Your thoughts on oligohydramnios/possible slow growth?

[Birth Junky]

After receiving all of my prenatal care with a midwifery practice and planning a homebirth, I was referred for an ultrasound for questions about the baby's growth. Since then I have been on regular (first every two weeks, then weekly) monitoring, and there have been some concerns about low fluid and also about the baby's rate of growth.

My AFI three weeks ago was 8, then 7 the next week, then 8.5 last Monday, and 7 again last Friday. (I have been drinking lots of water--over a gallon a day--and last week started drinking electrolyte drinks as well.)

There is also some concern over the baby's small size, although we won't know more until the next ultrasound growth check on the 10th.

Baby has been very active throughout the pregnancy (she never takes more than 10 minutes to get to 10 movements during fetal kick counts; NSTs are always excellent; biophysical profiles, she scores 8 out of 8). At last palpation, the midwife estimated she was a little over 5 lbs--at 36weeks, 2days.

My question for all of you wise midwives: how concerned should I be? If her growth is slowing and fluid levels look low but she is still active and seeming healthy on NSTs and kick counts? I will be 37.5 weeks on the 10th, when they check her growth next . . . AND I consented to corticosteroid injections at 36weeks because they were so insistent that they might want to get her out early. Even if she is gaining slowly, as long as she IS gaining, my feeling is that we should let her stay put and put as much weight on as possible.

I also know that ultrasound weight estimates can be wayyy off, and have heard that fluid estimates can also be fairly inaccurate . . .

Thoughts, anyone? I have another NST with the midwives on Tuesday, and then the ultrasound on Friday. I am usually pretty good at standing up for myself, and am passionate about pregnancy and childbirth (it is all I have ever wanted to do with my life), but could use some more experienced advice. (I will also be discussing this further with my beloved midwives on Tuesday.)

Thanks in advance . . .

[mamaverdi]

Are her kidneys okay?

[Xiaguan]

Wow~ I am not a midwife but I have been somewhat in your shoes~ I leaked fluid with my last baby & she was induced at 35.4 weeks because of prolonged open membranes(13 weeks) & she come home with me less than 48 hours after birth~

I see this is your first baby~ You might just grow them small~ None of my 4 kids were larger than 7.14 at birth~ My littlest was 4.15~ Even though your fluid levels seem low they are at a decent level~ Once they go below 6 was the level they told me I had to go from home bedrest to hospital bedrest~ I know some women who have PROM who would love to have a level of 8:)

I will be thinking of you & sending you lots of good vibes~ If you are not comfortable with anything make them explain why they want you to do it~ Here is a good site to get some good info(it is a PROM site) but it might help you some: http://www.kanalen.org/prom/list/

Hope this helps some~

Warmly,
Melissa

[hookahgirl]

Im not a MW, but I went through the same thing. My scores were the same, they said the babe would be 5 lbs. Her BFP was fine, her kidneys were fine ect...
They stressed me out, and wanted to induce me.
4 weeks of NST and U/S twice a week were horrible and scarey.:irked:

At 38.5 weeks, i went into labor on my own and my DD was a whopping 7 lbs, not the less than or exactly 5 they predicted . DOnt forget U/S can be off by a few pounds, esp. the further along you are!

If everything looks fine besides the fluid, and your babe is ok, I think it will be fine! Just MO! Put your feet up, keep drinking water and relax a bit!
Keep doing kick counts at home, and keep a log. That way you can show anyone who asks!

I have also been reading about fluid naturally lowering when you are close to going into labor. Close meaning a few weeks or a month!

My DH and I were both around 5 pounds at birth and are still little people. I couldnt understand why they wanted me to grow such a large baby! Are you and your partner small? You could jsut end up with a small baby!

[Birth Junky]

Wow--wonderfully reassuring posts, mamas--thank you!

Mamaverdi: yes, her kidneys are fine. All internal organs look great, in fact--no blockages or defects, all four chambers of the heart healthy & pumping. Even the more discouraging doc told me that she looks good.

Xiaguan: Thanks for the link! I am also thinking that perhaps I am just made to grow smaller babies . . .

Hookahgirl: Nice to hear of yet another mom whose baby outweighed the ultrasound estimates; I have heard so many "they wanted to induce me because the baby was going to be over 9lbs and then I gave birth to a 7lber" stories that I knew there must also be some "they told me baby would be under 5 at birth and then I gave birth to a 7lber" stories as well! :lol

My partner and I are NOT small, actually--he is over 6ft, I am 5'8", and he we were both large at birth (he was 8.15 and I was 9.3), but there have been plenty of smaller babies born into my extended family. My grandmothers both had smaller babies (14 of them, between the two families!), and THOSE babies grew up to have babies of wildly different sizes . . . so not sure that I buy the whole "moms will have babies the same sizes that they were" thing.

The other main reason I want to leave her in (other than letting nature work on its own) is that, at last ultrasound (36.5weeks), she was breech . . . and I am doing everything in my power to get her to turn, but want to give her the TIME to get into position as well. If they start talking early delivery on Friday and she is still breech at that point, it will be a c-section . . . and I would hate to think that she would've turned head-down on her own (as well as gaining another pound or two) if we just left her alone in there. :)

I will be back with more updates as they become available . . . I am doing my best to rest (in between chiropractic appointments, NSTs, ultrasounds, etc.), drinking, eating lots of protein, and concentrating on growing this baby. My BELLY is definitely getting bigger, so I can't believe that she isn't growing along with me! :wink

Thanks again for the kind words, mamas--I will let you know how it goes.

[Charmie981]

I think that the AFI is the new reason to induce. Yes, low amniotic fluid and slow growth can be a sign of something wrong (I just had a client with these symtoms who had a two-vessel cord and an abnormal cord insertion) and so I think your midwife was right to refer you for a sonogram, but in the absence abnormalities and with an active baby, I wouldn't be concerned at all. Some babies are just SMALL and that's okay!

[JanetF]

You may find this helpful too.

Suspect Diagnoses Come with Biophysical Profiling
http://www.midwiferytoday.com/articles/biophysical.asp

[Birth Junky]

Thanks for the informative article link, JanetF . . . I am DEFINITELY going to have to talk to my midwife at tomorrow's NST about this whole "low fluid" thing; I am feeling more and more like it is an arbitrary designation (in my case), as baby is so obviously thriving (as evidenced by her almost constant movement and fantastic performance every time we monitor her heartrate).

If oligohydramnios is taken out of the equation, that leaves us only with a breech baby who may (or may not) be "small" . . . and will hopefully be turned by the end of the week. :thumb

[Paige, CPM]

Hi Birth Junky,

First I wanted to add in the usual disclaimer...it is really hard to comment on what is going on with someone if they are not under your care and you can not see thier chart. So, of course my comments may or may not apply to your situation.

Having said that if everthing checked out ok with regards to congenital issues and fetal health, that is an excellent sign!

I am just going to address different sections of your email in blue...

(This is vanity speaking...but I am so sorry about my horrible spelling, my brain talents lie elsewhere!)
_________

Your thoughts on oligohydramnios/possible slow growth?

--------------------------------------------------------------------------------

After receiving all of my prenatal care with a midwifery practice and planning a homebirth, I was referred for an ultrasound for questions about the baby's growth. Since then I have been on regular (first every two weeks, then weekly) monitoring, and there have been some concerns about low fluid and also about the baby's rate of growth.

My AFI three weeks ago was 8, then 7 the next week, then 8.5 last Monday, and 7 again last Friday. (I have been drinking lots of water--over a gallon a day--and last week started drinking electrolyte drinks as well.)

Amniotic fluid alone, unless significant deficiancy, is not a good enough reason to induce, from what I understand studies say. As your changing levels show, it can be replenished.

There is also some concern over the baby's small size, although we won't know more until the next ultrasound growth check on the 10th.

Baby has been very active throughout the pregnancy (she never takes more than 10 minutes to get to 10 movements during fetal kick counts; NSTs are always excellent; biophysical profiles, she scores 8 out of 8). At last palpation, the midwife estimated she was a little over 5 lbs--at 36weeks, 2days.

Normal Fetal weight at 36 weeks is around 5 1/2 pounds, give or take. For this date your baby sounds like a very normal size to me. My dear friend had a baby at 42weeks that was a little over 6 pounds and perfectly healthy, and I have seen this with many people. People are different, she happens to be on the smaller size (and so is her husband).

Palpitation is very subjective and inconclusive for size/weight. I guess, but it is only a guess, sometimes I am close and sometimes off, I make no promises. If I felt a baby was not appropriate size in consective appointments, alongside with funny measurements in consecutive appointments I would definatley consider consulting for an unltrasound, do fetal kick counts, fetal well being tests. However, 2nd and 3rd trimester ultrasounds for dates and weights are notoriously inaccurate. Though, some ultrasonographers are better than others. And what is really funny to me is that different people perform the different serial unltrasounds sometimes which makes it pretty inaccurate.

My question for all of you wise midwives: how concerned should I be? If her growth is slowing and fluid levels look low but she is still active and seeming healthy on NSTs and kick counts? I will be 37.5 weeks on the 10th, when they check her growth next . . . AND I consented to corticosteroid injections at 36weeks because they were so insistent that they might want to get her out early. Even if she is gaining slowly, as long as she IS gaining, my feeling is that we should let her stay put and put as much weight on as possible.

Again, maybe there is something I am not understanding or missing about your situation. So, I am not sure about the lung-developement injection at 36 weeks...why they would have given it at all. Maybe there is a reason besides just guessed size and gestational age. In my practice, I go by what medical studies say and would deliver a baby at 36 weeks at home because the lungs should have enought surfactant to work well. In many practices they might call anything before 37 weeks premature...but this is based on the fact that a given practice might have so many clients that they are overly cautious because they cant be sure everyone is sure of thier dates, and ultrasounds aren't perfect, and different practitioners are measuring fundal hights...do you know what I mean? Where I attended school in TX, the law also stated 36 weeks was fine to deliver out-of-hospital.

I also know that ultrasound weight estimates can be wayyy off, and have heard that fluid estimates can also be fairly inaccurate . . .

Thoughts, anyone? I have another NST with the midwives on Tuesday, and then the ultrasound on Friday. I am usually pretty good at standing up for myself, and am passionate about pregnancy and childbirth (it is all I have ever wanted to do with my life), but could use some more experienced advice. (I will also be discussing this further with my beloved midwives on Tuesday.)

So, I am not sure about your case, but, many times in a large practice, depending upon the practice, if someone thinks there is something unusual and your are assesed for this you can been seen as risky and continue being assesed as a risk when really everything has checked out fine.

You can discuss what it is they are worried about and looking for and tell them you think it is appropriate or that you don't feel it is appropriate and they may just be fine with that position.

It is funny, I have a labor-support client in a similar situation currently. They were worried about something, it checked out fine and yet they are continuing with what appears to be serial ultrasounds and frequent appointments. She is going to have a talk with them about going back to regular care, which is a very reasonable point. She said she was going to call the office to change her appointment to make sure she had her favorite midwife to talk about it with.

Good luck, keep us posted.

Thanks in advance . . .

[MAMom]

Wanted to pass along this link on AFI (http://www.transitionsdoula.com/downloads/afi.pdf) that I've found very useful.

[Birth Junky]

Today's NST was, although not ominous, certainly not up to the level of all of the OTHER NSTs I have had since starting the hyper-hydration and high-protein diet, lots of rest, etc. My fundal height hadn't gone up, again. And the MW felt that there was not a ton of fluid in there on palpation.

She faxed the NST results to the Maternal-Fetal Medicine unit and talked to the doc there, who agrees with her that perhaps it is time for this baby to come out. I am scheduled for another ultrasound/BPP tomorrow morning, and we will decide where to go from there.

Fetal movement continues to be good, but this issue with fluids is concerning to both of them because I have been drinking SO much water, and it does not seem to be making a difference.

I discussed the whole "plexiglass bathtub" scenario with the MW, and she told me that she feels very comfortable with the team at MFM that we have been working with . . . they have great skills, and are usually very accurate as far as fluid level estimates, as well as weight estimates on the very large or very small babies.

I am 37 weeks today, so technically "term" . . . and the steroid shots from last week (done in case one of the earlier NSTs had come up iffy and they decided to induce earlier) should give baby a little extra nudge towards lung maturity.

I am horribly depressed and feeling like a failure as an incubator, but also oddly relieved that all of the stress and monitoring may well be over soon. I have been very skeptical about the advice given me by the docs at MFM, but have absolute trust & confidence in my midwives . . . and they are really feeling concerned that something is not quite right with this pregnancy.

We'll see how tomorrow goes, but it sounds pretty certain that they will be scheduling a section after the BPP (baby is still breech).

(*sigh*)

[mamaverdi]

Why can't you have the baby breech vaginally?

IMO, you need to put your total faith in YOURSELF, not elsewhere. Do you feel something is wrong? Have you felt something is wrong?

My son had decreased fluid volume along with leaking, and I felt something was wrong. But no one would take me seriously because they couldn't find anything wrong. Turns out, he did have a minor obstruction in his urethra. It was not detectable via ultrasound.

I have had two friends now with girls with urinary anomalies that were UNDETECTED via prenatal ultrasound. In one case the little girl has a complete obstruction to her one kidney which wasn't found until she was 3. In the other, the 9 month old has moderately severe reflux that wasn't found until she was 9 months. Both had many many prenatal ultrasounds.

No matter what you decide, let it be your decision.

And even if she appears healthy via prenatal ultrasound, if your fluid level is very low, having a renal ultrasound for HER may be worth while once she is born.

Ultrasound is still very new technology. Comfortable or not with their MFM specialists, doctors get things wrong all the time.

[Birth Junky]

No docs around here will attend a vaginal breech delivery . . . there is one midwife who has experience with it, but ultimately MY midwives don't think that this is the right baby to attempt a breech homebirth with--too many things causing concern. My midwives are big proponents of vaginal breech deliveries, when the situation is ideal (one of them actually wrote papers on the subject), but everyone just "has a feeling" that this baby requires extra monitoring, special watching, etc.

I am starting to agree, after the NST today . . . all along I had been telling myself that as long as her kick counts were good and the NSTs favorable, then there was no reason to jump to a bad place over small size and possible low fluid. Then at today's NST she was less reactive than she has been up until now, AND there was one dip that could be considered a decel . . . brought my heart up into my throat.

We'll see how tomorrow goes, I guess . . .

[courtenay_e]

Hey, our thoughts are with you today, Birth Junky. Let us know the outcome.

[mwherbs]

vitamin E may help a bit but this is very late- what have you decided to do?

have they done any studies of the placenta- like uteroplacental bloodflow?

how is your bp and labs?

[Xiaguan]

Sending you good thoughts~

Warmly,
Melissa

[mamaverdi]

Thinking of you.....hoping everything works out for the best.

mv

[cathicog]

I think they are giving you too many ultrasounds. Sounds like you are doing fine, and most babies stay breech til 38 weeks or so. If the practice keeps getting antsy on you (they may be under pressure to transfer care to OBs so they(the OBs) can get more money- one practice in VA I know of was closed because the midwives weren't bringing in enough money for the docs satisfaction!) I would heist myself to the nearest CPM or other midwife, who is more holistically oriented...these midwives may be meddlers during the birth as well. I think you need to be left alone more to do what you seem to be doing quite well, and that is growing a healthy baby....

[cathicog]

Today's NST was, although not ominous, certainly not up to the level of all of the OTHER NSTs I have had since starting the hyper-hydration and high-protein diet, lots of rest, etc. My fundal height hadn't gone up, again. And the MW felt that there was not a ton of fluid in there on palpation.

She faxed the NST results to the Maternal-Fetal Medicine unit and talked to the doc there, who agrees with her that perhaps it is time for this baby to come out. I am scheduled for another ultrasound/BPP tomorrow morning, and we will decide where to go from there.

Fetal movement continues to be good, but this issue with fluids is concerning to both of them because I have been drinking SO much water, and it does not seem to be making a difference.

I discussed the whole "plexiglass bathtub" scenario with the MW, and she told me that she feels very comfortable with the team at MFM that we have been working with . . . they have great skills, and are usually very accurate as far as fluid level estimates, as well as weight estimates on the very large or very small babies.

I am 37 weeks today, so technically "term" . . . and the steroid shots from last week (done in case one of the earlier NSTs had come up iffy and they decided to induce earlier) should give baby a little extra nudge towards lung maturity.

I am horribly depressed and feeling like a failure as an incubator, but also oddly relieved that all of the stress and monitoring may well be over soon. I have been very skeptical about the advice given me by the docs at MFM, but have absolute trust & confidence in my midwives . . . and they are really feeling concerned that something is not quite right with this pregnancy.

We'll see how tomorrow goes, but it sounds pretty certain that they will be scheduling a section after the BPP (baby is still breech).

(*sigh*) They may be setting you up for an unnecessary section...:(
I don't have your records in front of me, but I still feel like they are making a mountain out of a molehill.... but it is your birth....you aren't a failure, at all, and don't beat yourself over the head for it...life isnt' perfect. (I still think you have a fairly normal baby in there and they are rushing things. Have you done any research on low amniotic fluid levels? Maybe it is a smaller placenta, since that is what produces the af to begin with... hope that helps.

[cathicog]

I found this on the March of Dimes website

Amniotic Fluid Abnormalities

The amniotic fluid that surrounds a developing baby plays a crucial role in normal development. This clear-colored liquid cushions and protects the baby and provides it with fluids. By the second trimester, the baby is able to breathe the fluid into his lungs and to swallow it, promoting normal growth and development of the lungs and gastrointestinal system. Amniotic fluid also allows the baby to move around, which aids in normal development of muscle and bone.

The amniotic sac that contains the embryo forms about 12 days after conception. Amniotic fluid immediately begins to fill the sac. In the early weeks of pregnancy, amniotic fluid consists mainly of water supplied by the mother. After about 12 weeks, fetal urine makes up most of the fluid.

The amount of amniotic fluid increases until about 28 to 32 weeks of pregnancy, when it measures a little less than 1 quart. After that time, the level of fluid generally stays about the same until the baby is full term (about 37 to 40 weeks), when the level begins to decline.

How are oligohydramnios and polyhydramnios diagnosed?
An ultrasound examination can diagnose either too little or too much amniotic fluid. Doctors commonly measure the depth of the fluid in four quadrants in the uterus and add them up. This method of measuring amniotic fluid is referred to as the amniotic fluid index (AFI). If the amniotic fluid depth measures less than 5 centimeters, the pregnant woman has oligohydramnios. If fluid levels add up to more than 25 centimeters, she has polyhydramnios.


If you read the article further, it goes on to tell about some of the possible consequenses of oligo...but, who decided it was a problem if all your current levels are normal?? More babies are damaged by the pitocin and epidurals in hospital than are damaged by normal (upright,walking around,eating and drinking freely) labor that you might have in a birth center or home...I hope they aren't selling you a bill of goods. it is normal for the fluid levels to either level off or go down slightly toward the end of pg....Please be careful....keep us posted, Cathi