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A recent discussion with a family member has led me to look into more research concerning the use of the AFI(Amniotic Fluid Index). The AFI is used to determine whether an overdue mother should be induced. Coincidentally, the bloggers at www.scienceandsensibility.org (now defunct) came out with a blog post on the same topic. Thus, I thought it would be timely to discuss the doula’s role when a medical provider decides that an induction is needed due to low amniotic fluids when pregnancy is at term (39+ weeks).

First off, a few points from the research discussed at scienceandsensibility.org.

  • The Ultrasound measurement is a poor predictor of actual amniotic fluid volume.
  • Another method, called the single deepest pocket method of measurement, actually has fewer risks and is a better predictor of amniotic fluid volume.
  • Poor outcomes seen with low amniotic fluid are usually due to underlying complications such as pre-eclampsia, birth defects, or fetal growth restriction.
  • The main risk of low amniotic fluid at term in a healthy pregnancy is induction (and Cesarean delivery as a result of the induction) and potentially the risk of lower birth weight.
  • Current evidence does not support induction for isolated oligohydramnios at term.

With the science on the table, many doctors still will determine that a women needs to be induced if her AFI comes back low, particularly if she is overdue. As a doula, it is not your job to be the decision maker in this type of scenario. Rather, you need to attend to the woman’s needs at the time the decision is being made between her and her caregiver.

Here is what I would write as a birth plan. (For those who are taking my course, you’ll recognize the format. For those who haven’t, I teach a specific format based off of theories in nursing and psychology to help organize the plan).

Birth Plan for Oligiohydraminos (Low Amniotic Fluid)

From previous interviews and discussions, you know that your client wants a natural birth and does not want to be induced. She wants to be able to move around, eat and drink, and use the birthing ball. This is her first pregnancy and is not quite sure how she will react or what to expect, but she is very worried about being pressured into an induction or c-section. She is going to a midwife, but she is residing in an area that has a high induction and epidural rate. She is currently 40 weeks and 4 days. She just had her amniotic fluids levels checked to make sure that her baby is still doing okay. Her fluids are low, and she was told that if she was not induced at this point, her baby may have serious complications. After her appointment, you sit down with her to discuss her new plan and figure out how she wants to deal with the information given her.

Client’s three main goals:

  1. I want to make sure both me and my baby have minimal medical complications.
  2. I want to avoid induction.
  3. I want to have a natural birth.

Problem identification:

Physiological Needs

Mom is healthy overall, but needs more sleep. Her anxiety related to this event has interfered with her ability to sleep well at night. She is eating well and gaining appropriate weight.

Safety Needs

Fear and anxiety is the major concern at this point. She is worried about her baby’s health, but she also feels like the midwife is not listening to her concerns. She is worried that she may need an induction and what the consequences of that may be. She feels pressured to just go along, but is not sure that it is the safest choice. She is unsure that she has the ability to make the right choice and that she may jeopardize the health of her baby.

Social Needs

She feels like she would like to discuss her options with her friends and family. Other than that, her social needs are the same.

Esteem Needs

She does not feel capable of making these decisions.

The very first thing I would do  is see if she would like to take a little time to sleep. When she feels more rested, she will be able to think more clearly.

One of her biggest problems was her disbelief in her ability to make decisions, so giving her information will be a top priority. (Remember the scienceandsensibility.org blog post  has a lot of good information that you can share with clients that are in the same situation.) She may also need to discuss and confer with family or friends that she feels will help her. As the doula, you can help facilitate this by helping her find a time where people can meet.

Fear and anxiety will also be high on the list of concerns. Giving her information will help her with this, but she may also need some physical exercises to help her calm down. There are numerous ways to do this. I just list a few here: music, massage, reflexology, positive affirmations, hot water, aromatherapy and deep breathing.

A doula can help her to relax and come to a place where she feels she is able to make decision that she feels comfortable with. If a woman is not wanting to make decisions, or feels she is unable to, the comfort measures for fear and anxiety will at least help her to feel she is safe and supported.

The birth plan could then go on to mention some of the most important things you have talked about surrounding her other goals.

(Pam England, a midwife and birth advocate, also has discussed the need to face our fears. I am including one of her handouts that she uses to help work through some of the fears your client may have.)

Discussion with Care Provider

Ideally, the care provider is included in this discussion. Yet often, they are not and it is never addressed until the moment of decision is at hand. When a decision needs to be made, the care provider may not be there and wait for the woman to make a decision on her own.  Some may even put pressure on the woman to make the decision right then. In either case, a brief example follows of what the woman needs to discuss with her care provider.

I feel safer waiting to be induced for these reasons, even with low amniotic fluids because (the woman should explain her reasons for wanting to wait which will be unique to every woman).

Other questions that may be asked:

  • What are the risks associated with induction?
  • What are my risks associated with waiting?

Here is one example of what the woman might discuss with her care provider (ideally, before the moment of decision is at hand):

I understand that my fluids may be low and would like to get my fluids rechecked after I have had more to drink. I would also like to request that the single deepest pocket method is used. I would like my baby to continue to be monitored for any other signs of problems. If it is determined that I do need to be induced, I would like to try natural methods first. If that is not working, I would like to not use cytotc, and I would like my pitocin to be at the lowest level needed.

My hope would be that this discussion will help illustrate how a doula may help in this situation, as well as promote communication between all parties involved.


Research on amniotic fluid index

Facing your fears

Follow Rachel Leavitt:

Rachel has worked as a register nurse (BSN from University of Utah) since 2004 with a work history in Labor and Delivery, NICU and Postpartum Care. She is also the founder of New Beginnings Doula Training which she organized in 2011. When she's not busy being a mother and grandmother, she can be found reading research papers related to some aspect of childbirth.

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