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.

Too Many C-Sections: Docs Rethink Induced Labor

By TIFFANY O'CALLAGHAN Monday, Aug. 02, 2010

LWA-Stephen Welstead / Corbis

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The rise in cesarean-section deliveries in recent years has been characterized by some as a key indication of the overmedicalization of childbirth. While the procedure undoubtedly saves lives and leads to better health outcomes for mothers and infants who face problems during pregnancy and labor, many experts say the procedure is being performed too often, and in many cases for nonmedical reasons, putting healthy women and babies at undue risk of complications of major surgery.

The rate of C-sections has reached more than 31% in the U.S., a historical high, according to 2007 data from the American College of Obstetricians and Gynecologists (ACOG). The reasons for the increase are many and have been widely discussed: the rising rate of multiple births, more obesity in pregnant women, the older age of women giving birth. In fact, C-sections have become so common that many women may have an inflated sense of safety about them. "For the most part, moms and babies go through the process healthy and come out healthy, so maybe there's this sense that we're invincible," says Dr. Caroline Signore of the Eunice Kennedy Shriver National Institute for Child Health and Human Development.(See pictures of pregnant-belly art.)

But C-section carries all the attendant risks of major surgery; and data show that compared with vaginal birth, cesarean delivery increases the odds that a mother will end up back in the hospital after birth with complications such as bleeding or blood clots.

Now obstetrics experts are actively seeking ways to drive down the number of C-sections. On July 21, the ACOG issued new guidelines recommending that hospitals allow most mothers who desire vaginal birth after cesarean, or VBAC, to attempt a trial of labor, including some mothers who are carrying twins or have had two prior C-sections. Despite studies showing VBAC to be safe for most women — ACOG data suggests that 60% to 80% of women who attempt VBAC will succeed — many hospitals have urged women to undergo a repeat cesarean over the past decade, largely to avoid medical risks and malpractice suits.(Read how postpartum depression can strike fathers.)

Another factor contributing to high C-section rates is the increase in induced labor, especially between 37 weeks and 38 weeks of gestation — a period obstetricians describe as "early term." (While any birth between 37 weeks and 41 weeks is considered full term, some experts distinguish the earlier period.) The use of labor induction in the U.S. has risen from less than 10% of deliveries to more than 22%, between 1990 and 2006, according to data from the Centers for Disease Control and Prevention, and research suggests that induced labor results in C-sections more often than natural labor. A study published in the July issue of the journal Obstetrics & Gynecology found that among more than 7,800 women giving birth for the first time, those whose labor was induced were twice as likely to have a C-section delivery as those who experienced spontaneous labor.

The study's lead author, Dr. Deborah Ehrenthal of Christiana Care Health System in Newark, Del., says that she was not surprised to see an association between induction and risk of C-section, since previous studies had come to the same conclusion. But Ehrenthal says she was surprised by the high rate of induction overall. In her study of ethnically and socioeconomically diverse mothers delivering before 41 weeks' gestation, who did not have pregnancies complicated by breech presentation, 44% of women had their labor induced.(Read about the risks of late preterm births.)

The rate is significant because ACOG guidelines, which have been in place since 1982, recommend against elective inductions in the early term, or anytime before 39 weeks. Research shows that after 41 weeks' gestation, at which point it is standard policy to induce labor, it may lower the risk of medical complications for mother and baby — including the risk of stillbirth — and even decrease the likelihood of C-section delivery, but those same effects are not seen in women who induce labor before the 41-week mark.

Medical reasons for earlier induction may include advanced size or lack of proper growth of the fetus and maternal issues like diabetes. But in an editorial accompanying Ehrenthal's paper, Signore also suggests that the high rate of early-term induction may reflect lifestyle choices: health care providers' and new parents' desire to control the timing of delivery. "Many women believe that delivering a few weeks early is just as safe as delivering on the projected due date and may request delivery for any number of reasons of comfort or convenience," Signore writes. "However, we must remember that incautious use and timing of interventions — particularly in elective cases — can lead to unnecessarily poorer outcomes for women and newborns."

Among the women whose labor was induced in Ehrenthal's study, nearly 40% of cases were categorized as elective. In other words, there was no pressing medical indication for induction. Extrapolating from the study findings, Ehrenthal suggests reducing the use of elective labor induction could lower the national C-section rate by as much as 20%.

Several hospitals have already begun reducing medically unnecessary induction as a way to lower the rate of cesareans. In 2006, the Magee-Womens Hospital in western Pennsylvania began limiting the pool of women eligible for elective inductions to those delivering after 39 weeks. The hospital also established stricter protocols for elective induction in women after 39 weeks — insisting on high levels of cervical "ripeness" as measured by the standard Bishop score before induction — and prohibited other labor-hastening efforts, such as the use of cervical ripening agents. Additionally, the hospital instituted a new scheduling system requiring physicians to document specific reasons for induction when used.

Researchers found that under the new policy the overall induction rate dropped 33% and the rate of elective inductions fell by roughly the same amount. What's more, the total number of C-sections among first-time mothers who underwent elective induction dropped 60%. The results of the Magee-Womens study were published in April 2009 in the journal Obstetrics & Gynecology.

If a relatively simple policy shift based on medical evidence can successfully cut the rate of induced labor and C-sections at a single hospital, experts say similar changes applied broadly may help lower the rate of C-sections on a national level.

But as with the new guidelines regarding VBACs, decisions about labor induction and other issues surrounding childbirth must be shared by women. Patients should be informed and included in the decisionmaking process, Ehrenthal says. "Unlike the decision to do an emergency C-section where there's no time to talk, usually there is time to have a discussion about induction," she says.

Read more: http://www.time.com/time/health/article/0,8599,2007754,00.html#ixzz1PApJAvQV