polyhydramnios and HB

[lilitchka]

Hi ladies again!

I would like to have your opinion on this.

so, I am close to 38 weeks. At my last MW visit, she had a clinical suspicion of polyhydramnios. Mainly by palpation (baby hard to find), and also because of a big jump in my fundal height. I was at 38cm at the 36 weeks visit. and this week (1 week later) I was at 45cm.

i also developed a lot of stretch marks during the last weeks, so I think my belly grew rapidly.

now, to develop polyhydramnios late in pregnancy, it is usually idiopatic (foetal malformations unlikely, since it only started now). I don't have diabetes.

she suggested an U/S. I accepted, but reluctantly (and told her about it).

first, U/S are not very accurate at evaluating amniotic fluid volume. they have poor predictive value. but it,s the only non invasive test available. It uses AFI. If  my AFI is less then 25, I guess we will go with home birth. if it is more, we have to see.

I think it's a little sad, since these values of AFI are poorly correlated with the real volume: So the decision of HB vs no HB will be arbitrary.

although there is increased risk of obstetrical complications at birth with polyhydramnios, they pretty rare with an idiopatic one.

of course, just thinking about these complications made me cry for 48hrs: cord prolapse, placenta abruptio and possible malformations that baby has.

after being stressed for 48hrs, I tried to relax and remain objective.

I realized that we are trying to diagnose a self-resolving problem that has no treatment.

what is the purpose of diagnosing something that has no treatment? and that will go away with birth? other then causing anxiety......

c-section/induction are not indicated for polyhydramnios. removing fluid at this stage of pregnancy is not indicated.

so I am wondering if I should do the U/S. It is scheduled for this Wednesday.

my other ''problem'' with U/S is the possibility to find other stuff that is really not there: like a too big baby (my first was close to 10 pounds, so this U/S could show an 11 pound baby, while really he is only 10), which will influence my midwifes decisions about transfer if slow labor progress (but we openly discussed this, and they said they will not look at the U/S weight....still, they will have difficulty ignoring it I think).

same with the BPP: if baby is sleeping,and doesn't move, and scores badly on it, I will have to have more tests/interventions for nothing.

This is not objective, but I feel my baby is completely fine, and birth will be fine too. I have no doubt about it. he is moving, well positioned , head already engaged in pelvis etc....

Oh, and with my first baby, my OBGYN also wanted to R/O polyhydramnios at 33 weeks, and I had U/S then, of course, everything was normal. But i wasn't stressed then like this time, because I was planning a hospital birth anyway.

also, for this pregnancy, I had the routine 20 week morphology U/S, and all was normal.

So, would you go to the Wednesday U/S?

[lilitchka]

any opinions? ideas?

thanks!

[McGucks]

Personally, yes.  I would have the ultrasound.  The information you will get will be yours to act upon or not, but if there is something you can do to improve the likelihood that you will have a healthy child, my opinion is that you have a responsibility to your child to get that information.

Additionally, if the U/S indicates all is well, the relief from worry will help both you and your child.  Being more stressed than you have to be is bad for you both, physically and psychologically.

Your MW is a medical professional.  If you trust her, follow her advice.

[lilitchka]

Originally Posted by caedenmomma 

Personally, yes.  I would have the ultrasound.  The information you will get will be yours to act upon or not, but if there is something you can do to improve the likelihood that you will have a healthy child, my opinion is that you have a responsibility to your child to get that information.

Additionally, if the U/S indicates all is well, the relief from worry will help both you and your child.  Being more stressed than you have to be is bad for you both, physically and psychologically.

Your MW is a medical professional.  If you trust her, follow her advice.

thank you for your post!

the problem is that U/S doesn't improve the likelihood that I will have a healthy child. If it did, I would do it asap! I wouldn't need to open this thread.

I agree, however, that if the result is normal, I will worry less, and just for that, it might worth it.....but i can also work on my worries in other ways.

late pregnancy U/S has significant risks: I am not talking about the sound waves emitted by the machine. I am talking about U/S showing stuff that is not really there. Like a too big baby ( that is really normal) or  too much fluid (when the volume is normal). this can lead to unnecessary interventions that is not good for my baby.

I agree that my MW is a medical professional. It doesn't mean that I should just follow her advice. If i had an OB that would advice me to have an episiotomy to prevent a tear, I am not sure that I should just follow his advice because he is a medical professional.

this doesn't mean that the advice my MW is giving me is wrong, or that I shouldn't trust her. it is up to me to make the final decision. I am the one who is pregnant and has to live with the consequences.

I am a health professional myself, and when I give suggestions/advice to my patients, I don't expect them to agree. I want them to understand all the risks/benefits, but then, ultimately, I think that they are way better then me to make the best decision for themselves (assuming they understand the consequences).

Exemple: when my MW was pregnant, her baby had IUGR. She, herself, would refuse/advice against delivering an IUGR baby at home. But for herself, she chose homebirth. So she understands me completely.

her job is to advice/offer suggestions that generally she would do in a similar case, my job is to decide if these suggestions apply to me.

obviously, all this thread and thinking is to make the best choice in order to have the healthiest baby possible.

If it was obvious to me what decision (U/S or not U/S) would lead to a healthy baby, I would have mad my choice by now.
 

[McGucks]

I started my post with the word "personally" for a reason.

It sounds like you have already made up your mind on the matter and were offended by my suggestion that you follow your midwife's advice, so I am not sure why you posted.

I wish you luck with your pregnancy.

[lilitchka]

thank you.

you are right, you did start the post with personally.

I assumed that you meant that the health of my baby is secondary to me.but I must have misunderstood (English being not my first language).

No, I haven't made my mind...I still don't know what to do.....

I guess I still have a couple of days until Wednesday to figure out.

My husband thinks that we could either do it or not. It doesn't matter to him, he is convinced that everything is well.

[McGucks]

One way to think about it is this:  what would be a reason not to do the U/S?  I understand that there might be reasons not to; I just honestly don't know what those reasons could be.

I absolutely did not mean to imply that you didn't take your baby's health into consideration.  I have no doubt that you did and that you do!  You wouldn't have posted otherwise.

I understand your point that the act of having an ultrasound will not, in and of itself, improve the likelihood of a healthy child.  My thought was that you might get information that you could use to keep your baby safer or healthier.

You must have some ambivalence regarding the U/S or you would not have posted about it.

When I was pregnant, I could barely decide between a small or a large glass of water...my head was so full of worry that I was not capable of rational thought sometimes.  You have a big decision to make and I am glad you have a supportive husband to make it with.

Again, good luck.  Perhaps someone with more experience with this kind of thing could pipe in.  I'm pretty unschooled in the UA/Homebirthing area, but I did write in since nobody else did and the OP was asking for opinions and WWYD.

[mirandamiranda]

Another way to think about it might be: what would you do differently if you do get a diagnosis of polyhydramnios? I appreciate this in itself is not an easy question! But this seems to be the central concern you have. If the tiny increased risks associated with this specific diagnosis will not, in the end, put you off homebirth, then there is there any point having any tests? This was roughly how I felt about prenatal screening.

Of course, I realise this may be exactly what you are asking. I'm not really acquainted enough with the risks involved to be sure what I'd do. Another issue would be how confident you feel resisting pressure to have interventions that might follow an ultrasound.

Good luck with your decision, I hope things turn out well for you...

[lilitchka]

this decision is stressing me more then I want to admit.

until yesterday night, I was thinking: '' lets just do the U/S, and there is chances that all will be normal, and we will continue with HB plan etc''

then, last night, we had a good discussion with DH, and he thinks like PP.

we reviewed the literature on U/S for diagnosing amniotic fluid volume, and it is a poor test for it. It misses a lot of true polyhydramnios, and also diagnoses a lot of false polyhydramnios.

So, if we do the U/S, we will be happy with a normal result (even though it could be  a false negative). So why do the test at this stage of pregnancy?

I guess the only issue is HB vs non HB.

DH feels that, if I am comfortable with it, and MW are also, we can just skip the U/S and give birth at home.

so, we decided to go to MW appt tomorrow 1 hour before the U/S, and ask MW what she thinks, see how she feels the baby is (easily palpable or not.....he seems normal to me, but I don't have her expertise), measure uterus again and see how she feels about U/S.

if she is OK with HB even if we refuse U/S, I think we will skip the test.

If she refuses or worries to much about HB without U/S, the  we will do it.

I guess, I prefer an U/S if it will avoid unnecessary hospital birth.

I just wish U/S only gave info on fluid, and then we decide if we want more....but they do BPP/weight assessment automatically......and it will lead to info we where not looking for.

[mirandamiranda]

Sounds like you've come up with a good plan - although it's a shame you can't refuse the unwanted testing. Presumably your midwife will support you if the hospital team are putting pressure on you for an unwanted induction for other reasons?

Good luck! I'd be interested to find out how you get on.

[lilitchka]

thank you!

I keep finding the same info form the medical litterature.

here is a quote from the clinical practice guidelines of the SOGC (society of Obstetriciens and Gynaecologysts of Canada):

''There is evidence from recent RCTs that use of AFI, rather
than pocket size, increases intervention frequency without
improving outcomes.86–89 This is despite a well-conducted
blinded prospective cohort90 that found AFI as a more
sensitive, but still poor, predictor of adverse pregnancy
outcome.''

So, hopefully MW wil realise that we are making informed decisions and that her role is just to make sure we understand all the consequences.....and then go with our decision.

I think she will be fine with it....but I don't want anybody nervous at my labor.

[lilitchka]

met with midwife today. It is the second midwife that takes care of us (we alternate between them at each visit, so this one is different from last week)

told her about the U/S and that we are not interested.

She understands us and respects the choice. she says that, legally, she has to suggest the U/S to R/O severe polyhydramnios then, if it is the case, advise against home birth.

we reviwed the risks/benefits. we decided that we don't want the U/S but will continue with the homebirth plan. She is OK with this.

When she palpated my abdomen, she didn't think I had polyhydramnios....just lots of fat under the skin

my fundal hight only increased 1 cm since last week.

baby's head is well engaged, and I don't feel that he moves like in a giant pool. he changes with anterior/posterior positions, but never breech or transverse.

babies heart was not far, was easy to hear. I didn't have a thrill from too much fluid.

DH asked lots of questions, and thinks like me.

so I am happy with our decision!

[mirandamiranda]

Good! I am glad you came to a decision that worked for you, and your midwife was supported. Best of luck with the birth!

[lilitchka]

thank you mirandamiranda!

I feel much better since we made that decision!

It is a good lesson for me.

I realize that I have hard time to go against what I perceive as authority (midwives in this setting), even when I think that my decision is better for me.

I am not sure if it is because I am an MD or because I want to be a ''good girl''

with our DS, 2 and half years ago, we left the NICU against medical advice. we should have done it earlier, because our stay there was completely unnecessary....but i had also hard time doing it, like refusing the U/S this time. It seems so easy for my DH!

[McGucks]

Just curious...why was your stay in the NICU completely unnecessary?

Also, may I ask what kind of MD you are?  Your comment towards another poster with an eating disorder did not seem like one that a physician would have even considered making.

[lilitchka]

Originally Posted by caedenmomma 

Just curious...why was your stay in the NICU completely unnecessary?

Also, may I ask what kind of MD you are?  Your comment towards another poster with an eating disorder did not seem like one that a physician would have even considered making.

Hmmm....doesn't sound like a nice post. from what I understand.

but that,s OK.

NICU: for idiopatic thrombocytopenia.

Kind of MD: ER.

comment toward another poster with an eating disorder not seem like one of  a Physician: I never posted to any thread other then the ones I started yet. can you put the link please?

or maybe it was in one of my threads?

what does it suppose to mean exactly? it doesn't sound very respectful!

I mention my job because it has a big influence on my perceptions of different tests and (unfortunately birth also). I post in this forum because that's the only one I know that talks about HB (I am sure there is more....I just don't know them). My friends/relatives did not consider HB, so I am pretty isolated.

You absolutely don't need to believe me or even read my posts/threads. But if you decide to participate, can you be respectful?

[McGucks]

Holy cow and big apologies.  I just checked the eating disorder thread I referenced, which I absolutely should have done prior to posting what I did.  Similar screen name to yours, but definitely not the same person.  On that note, I completely apologize.

Your being a doctor but being (seemingly, to my perception) dismissive of HCP advice seemed incongruous to me.

And, you are also right.  I was being disrespectful, and I apologize for that, as well.

[lilitchka]

Originally Posted by caedenmomma 

Your being a doctor but being (seemingly, to my perception) dismissive of HCP advice seemed incongruous to me.

that's what made my decision so difficult for me. For my DH, who is not a HCP, it was really easy to make the decision to avoid U/S.

being an MD, helps me to see the other side of the question.

I know that I often offer tests/investigations because I assume patients want them (even though it won't change the outcome for them), or because it is the ''protocol'', or, unfortunately, to avoid malpractice  law suites. So I know very well, that if a HCP offers a test, it doesn't mean I need it, or that it will contribute necessarily to a positive outcome.

I think that DS stay in the NICU influenced heavily our choice to have a HB and our commitment to make sure our babies don't experience unnecessary interventions. I think it's my responsibility as a parent to protect them.

[lilitchka]

Originally Posted by caedenmomma 

And, you are also right.  I was being disrespectful, and I apologize for that, as well.

[member234098]

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Edited by member234098 - 5/23/12 at 6:12pm