Low Amniotic Fluid Scam

This article from Medscape illustrates the folly of diagnosing oligohydramnios through ultrasound. True low amniotic fluid at full term is an extremely rare condition which can be diagnosed properly only by doing palpation of the pregnant belly. Thousands of women have been unnecessarily launched down the cascade of obstetrical interventions by being frightened by this erroneous diagnosis at 41 weeks gestation. It’s time to ditch the “Biophysicial Profile” as an indicator of pathology. It is not based on science and continues to cost women their births and good health. Gloria Lemay

Oligohydramnios at Term
(From Journal of Midwifery & Women’s Health
Oligohydramnios at Term: A Case Report

Maria L. Lanni, CNM, MS; Elizabeth A. Loveless, CNM, MS

Posted: 02/07/2007; J Midwifery Womens Health. 2007;52(1):73-76. © 2007 Elsevier Science, Inc. )

(excerpt)
In Conway’s[13] retrospective, case-controlled study, women who were induced for oligohydramnios had an increased rate of cesarean section when compared women with oligohydramnios who were in spontaneous labor. The authors postulated that this increase was caused by the induction process itself.[13] One may conclude that a woman who is at term with isolated oligohydramnios with reassuring fetal surveillance and the absence of maternal morbidity and evidence of FGR is not associated with adverse perinatal outcome. (End of except)

Conclusion (of Medscape article)

Adverse perinatal outcomes associated with oligohydramnios are: umbilical cord compression; uteroplacental insufficiency, which is related to fetal growth restriction, pre-eclampsia, and other maternal morbidities; and increased incidence of meconium stained amniotic fluid.[3,4,14] The adverse outcomes associated with oligohydramnios have led to recommendations of delivery following the diagnosis of oligohydramnios in pregnancies at or past 37 weeks.[2] However, Sherer[18] identifies a number of the original studies linking oligohydramnios with adverse perinatal outcomes that included fetuses with structural anomalies, small-for-gestational-age and FGR fetuses, postmaturity syndrome, and fetuses of mothers with various comorbidities, all of which may have affected AFI and led to the adverse outcomes. Thus, low AFI may be an epiphenomenon. The true number of adverse outcomes solely caused by isolated oligohydramnios is difficult to know.

The question of the best management for AFI remains. Individualized care, with consideration of the many maternal and fetal factors, including time of day, cervical readiness, and emotional readiness for labor, should be considered. While research has shown that expectant management with maternal hydration has comparable maternal and neonatal outcomes in women with isolated idiopathic oligohydramnios at term, clinicians may be reluctant to abandon the approach of active management. It is reasonable to begin with active maternal hydration prior to routine fetal surveillance of term pregnancies or for borderline AFIs. More research needs to be done on the effect of acute hydration prior to fetal surveillance. It may be beneficial for providers to encourage adequate hydration to our patients prior to assessment of AFI to decrease potentially unnecessary interventions.

http://www.medscape.com/viewarticle/551032

Related post: http://www.glorialemay.com/blog/?p=60

About gloria

I live and work in Vancouver BC Canada. I've been in the childbirth business for 30 years. I teach midwifery and doula courses both online and in person.
This entry was posted in Holistic midwifery & doula education, Hospital birth. Bookmark the permalink.

31 Responses to Low Amniotic Fluid Scam

  1. Lisa RM says:

    Thanks for posting this. My second birth was induced due to oligohydramnios, but I did manage a vaginal, unmedicated birth. I’ve always wondered though, if this was really an actual reason to induce (I was 38 weeks).

  2. Teresa Pitman says:

    Thank you, Gloria!I am also frustrated by the fact that the Biophysical Profile keeps being used despite the research showing that it is not useful in predicting anything.

  3. Thank you! This test which sends my clients into a panic should be banned! I live in hopes that those who care enough will continue to educate themselves and make an informed decision. Thanks for caring.

  4. Janet says:

    How many ways can we pathologise the normal? Oh yes, how many dollars are there in the world?

    *head desk*

  5. Sheridan says:

    Thank you! I love your previous post on this as well and now suggest it to all moms going in for NST/fluid checks. I have had so many doula clients induced because of “low fluid”. It is the new “big baby”

    If their baby isn’t big, then hopefully their fluid is low so we can induce them! This seems to be the prevailing attitude. Very sad.

  6. Helena says:

    Hmmmm. Have moms drink water? What a concept! I have had some clients with low AFI bring it up with hydration. Expensive biofeedback tool- ultrasound.
    Moms- take care of yourselves!
    Midwives and docs- hone those palpation skills!

  7. gloria says:

    I am concerned that women are “over hydrating” in response to this false testing. It’s not up to the woman to respond to bad science. It’s up to medical people to stop using bad technology.

    When I was pregnant in 1981, they had a test called the “estriol test”. Many women were induced because someone thought that the urine estriol levels said something about the well-being of the fetus. It was all a mistake and the test was quietly done away with. BPP needs to be done away with, too.

  8. gloria says:

    This is something I snagged off the ICAN list:

    Once upon a time people were not able to peek into other people’s bodies and take a guess at how much fluid was in there. We didn’t see it and we didn’t worry about it and it didn’t matter. Babies were born with a gush of water – a little or a lot.

    Once upon a time we didn’t look at babies in the womb and take a guess at their size. We couldn’t tell and it didn’t matter because babies were born anyway, some big and some small.

    Once upon a time people didn’t measure their exact due dates and intervene if the baby had not arrived by that date. And it didn’t matter. People knew babies would come when they were ready, and “in the spring” or “in the winter” was a close enough prediction.

    Once upon a time we couldn’t see and we couldn’t predict and didn’t measure everything and it didn’t matter, because most babies came just fine.

    Once upon a time women were not watched so closely to prevent something bad from happening. And generally, nothing bad happened anyway.

    Sheila Stubbs

    • Amy says:

      @Sheila — While I absolutely agree with you, “once upon a time” women and babies also used to die during childbirth. So while all the points you raise are valid, don’t blame the poor uninformed mothers for believing everything their medical professionals tell them.

      • gloria says:

        Women and babies die in birth today. Cesarean section complications are the biggest contributor. The number of Amniotic Fluid Embolism deaths of mothers is shocking. Modern obstetrics has not led to more live babies and mothers. The most important thing about surviving birth for both mother and baby is improving nutrition and no one spends any time worrying about that in the obstetric field.

    • Rasalila says:

      Cool story :D

  9. Terri F. says:

    I was “diagnosed” as having low amniotic fluid with my daughter (1st child) and they wanted to induce. My husband and I did NOT feel comfortable with this decision and decided to go home and wait it out for a few days. Well- low and behold, my daughter decided to make her appearance the next day and I was able to have a normal vaginal delivery with no epidural/pain meds. Had I been induced (before she was ready) who knows what her birthing time would have been like. So thankful we went with our gut instinct and NOT what was being “forcefully suggested”.

  10. Terri F. says:

    By the way- forgot to mention that the Ultrasound Technician and Perinatologist tried to suggest the same thing with my son (2nd birth)- low amniotic fluid= need to induce. We knew better at this point and just went home to wait it out. My son was born perfectly healthy in a birthing tub at the local birth center.

  11. Tamra Larter says:

    My neonatologist friend says this:

    I never heard this before, that palpation alone can accurately diagnose oligohydramios. Is this method more sensitive than ultrasound, and with less false positives and false negatives than ultrasound? Where can I find a reference for this?

    Can you help?

    • gloria says:

      I would request that the neonatologist provide evidence that u/sound diagnosis has helped in any way to improve the health of the newborn population? It has not. The only two things that have ever been proven to give better obstetric outcomes are 1. improving maternal nutrition 2. improving social support for the mother.

      When there is true oligohydramnios, the uterus loses its smooth ovoid shape and the baby’s parts can be felt more distinctly. This is the most basic of obstetric skills.

  12. Grace says:

    With my son (2nd pregnancy), I had routine ultrasounds to keep an eye on my abnormally large placenta, and his growth. They happened to note at one visit that my fluid looked low, so they found another thing to keep an eye on for each ultrasound visit. My son decided he wanted to be born early, so my bag of water ruptured at 34 weeks & 2 days…I leaked only a little fluid initially, and then it stopped leaking until my labor was induced at 35 weeks (although my labor was slowly starting on its own before that)…so maybe it was more of a labor augmentation. Anyway, when my son was born, there was PLENTY of fluid that came out with him, so again the ultrasounds inaccurately said I had “low” fluid. Or maybe it was just the Doctors that were making it up. Anyway, my son is happy and healthy, and has been since birth! I will definitely keep this in mind for future pregnancy.

  13. Lisa says:

    Great article Gloria thank-you So much…there’s a Doc in my area who thinks everyone has this condition, it just so happens he’s in a solo practice and it’s his induction excuse of choice and it works to scare the parents into submission if they are not ready and many aren’t.
    Also to remind us all that it’s really malpractice attorneys are the ones who love the biophysical profiles the most ;-)

  14. Nicole says:

    I agreed to an induction at 42w5d, about a year ago, and I still can’t stop thinking about whether or not I did the right thing. On the border of oligo(5.5) but at that far along i knew it was hard to tell if accurate. Had planned a homebirth, and although we had one of the better hospital births, it was hard for me physically (doubled contractions), and my baby (decels). However, my homebirth midwife did say, before the ultrasound, that the fluid did seem low (baby much easier to feel than 2 days earlier). That, coupled with that fact that I did not feel like labor was imminent, and I was under a huge amount of stress from work, made me agree. I unfortunately did not feel confident and healthy, I felt like maybe long-term stress affected my entire system. Baby was almost 9lbs and healthy, not much vernix, peely hands and feet, very beautiful to me! I am very much against unnecessary inductions, and I wish I could come to terms with mine and decide if it was necessary or not.

  15. Pingback: checking fluids at 40 wks - AllDoulas.com

  16. Carol-Anne says:

    I had a biophysical done with my 4th child (11 years ago now) the day before he was born. I was 10 days over my “due date” – 5/6 of my children were at least a week late. It was done by an OB for “improved accuracy”. I was told that I had excessive fluid and my son was 7.5lbs.

    This impacted my planned home water birth as the midwives became extremely concerned when my son didn’t drop once labour had started. This is not uncommon and had happened with my 3rd child too but with the excessive fluid diagnosis hanging in the air the midwives were very concerned about a prolapsed cord and recommended a hospital transfer.

    I declined, and the midwives opted to try a “controlled break” of the amniotic sac. They of course discovered there was no extra fluid and my son was actually 9lbs 12oz.

    As an aside – I wish our midwife had actually “allowed” him to be born IN the water instead of telling me to raise up out of it once his head crowned.

    The “cascade of intervention” can clearly impact on our births…

  17. Jen Burnett says:

    This happened with my first at 37 weeks. They told me my fluid was dangerously low and I needed an induction right away. They did cytotec and hooked me up to pit. When they broke my water, I flooded the floor AND the first year resident who came up with this ridiculous diagnosis. She looked shocked then said, “Well the fluid must have all been behind the baby on the u/s. Oh well, we can’t turn back now.”

  18. It scares me to no end that the skill of palpation is going the way of the do-do bird. It’s amazing that you said on facebook – that you don’t even need to palpate, even looking at the belly with mama laying down can tell you!

    I’m totally exhausted of hearing otherwise healthy women getting “bio-physicals” only to turn around and be induced at 9am the following day (because, really, if it was a true medical need they wouldn’t wait until such a perfect time for the medical staff).

    Thank you for sharing Gloria!

  19. Michelle says:

    Yes, at 41 wks and 4 days I went in for a BPP. The technician, after saying he couldn’t get a good look at one area (darn those dropped babies ready for birth!) and that my levels were “only” 7 when they needed to be higher than 5, said to us “If you were my wife I’d induce you.” I almost said “And that’s why I’m having a homebirth.” (Wish I had!) We had our little girl at home a day and a half later. Psh. The fear -mongering.

  20. Chris says:

    My wife is 25 weeks today. We’ve been scared for the past six. Our fetus was called normal at 13 weeks, then 18 weeks mild VM but otherwise on target EFW. At 22 weeks the bottom fell out, IUGR and oligoydramnios (8) with short long bones and club foot. I asked my wife to go on bedrest and drink 4L of water for the next two weeks. At 24 weeks at the high risk hospital we were told the placenta was large, fetus only 400 grams, placental function normal, therefore 25-50% triploidy. Did a CVS the next day and I could see the placenta took up inceasingly more space, not enough fluid to do an amnio. They did a CVS and it came back negative for triploidy as well as the four main trisomies. The placenta is not hydropic, but texture was unusual to the doctors and it took 3 passes with needles to get even a small amount of tissue. They want to do another CVS on Tuesday. Baby went into temporary brachycardia during the CVS as my wife started contracting. So I am worried.

    Gloria, I am trying to understand. Is the placenta large because the amniotic fluid is not being produced to push it back? How severe must the IUGR be before you are certaan it will expereience mental and physical deficiencies? Baby only grew 40 gms in 2 weeks. I have read about 25 week babies or babies less than a pound making it.

  21. gloria says:

    This is a link to a new article with newer research citations on the above subject:
    http://www.scienceandsensibility.org/?p=5294

  22. Pingback: Low Amniotic Fluid. . . I don’t think so | Gloria Lemay

  23. Kari says:

    My first pregnancy was your typical, overly-managed hospital birth. I have type 1 diabetes, and even though I kept (keep!) it very, very tightly controlled, and even though baby and I were perfectly healthy, with no complications whatsoever, standard protocol required weekly NSTs & BPPs starting around 30-some weeks. I remember my doctor frequently talking about “my induction” at 38 weeks, and my telling him I did not wish to be induced unless me or my baby were unhealthy. Well, at my 37wk BPP it was discovered that baby was not practice breathing. Rather than repeating the test, the dr rushed me into an induction, upped the pit so fast and so hard that he put my son in fetal distress, and I ended up with an unnecessary c/s. I now birth my babies at home (type 1 diabetes be damned! I can certainly take care of myself and monitor myself just as well as they can) and have had no issues. I don’t go for tests, now. Don’t trust them, and don’t trust the people who insist that I submit to them.

  24. gloria says:

    This is the full text of the Medscape article mentioned above for those who don’t have a sign in on Medscape:

    http://www.medscape.com

    Oligohydramnios at Term: A Case Report

    Maria L. Lanni, CNM, MS, Elizabeth A. Loveless, CNM, MS

    J Midwifery Womens Health. 2007;52(1):73-76.

    J. L. is a healthy, 20-year-old gravida 2 para 0010 at 41 and 0/7 weeks’ gestation, based on the first day of her last menstrual period and first trimester ultrasound. She was admitted to the labor and delivery unit at 10:00 AM for induction of labor. Earlier in the day, J. L. had a biophysical profile (BPP) performed per hospital protocol for all women whose pregnancies continued beyond 40 weeks’ gestation. The BPP revealed an amniotic fluid index of 4.97 cm. All other components of the BPP were normal (fetal breathing, fetal tone, fetal movement, and reactive nonstress test). The estimated weight of the fetus was 3178 grams. J. L.’s prenatal course was uncomplicated. She had adequate fetal growth and no signs of maternal or fetal morbidity. Her initial cervical exam was 2 cm dilated, soft, posterior, 50% effaced, -2 station, and vertex. She was not having any uterine contractions. The amniotic membranes were intact. The baseline fetal heart rate (FHR) was 140 to 150 beats per minute (bpm) with moderate variability, accelerations, and no decelerations. The collaborating obstetrician recommended inducing labor with oxytocin infusion if labor did not begin spontaneously within 12 hours after admission. After 12 hours of observation, her vaginal exam was unchanged. The FHR pattern was reassuring throughout the day.

    At this time, after obtaining the patient’s informed consent, the midwife began induction of labor per protocol, starting at 1 milliunits (mU) per minute of oxytocin, increasing 1 mU/minute every 20 minutes until a contraction pattern of every 2 minutes with moderate intensity was established. Three hours later, at an infusion rate of 6 mU/min, uterine contractions were every 3 to 4 minutes. At that time, an episode of prolonged fetal bradycardia occurred (to 70 bpm, lasting 90 seconds before returning to a baseline of 140-150 bpm). The oxytocin infusion was stopped, and an amniotomy was done. This revealed a small amount of clear, odorless fluid. A fetal scalp electrode was inserted.

    Nineteen hours after admission, 7 hours after beginning the labor induction, J. L. requested pain medication. One milligram of butorphanol tartrate augmented with 25 mg of promethazine was administered via intravenous (IV) push for pain relief. The oxytocin infusion was restarted at 1 mU/min, increasing by 1 mU every 20 minutes. Twenty-four hours after admission, an epidural was placed at J. L.’s request. At this time, her cervix was 5 cm, 80%, and -1 station. The FHR was reassuring and contractions were every 2 to 4 minutes. At 3:00 PM, 29 hours after admission, the consulting physician and midwife decided to do an amnioinfusion and place an intrauterine pressure catheter (IUPC) secondary to the presence of repetitive variable decelerations that had a quick recovery to baseline. At the time of the amnioinfusion and IUPC placement, J. L.’s vaginal exam was 8 cm, 100% effaced, and -1 station. The patient reported exhaustion and felt that she could not continue with the labor. Seven hours later, J. L. was contracting irregularly and reported that she had the urge to push but felt too exhausted; her cervix was anterior lip (9 cm), 100%, +1 fetal station. Thirty-five hours after being admitted to the labor unit, maternal pushing efforts began, the anterior lip was reduced, and the fetus’s station was +2 with a well-flexed head. The FHR pattern was reassuring. After 1 hour and 50 minutes of maternal pushing effort, a decision was made by the patient, midwife, and physician to proceed with a cesarean section because of the arrest of fetal descent and maternal reports of exhaustion and inability to continue pushing. A vigorous baby boy was born at 11:45 PM, weighing 3265 grams, with Apagar scores of 9 and 9, at 1 and 5 minutes. Both mother and baby did well postpartum.

    Several areas of this case presentation warrant discussion. Among these are the diagnosis and management of oligohydramnios, the management of pregnancy beyond 40 weeks, supporting the circadian rhythms and emotional and physical needs of laboring women, beginning an anticipated long induction of labor at midnight in the absence of evidence of urgent maternal or fetal need, the consequences of prolonged induction of labor on maternal pain tolerance, and second stage labor management in the presence of maternal exhaustion. This article provides a brief review of oligohydramnios in the clinical setting, and presents a suggested management guideline.

    Oligohydramnios refers to low amniotic fluid. Amniotic fluid can be assessed qualitatively or quantitatively via ultrasound. The quantitative method measures single pockets >2 cms. The most common quantitative measure used in clinical practice is the amniotic fluid index (AFI). The index is calculated by dividing the uterus externally into 4 quadrants and using ultrasound to measure the largest vertical pocket in each quadrant in millimeters, which are then summed to calculate the AFI.[1] An AFI ≤5 cm is the accepted cutoff for the diagnosis of oligohydramnios.[2]

    Oligohydramnios occurs in about 1% to 5% of pregnancies at term.[3] It may be associated with 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.[4] Oligohydramnios may be responsible for malpresentations, umbilical cord compression, and difficult or failed external cephalic version.[5] Oligohydramnios can also be an idiopathic finding in women who have low-risk pregnancies and no medical or fetal complications.[3]

    The AFI was introduced in 1987 as a technique to assess the amount of amniotic fluid in the amniotic sac.[3] 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]

    While error exists in simply determining the AFI, studies also show that the AFI is a poor predictor of perinatal outcome.[1,6,11] In women who have idiopathic oligohydramnios without other obstetric complications, there is no increase in adverse perinatal outcomes when compared to women who do not have oligohydramnios.[14] Although a low AFI does not reliably detect adverse pregnancy outcomes, it may lead to an increase in obstetric interventions without improving neonatal or maternal outcomes.[1,6,11-13]

    Oligohydramnios at term may be managed actively via induction of labor or expectantly via hydration and fetal surveillance, and/or regular ultrasounds assessing amniotic fluid volume.[2,4] While both options exist, active management is the common approach for women with term pregnancies with or without maternal or fetal obstetric risk factors.[4,12,14]

    Inducing labor in women with low-risk pregnancies with isolated oligohydramnios is the most common practice, although it is not found to improve perinatal outcome.[4,12,14] In a small prospective, randomized pilot study (N = 54), Ek et al.[14] found that active versus expectant management of oligohydramnios in women with uncomplicated pregnancies at term resulted in no difference in maternal or neonatal outcomes. Because of the small number of women in the study group, this study did not have sufficient power to determine a significant relationship between oligohydramnios and neonatal outcomes. Conversely, a prospective study by Alchalabi et al.[4] divided 180 women between 37 and 42 weeks’ gestation who were admitted for induction of labor into 2 groups: the women in one group had an AFI ≤5 cm (n = 66) and the women in the other group had an AFI of >5 cm. Although the 2 groups had comparable demographic and obstetric characteristics prior to induction, the women in the low AFI group had an increased rate of cesarean section secondary to fetal distress (27.3% vs 5.5%; OR 6.75, 95% CI 1.8-23.2; P = .004).[3] Conway et al.[13] randomized 61 otherwise healthy women with isolated oligohydramnios (AFI ≤5 cm) at term to expectant management or induction and found no differences in maternal or neonatal outcomes. These authors concluded that expectant management with twice weekly fetal surveillance is a sensible alternative to labor induction, and that the majority (67%) of women will go into labor spontaneously within 3 days after diagnosis.[13] 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. Expectant management may have equally good neonatal outcomes, yet that approach is not widely used.[14]

    One approach to treating oligohydramnios during labor is to perform an amniotomy followed by amnioinfusion to increase the fluid inside the uterus.[5] However, if expectant management is desired, maternal hydration can increase the AFI. Oral or IV maternal hydration has been studied as a treatment for oligohydramnios in women with otherwise healthy term pregnancies.[5] In the second trimester of pregnancy, the majority of the amniotic fluid is produced through fetal urine production and is reabsorbed through fetal swallowing. Amniotic fluid is also reabsorbed via the fetal lungs and by the placenta.[15,16] Maternal hydration and maternal osmolarity affect the amount of amniotic fluid available to the fetus for urine production and reabsorption near term.[15,17] In a systematic review, Hofmeyr[5] found that amniotic fluid volume is increased in women who have reduced or normal AFI and who drank 2 liters of water or who received IV hypotonic hydration; isotonic IV hydration had no measurable effect.[5] The amniotic fluid volume, assessed 6 hours later, was shown to increase by an average effect size of 2.01 (95% CI, 1.43-2.60) with oral hydration, and 2.3 (95% CI, 1.36-3.24) with a hypotonic IV solution. While no clinically important outcomes were assessed in any of these trials, hydration is a simple, inexpensive, and noninvasive method that may apply to clinical situations. Leeman and Almond[3] reported an increase of 30% in the AFI in women who consumed 2 liters of water 2 to 5 hours before repeat ultrasound, compared to women who were not orally hydrated. They recommend that maternal hydration should be considered before retesting the AFI 2 to 6 hours later, in cases of isolated oligohydramnios (Figure 1).

    Proposed algorithm for managing oligohydramnios. EFW = Estimated fetal weight; FGR = fetal growth restriction. Reprinted with permission from Dowden Health Media.[3]

    In the case presented here, the woman had isolated oligohydramnios at 41 weeks’ gestation with no other risk indications or risk factors for maternal-fetal adverse outcomes. The result of her induction of labor was a cesarean section for arrest of descent because of maternal exhaustion, not for non-reassuring fetal status. The duration of time from admittance to delivery was 37 hours. No intervention or observational testing occurred during the first 12 hours of hospital admission.

    In Conway’s[13] retrospective, case-controlled study, women who were induced for oligohydramnios had an increased rate of cesarean section when compared women with oligohydramnios who were in spontaneous labor. The authors postulated that this increase was caused by the induction process itself.[13] One may conclude that a woman who is at term with isolated oligohydramnios with reassuring fetal surveillance and the absence of maternal morbidity and evidence of FGR is not associated with adverse perinatal outcome.

    Many questions remain regarding how we measure and assess fetal intolerance of labor. How valid are the cut off measures that we use for oligohydramnios? Is the increase in cesarean section secondary to fetal intolerance of labor from low AFI or the induction process itself? More clinical research needs to be done to evaluate neonatal outcomes following expectant management of women with oligohydramnios.

    In the case presented here, alternative approaches to diagnosing oligohydramnios could have led to a different outcome. One approach is to advise adequate oral hydration before doing a routine BPP to avoid potentially unnecessary and risky interventions. However, the clinical outcomes of the fetus and mother following acute maternal hydration have not been researched and warrant further studies. Challenges of inter- and intrarater reliability of AFI determination suggests that all medical, midwifery, and nursing staff may benefit from periodic review of technique of measurement.

    Adverse perinatal outcomes associated with oligohydramnios are: umbilical cord compression; uteroplacental insufficiency, which is related to fetal growth restriction, pre-eclampsia, and other maternal morbidities; and increased incidence of meconium stained amniotic fluid.[3,4,14] The adverse outcomes associated with oligohydramnios have led to recommendations of delivery following the diagnosis of oligohydramnios in pregnancies at or past 37 weeks.[2] However, Sherer[18] identifies a number of the original studies linking oligohydramnios with adverse perinatal outcomes that included fetuses with structural anomalies, small-for-gestational-age and FGR fetuses, postmaturity syndrome, and fetuses of mothers with various comorbidities, all of which may have affected AFI and led to the adverse outcomes. Thus, low AFI may be an epiphenomenon. The true number of adverse outcomes solely caused by isolated oligohydramnios is difficult to know.

    The question of the best management for AFI remains. Individualized care, with consideration of the many maternal and fetal factors, including time of day, cervical readiness, and emotional readiness for labor, should be considered. While research has shown that expectant management with maternal hydration has comparable maternal and neonatal outcomes in women with isolated idiopathic oligohydramnios at term, clinicians may be reluctant to abandon the approach of active management. It is reasonable to begin with active maternal hydration prior to routine fetal surveillance of term pregnancies or for borderline AFIs. More research needs to be done on the effect of acute hydration prior to fetal surveillance. It may be beneficial for providers to encourage adequate hydration to our patients prior to assessment of AFI to decrease potentially unnecessary interventions.
    References

    Ott WJ. Reevaluation of the relationship between amniotic fluid volume and perinatal outcome. Am J Obstet Gynecol 2004;192:1803-1809.

    American College of Obstetricians and Gynecologists. Antepartum fetal surveillance (Practice Bulletin No. 9.). Washington, DC: American College of Obstetricians and Gynecologists.

    Leeman L, Almond D. Isolated oligohydramnios at term: Is induction indicated?. J Fam Pract 2005;54:25-32.

    Alchalabi HA, Obeidat BR, Jallad MF, Khader YS. Induction of labor and perinatal outcome: The impact of amniotic fluid index. Eur J Obstet Gynecol Reprod Biol 2005;. [published online December 19, 2005]

    Hofmeyr GJ, Gulmezoglu AM. Maternal hydration for increasing amniotic fluid volume in oligohydramnios and normal amniotic fluid volume. Cochrane Database Syst Rev 2006;1:.

    Moses J, Doherty D, Magann E, Chauhan S, Morrison J. A randomized clinical trial of the intrapartum assessment of amniotic fluid index versus the single deepest pocket technique. Am J Obstet Gynecol 2004;190:1564-1570.

    Moore TR. Clinical assessment of amniotic fluid. Clin Obstet Gynecol 1997;40:303-313.

    Magann E, Perry K, Chauhan S, Anfanger P, Whitworth N, Morrison J. The accuracy of ultrasound evaluation of amniotic fluid in singleton pregnancies: The effect of operator experience and ultrasound interpretive techniques. J Clin Ultrasound 1997;25:249-253.

    Magann EF, Doherty DA, Chaucan SR, Busch FWJ, Mecacci F, Morrison JC. How well do the amniotic fluid index and single deepest pocket indices (below the 3rd and 5th and above the 95th and 97th percentiles) predict oligohydramnios and hydramnios?. Am J Obstet Gynecol 2004;190:164-169.

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    Reprint Address

    Maria L. Lanni, CNM, MS, 304 West 92nd Street, New York, NY 10025. Email address: mll2106@columbia.edu

    J Midwifery Womens Health. 2007;52(1):73-76. © 2007 Elsevier Science, Inc.

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