positioning. She also helps the mom-to-be (and her partner, if one is there) gather information about the course of her labor and options during labor and delivery. And perhaps most important, she provides continuous emotional reassurance and comfort.

It's that word -- continuous -- that is such a vital part of a doula's role. "My doula met me at the hospital at noon, and was still there the following day at 4:30 when I finally saw my son for the first time," says Lawton.

"That continuous presence is extremely important," says Lesser. "It's a great asset. The doula never leaves the mom's side. That's her job."

Barnes-Jewish Hospital thinks so much of the value of doulas that in 1998, the hospital established its own doula program. Today, there are approximately 50 doulas on staff, so that any woman who would like to have a doula during her labor and delivery can request one. The service is provided free of charge. Approximately 25% of the women delivering at Barnes-Jewish ask for a doula, says Lesser.

Fewer Complications

Research findings seem to back up the value of having a doula during childbirth. In the late 1970s, Drs. John Kennell and Marshall Klaus looked into ways to enhance the emotional bonding between mother and newborn. They found that having a doula in the labor room not only improved that bond, but also seemed to decrease the incidence of complications.

"Studies have shown that doulas can lead to fewer Cesarean sections, a shorter labor, fewer requests for pain medication or epidurals, less need for oxytocin, and fewer instances of forceps delivery," says Lesser. "The role of the doula has increasingly been adapted as part of a positive birthing experience."

Sarah Pinkner is a doula at Barnes-Jewish Hospital. While many doulas are hired privately by expectant parents, Pinkner enjoys being part of the hospital's staff. "Women of so many different cultures come into Barnes-Jewish," she explains. "This is an opportunity for them to take advantage of a service they may not have known about, or perhaps could not afford on their own." The cost of a doula varies throughout the country, but generally ranges from $200-$800.

Hiring a Doula

There are no state licensing requirements for doulas, but many do go through a 16-hour certification process offered by DONA that includes training in:

• The emotional and psychological process of labor and birth.
• The anatomy and physiology of reproduction, labor, and birth.
• Comfort measures and non-pharmacological pain-management techniques.
• Appropriate topics for prenatal and postpartum discussion with clients.
• Discussion of ethics and standards of practice for the doula.
• Referral sources for client needs beyond the scope of the doula.
• Communication skills and values clarification.

If the birthing center you are planning to use doesn't provide doulas as part of its services and you are interested in hiring one privately, DONA recommends asking the following questions:

• What training have you had?
• What has been your experience with childbirth, personally and as a doula?
• What is your philosophy about childbirth?
• May we discuss our birth plans and what kind of role you can play in supporting me through childbirth?
• May we call you with questions before and after the birth?
• At what point do you come to us? Do you meet us at home or at the hospital?
• Do you meet with us after the birth?
• Do you work with any other doulas in case you're not available? May we meet with them?
• What is your fee?

"My doula was a very important source of encouragement," says Lawton. Which is just what the doula herself is aiming for, Pinkner says.

"It's a chance for me to make a difference."

http://www.webmd.com/baby/features/doulas-easing-birth