42-Week Ultrasound

[OurLittleNest]

I will reach the 42-week mark on Tuesday. My midwife said we can talk about what to do at my Tuesday appointment, including if I want to schedule an ultrasound. It's up to me. She's not pushy about things like this. But if I make it to the Tuesday appointment, I would like to have done some thinking and research first.

First of all, I totally believe that a baby will come when a baby is ready. An unnecessary induction with my first is what lead me to a home birth this time around and one of my requirements of a health care provider was that I would not be forced to induce and would not be put on a deadline to give birth. Fortunately, I found one.

So having an ultrasound seems to contradict this belief. If I truly believe that a baby is born when he or she is ready to be born, then why am I checking to make sure everything is okay?

If the answer to that question is: "What's the harm? Just go ahead and make sure the baby is okay. If nothing else, it will be reassuring." then my second question is: What is the likelihood of a false test result? What are they testing anyway? Who is interpreting these test results? I don't want a "fluid looks low. You should have this baby today" response from a doctor when the doctor's definition of low fluid is different than someone more naturally minded.

What are my options if the test indicates that things are not looking well? Hospital induction? Because I have a serious issue with consenting to a hospital induction unless I was completely and 100 percent convinced that it was totally and absolutely necessary. I don't even feel comfortable doing natural induction methods because I just believe that a baby will come when a baby is ready.

Anyone who can offer some advice, personal experience or point me in the right direction -- I would appreciate it! I don't want to find myself at this Tuesday appointment and making a decision without thoroughly thinking it through.

(P.S. I'm in Ohio by the way, if that makes any difference. I've read that some states won't let midwives deliver you after 42 weeks, but I haven't found anything that says Ohio is one of those states.)

[lillymonster]

I am almost 40 years old and a vbac. I am getting a u/s this week at 39 weeks, because they told me they won't do any more, but since I am a vbac and 40, I will need to discuss induction or c-section at 42 weeks. Price I have to pay using a hospital, but I am fine with it because my last midwife practice wanted u/s every 2 weeks after 36 weeks and I also had one at 32 weeks - all to check for "low fluid" and would schedule a c-section at 40 weeks.

There is a small increase in stillborn after 39 weeks due to AMA, but from what I have read, they are not sure what the cause it. I don't believe it was the 5% my old midwife was quoting me to get me to consent to all the u/s. 

The first thing I did do was ask what the protocol was for low fluid and my old midwife practice (er medwife) said they would induce if my cervix was favorable or they would schedule a c-section - no other measures such as i.v. fluids or drinking more water. My new practice said they would do iv or tell me to drink water if it wasn't too low. They did also say low fluid can cause issues such as cord prolapse and so that is why they look for it. She seemed more logical and not using scare tactics like my old office. Before you do the sonogram, ask what your midwife would do if you do have low fluid and how low it has to be. Ask her who makes the final decision if it is low - the OB (does an OB oversee her practice or can she help you with making the decision?) What are the problems with low fliud (are they trying to scare you or presenting facts?)

In the end I am doing it because I know either way I am can't go past 42 weeks unless I do a homebirth, but if I was younger and not a vbac, I might not consider it.

I also don't believe in induction (not as a vbac anyway) and I don't want to do anything else to push it along, but I may have to resort to natural methods because I am on a 42 week deadline.

Edited by lillymonster - 1/1/11 at 9:50am

[msmiranda]

My understanding of the 42-week thing is that in addition to low fluid, they will be checking the condition of the placenta.  After a certain point for some women the placenta starts to calcify and not function as well.  In general the risk for stillbirth is higher after 42 weeks, which is why they want women to give birth by that point.  As a general rule I agree that babies come when they are ready, but I also think there are circumstances in which a postdates baby is not doing well and would benefit from being born.  If it were me, I would want the reassurance that the baby was doing well to reinforce my decision not to accept an induction.  I definitely understand your concern about being pressured -- maybe it would make you feel better to know some specifics about placenta issues and fluid levels (e.g. what a calcified placenta looks like on u/s and exactly what level of fluid is considered normal vs. concerning).  That way you could go in armed with enough knowledge to be able to detect BS if that is what you get.  

I would also suggest talking the specifics over with your midwife if you can.  She would probably be able to give you more detailed information about what types of things would indicate a true medical need to induce, from the perspective of a naturally-minded practitioner.  And then if something on the u/s was concerning, you would probably have enough time to discuss the results with her before deciding on a course of action.

[noahs.mom06]

Originally Posted by msmiranda 

My understanding of the 42-week thing is that in addition to low fluid, they will be checking the condition of the placenta.  After a certain point for some women the placenta starts to calcify and not function as well.  In general the risk for stillbirth is higher after 42 weeks, which is why they want women to give birth by that point.  As a general rule I agree that babies come when they are ready, but I also think there are circumstances in which a postdates baby is not doing well and would benefit from being born.  If it were me, I would want the reassurance that the baby was doing well to reinforce my decision not to accept an induction.  I definitely understand your concern about being pressured -- maybe it would make you feel better to know some specifics about placenta issues and fluid levels (e.g. what a calcified placenta looks like on u/s and exactly what level of fluid is considered normal vs. concerning).  That way you could go in armed with enough knowledge to be able to detect BS if that is what you get.  

I would also suggest talking the specifics over with your midwife if you can.  She would probably be able to give you more detailed information about what types of things would indicate a true medical need to induce, from the perspective of a naturally-minded practitioner.  And then if something on the u/s was concerning, you would probably have enough time to discuss the results with her before deciding on a course of action.

I totally agree. Also, besides low fluid and placenta calcification, a lot of times at a late ultrasound is when they'll spring the "your baby's too big" news on you, so be prepared for that if it comes up. The only other suggestion I would have is to see if your midwife might actually go to the ultrasound with you, if you decide to do one, so that she can hear firsthand if they say anything that would indicate the baby should be born, rather than continuing to wait.

I'm hoping for you that baby comes before Tuesday, so you don't have to worry about it!

[mclisa]

Ask your midwife exactly what she is looking for.

[MamaChef]

My first DD was born at 42w3d because of the results of an ultrasound.  I have no doubt now that it was the best choice.  I was absolutely sure of my dates.

We went in on a Friday for a BPP and she had low normal fluid.  By Monday the largest pocket of fluid we could find in a 30+ minute U/S was .9 cm and the rest were scarce.  Her heart beat was flat and non reactive.  She was basically just hanging out in there.  My placenta was definitely aged.  I had been dedicated to hydrating.  We had tried a natural castor oil induction on friday after the US showing everything was okay.  My cervix was not favorable to induction.  My bishops score sucked.  I had 3 membrane sweeps by then with nada result.  The midwife could barely get a finger in to do the sweep.  We chose to proceed to section directly because induction likely would have resulted in a crash section.  At the time I was a second year midwifery student and had attended over 100 births at home.  It was an incredibly hard decision to make and not one that I had ever thought would be mine.

On birth she was covered in mec (totally normal with a baby 40+ weeks) but paired with no fluid, thick mec is a danger for aspiration syndrome.  She had a tight cord wrapped around her body and was posterior.  Because of her advanced fetal age the bones of her skull were quite ossified and it would have been pretty darn hard to get her out at that point.  We had no fluid to move her around in, her head was super wedged and asynclitic and my placenta was definitely not up to a really long labor and the forces my uterus would have needed to exert to man handle her into a better position, especially with that tight cord.

The technical numbers for oligohydramous  are less then 5cm of fluid.. and being able to find atleast one pocket of 2-3cm.  You have to decide where your comfort level lies.

Tips:

Flood yourself with water.

Take an hour long bath every day

If you still find yourself with a low afi and know that you have done everything you could to keep it stable, it can help you make a better decision about the reality of the state of your placenta vs what a US tech/docs say.

Good luck.

[SeattleRain]

MamaChef, my own birth was similar. I had gestational diabetes so it was a miracle that my OBGYN even let me go to 42 weeks, but she was totally fine... as long as I went and had an ultrasound to check on the baby. My fluid was fine, the heartbeat was fine, everything was fine, even the baby's weight wasn't even a problem (he was estimated at 8.5-9.5 and he was born at 8lbs9oz so they were pretty right on), so we kept going until 42 weeks. At that point I had gotten membrane sweeps, was walking my fat tush all over town and had even tried sex. My doctor told me not to try the castor oil because she basically said I'd just get the poops so I didn't do it. At 42w1d I was scheduled for induction with Cytotec because I was only .5cm and they let me do that for a day and a night. No progress. My bishops score sucked like MamaChef, so we went ahead with the section because we really had no other option. When they went in, they found him wedged at the top of my uterus with lot of mec and a really horrible looking placenta.

Basically what I'm saying is that not every baby comes on their own. After 42 weeks your risk of stillbirth goes up and you have to weigh how much risk you're willing to take. Some babies are just stubborn like that.

[lillymonster]

Originally Posted by noahs.mom06 

I totally agree. Also, besides low fluid and placenta calcification, a lot of times at a late ultrasound is when they'll spring the "your baby's too big" news on you, so be prepared for that if it comes up.

Very interesting conversation today with sono tech. She did my NST and biophysical profile and said that they would no way tell me my baby's size. They are not trained to do it and can't do it, so I think it was like a preface of "don't ask me your baby's size" Maybe a lot of people ask, I don't know - but you might want to ask the sono tech first if they can provide that information. I was very happy to hear that myself.

[starrlamia]

Placenta calcifcation generally happens pre-term not post term (from the few studies I have read), there have been quite a few studies showing no correlation between calcification and stillbirth.

http://books.google.ca/books?id=x8yz4I-vI04C&pg=PA133&lpg=PA133&dq=Tindall+and+Scott+placenta&source=bl&ots=FU3Ku2cDwS&sig=wivXNKPKjaIkn8opf2je2-nQcQE&hl=en&ei=IWciTbH6HN_hnQf0hYSLDg&sa=X&oi=book_result&ct=result&resnum=1&ved=0CBUQ6AEwAA#v=onepage&q=Tindall%20and%20Scott%20placenta&f=false

[MamaChef]

Well, I know in my personal case after having twice weekly U/Ss starting at 40w 3 days because my midwife was super conservative we noted a marked increase in the degradation of the placenta starting at 41 weeks.  The difference in what the placenta looked like at 41w5d to 42w 3d was indisputable even to my layman's eyes.  Same machine, same tech.  Obviously everyone's milage may vary.

Calcification is often a term that is thrown about because it's easy to describe.  What the big risk is that an aging placenta is more prone to Physiological placental failure or Placental insufficiency.  Infarcts are more concerning then calcifications..  10-20% of babies born post term have post maturity syndrome.

[MarineWife]

Originally Posted by lillymonster 

Very interesting conversation today with sono tech. She did my NST and biophysical profile and said that they would no way tell me my baby's size. They are not trained to do it and can't do it, so I think it was like a preface of "don't ask me your baby's size" Maybe a lot of people ask, I don't know - but you might want to ask the sono tech first if they can provide that information. I was very happy to hear that myself.

This is a good point. I have never had a tech who was allowed to give his/her interpretation. My understanding is that techs and even nurses aren't supposed to do that. Even if they are very experienced, they don't have the education or training for interpreting results. That is supposed to be left to a doctor.

[mckittre]

If I were you, I would get the ultrasound.  Nothing prevents you from refusing treatment, and it's good to know what you're dealing with.  It might just tell you things are great, and you can be reassured.

I had a biophysical profile ultrasound at 42 weeks, just last week.  They told me the placenta looked great, the fluid levels were great, the baby was happy and reactive, etc...  I left there confident I could wait for baby to show up.  And she showed up the next day at 42+1, with no meconium, still had vernix, no peeling skin, no ossification, and a perfect placenta.  Despite the fact that my dates came from a 1st trimester ultrasound, the midwife said she looked just like a 40 weeker (she was nearly 10lb, though!). 

But if it were me, I'd want to know if I had a long-cooking or inaccurately dated baby vs one who's having trouble in there.

[MarineWife]

Originally Posted by mckittre 

If I were you, I would get the ultrasound.  Nothing prevents you from refusing treatment, and it's good to know what you're dealing with.  It might just tell you things are great, and you can be reassured.

I had a biophysical profile ultrasound at 42 weeks, just last week.  They told me the placenta looked great, the fluid levels were great, the baby was happy and reactive, etc...  I left there confident I could wait for baby to show up.  And she showed up the next day at 42+1, with no meconium, still had vernix, no peeling skin, no ossification, and a perfect placenta.  Despite the fact that my dates came from a 1st trimester ultrasound, the midwife said she looked just like a 40 weeker (she was nearly 10lb, though!). 

But if it were me, I'd want to know if I had a long-cooking or inaccurately dated baby vs one who's having trouble in there.

Ultrasound dating, even early, can be off by a week or more. The measurements they use for dating are based on averages and, as we all know, different babies develop differently. I know my dates exactly but the measurements from every scan I've had so far (weekly from 5w to 9w) have put me 4-7 days ahead.

[starrlamia]

Originally Posted by MamaChef 

Well, I know in my personal case after having twice weekly U/Ss starting at 40w 3 days because my midwife was super conservative we noted a marked increase in the degradation of the placenta starting at 41 weeks.  The difference in what the placenta looked like at 41w5d to 42w 3d was indisputable even to my layman's eyes.  Same machine, same tech.  Obviously everyone's milage may vary.

Calcification is often a term that is thrown about because it's easy to describe.  What the big risk is that an aging placenta is more prone to Physiological placental failure or Placental insufficiency.  Infarcts are more concerning then calcifications..  10-20% of babies born post term have post maturity syndrome.

calcification is an overused term definately. IMO the only way I would go for post term U/S is if I knew for certain that my dates were right, it is way too easy to be off on EDDs, IMO I wouldnt start to worry about possible post maturiry syndrome or complications until after 43 weeks as indicated by most studies.

From Midwifery Today Sept 2010

 There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no signs).

 http://www.midwiferytoday.com/enews/enews1220.asp