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Saturday
Jul012006

Low AFI (NST/BPP)

I wrote this story/article as part of a book I would eventually like published. Its story is fiction; the truth is not.
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Non-Stress Testing, Amniotic Fluid Index & Biophysical Profile:
making sure you and your body are ready

Tori calls to tell me that her back-up doc wants to do an ultrasound “just to make sure everything is okay.” She’s 40 weeks and 3 days. As a midwifery client, Tori’s fairly aware of her options and doesn’t bat an eye at the doctor’s request. Her doctor called it a “Non-Stress Test (NST).”

I, on the other hand, feel my hackles rise, knowing that more and more, this seemingly benign procedure can be the springboard for a plethora of worries, tests, and the possibility of an induction or even a cesarean section. If any questions arise during the NST, a more in-depth test that includes an ultrasound, the BioPhysical Profile (BPP).

Many midwives have devised various ideas to help women have a “successful” post-dates ultrasound (and “post-dates” being somewhat subjective considering women gestate for differing lengths of time).

I spend a few minutes talking with my client offering some of these ideas.

The first is to let her know that even though the doctor made the procedure sound easy-going and not complicated, with certain findings, more and more screenings and testings are quite possible. When women understand the possibilities, they tend to be more understanding of the regimen I propose.

Mom can do a few preparatory exercises before heading in for the ultrasound. Tori listens intently and then heads home as she gets ready for her testing later that afternoon. (If the ultrasound isn’t an absolute emergency, asking for a few hours or even a day can be a good idea.)

Tori begins by going to the store for a bottle of orange juice. She’s spent much of the pregnancy not drinking juices, but eating the fruit instead since the fruit includes fiber, whereas juices do not. However, when preparing for this type of ultrasound, getting in a supply of sugar and/or caffeine is a good thing. For some women, the forbidden drink is a chai latte, others a full-sugar soda. Some, like Tori, find the taste of juice much more appealing.

Going through the store, Tori also picks up some electrolyte water. Smart Water and Recharge are two popular brands of this type of water. While water itself is good, when loading up on fluids, making sure the body has a balance of electrolyte solutions can be crucial. We have seen, albeit rarely, women over-hydrate with standard waters and they and their babies have had low sodium and low calcium issues in the immediate postpartum period. After seeing this, many of us really encourage these electrolyte solutions instead of plain water.

Heading down the pasta aisle, Tori picks up a package of already made cheese tortellini and some alfredo sauce. In the bread aisle, she grabs up an already-buttered loaf of garlic toast. She hasn't decided about turkey or beef meatballs, but will add one or the other, too. Her mouth watering, she heads to the check-out line.

While most pregnant women shouldn’t carb load quite like this, in anticipation of an NST, giving the baby some fuel can help a lot. Tori should eat her yummy meal about 1-2 hours or so before the NST. If the test is first thing in the morning, eating a breakfast of waffles, eggs, and juice can be helpful. (Just not if you are having your blood tested for glucose at the same time!)

Eating and drinking sugar or caffeine before an NST allows the baby some glucose to work off through movement. The doctor or nurse is looking for heart rate accelerations as the baby jumps around, so giving them something to see helps make the NST “reactive” – the term you are looking for. A non-reactive NST sends up red flags that lead to follow-up tests.

What exactly does the non-stress test show?

NSTs check the baby’s heart rate as he moves around inside mom. Monitor straps are placed around the mom’s belly, one to listen to the baby’s heart rate and another that measures contractions if any are happening. These are the same types of straps placed for the duration of labor when women choose to birth in the hospital.

Depending on who is asked, the answer to “What does an NST show?” will be different. The medical model believes that a non-reactive NST is cause for concern that the baby might not be tolerating pregnancy very well or that the placenta is deteriorating, not offering the baby as much nutrition and/or oxygen as earlier in the pregnancy. Sleep cycles can mimic a non-reactive NST, which is a great reason for the meal and soda boost pre-testing.

What if I “fail” the NST?

Another part of the pre-NST preparation is in anticipation of a failed NST and the subsequent Amniotic Fluid Index (AFI) and Biophysical Profile (BPP) that will be recommended.

Those bottles of electrolyte water Tori bought at the store will be taken directly to the bathroom so she remembers to drink them after her luscious pasta meal (or her yummy pancake breakfast).

Drawing a deep, warm bath, Tori prepares to settle into the tub for at least one hour, longer if she can stand it. Those bottles of water nearby, a favorite aunt tending to the other kids, a snack plate of cheese and crackers, and that stack of Mothering magazines she hasn’t had time to read all provide entertainment – and supplements – to her preparation. The water, while providing a soothing, relaxing environment for mom to spend time talking with the baby, also allows the body to absorb water where it needs to, hydrating her cells as she drinks to hydrate those same cells from the inside out. Our pregnant uteri carry a couple of pounds of amniotic fluid that completely changes out every 4-6 hours throughout the day and night – drinking water, and soaking in water, help stabilize the proper amount of amniotic fluid for each body and baby.

Before going to her NST, Tori understands the possibility of having a BPP and wants to make sure all is in her favor for a normal result. What is good about the entire regimen is that if something is amiss with the placenta, the baby, or mom, it is more clear because the mother has done her part to be ready, eliminating the variables not often taken into account by those in the medical model. In other words, if the NST is non-reactive, even after the meal, after water loading, after a long soak, after talking to the baby, after relaxing… if the NST is still non-reactive, then perhaps further testing is indicated.

A Biophysical Profile, the next step after an NST, includes an ultrasound to determine and measure several things.

Body Movement

Body Tone

Breathing Movements

Amniotic Fluid Volume

Heart Rate

Each of these is measured and graded with a possible high score of two individually; ten combined. Some areas hold more weight than others, namely the AFV. If a question of the amount of fluid comes up, an Amniotic Fluid Index will be done. The AFI measures four different pockets of fluid inside the uterus and a score of 8-18 (depending on which study or physician is asked). Even comprehensive studies speak of the variability of measuring the AFV because of the fluctuations in amniotic fluid day by day, and even hour by hour at times. If asked, most docs would deny water loading and soaking in a tub makes any difference at all. Most would also not allow that checking AFV in a day or so would make a difference. Those of us who do birth know differently. Over and over, midwives have seen AFI's done one day and then the next and the levels increase dramatically by soaking and hydrating.

How many women we have seen/worked with/heard about that were told they needed to have their babies now because the AFV was nearly gone, that their AFI was dangerously low, that if they waited even another day, there might be major cord compression or worse. Personally, I have had several women who were told they had dangerously low AFV and yet, as they labored and birthed, splashed amniotic fluid all over the place, often soaking me and those that worked beside me. What was the truth?

Most of Tori’s preparation is in anticipation of a BPP. When we first spoke and I described the series of things I wanted her to do before heading in for the NST, she laughed and thought I was over-reacting. She was soon to learn I was not.

After eating, soaking, and drinking, Tori glugged her bottle of orange juice before walking into the hospital. Some women choose that beloved Starbuck’s or a can of full-sugar soda as they step into the hospital environment. Sugar or caffeine loading is not necessary. Merely drinking one soda, coffee, or juice is plenty. You don’t want the baby dancing for hours after the testing!

Some women are required to register at Admissions before heading into their NST. Other docs or hospitals don’t do this. If the woman is having her testing at the doctor’s office, doing the standard pre-visit ritual is usually all that happens.

After being asked to pee in a cup, Tori is put into one of several smaller rooms that are separated by curtains and she hops up onto the bed. Some women are asked to remove their clothes and given a gown to put on, but she is not. Her blood pressure is taken, questions asked, including “When did she last eat?” “Is the baby moving?” and then the monitor straps will be pulled around her wonderful belly.

The nurse hands her a small devise and asks Tori to press the button on top whenever the baby moves.

“Even if the baby moves a lot?”

“Ayup.”

The nurse leaves and Tori finds herself alone in the room, listening to her baby clomp clomp clomping under the monitor’s microphone. Maybe she should have brought someone to keep her company. Instead, she focuses on the baby and the button she is to press during the 20 minute strip.

After a few minutes, the nurse comes back in and readjusts the monitor belts, mumbling something about the baby moving and it being hard to find the baby’s heart tones. Tori feels slightly embarrassed that she might be the reason for the activity, but remembers that it is much better to have the baby moving around than not, and relaxes. It really is okay for the nurse to come in and readjust the monitors as often as they need to, but the one drawback is that they tend to want a continuous 20 minute strip and when the straps have to be readjusted, the 20 minutes begin again and again.

35 minutes pass and Tori has to go to the bathroom again. Once the nurse reappears, she jumps off the table and goes to pee. When she returns, the nurse is studying the strip and has a look on her face that isn’t reassuring.

“I want to let the doctor see this before we let you go.”

Tori sits in the chair at the foot of the bed she’d just gotten out of, waiting and wondering what the nurse had that face on for. She didn’t have to wonder long.

One of the doctors in the practice that she hadn’t met yet breezes into the room, his white coat floating behind him as the door closes, leaving him alone with Tori.

“I think we need to do further testing. I don’t like what I see here.”

Describing fetal heart tone patterns that mean nothing to her, Tori feels her concern rise as the doctor spills words regarding her care. Words including “cord compression,” “induction,” “pitocin,” “decelerations,” and others she doesn’t hear because she is so taken aback that there might be anything wrong at all. As the doctor speaks about the Biophysical Profile, she recognizes those words and asks to come back with her husband tomorrow morning. The doctor says he doesn’t want to wait that long, so she asks for an appointment later in the day. He agrees.

On her way home, she calls me and we go over the preparations once again… eating, drinking, soaking… that she will do before she heads back in. I let her know what the possibilities are with this doctor.

1. Everything will be great and he will want to see her in 2-3 days to re-do it all again (and continue every 2-3 days until something changes or birth)
2. He will suggest an induction either immediately or the next morning
3. He will suggest a cesarean immediately

Tori, crying on the phone, can’t believe she is having to do this after such a wonderful pregnancy. Gently, I let her know that she still has choices. She doesn’t have to do any of the things the doctor is asking of her… the NSTs, the BPPs, the induction, the cesarean… she has choices still. And if it were critical, she would know; he would never have let her leave in the first place. And, babies in distress might need to come out, but not with pitocin inductions.

It’s hard when women are thrown curve balls by their caregivers, even if they are the augmented caregivers.

When I began midwifery again after a several year hiatus, I saw induction after induction because of low amniotic fluid volume. I also began seeing loads of posterior babies, but that was easily explained by recliners and SUVs. There wasn’t as easy an explanation for the Low AFV’s, but I shrugged and took it as it was.

At a Medical Board meeting a couple of years ago, I had breakfast with a woman in the International Cesarean Awareness Network (ICAN), listening intently as she described her BPP and her incredibly low AFI of four and how, with a failed induction, she had a cesarean. She spoke of her anger at the railroading, the lack of information she’d had pre-op and how, since, she has learned that AFI’s were subjective and how she vowed to have a VBAC next time. I listened with interest, but had to tell her that I would have agreed with the induction with an AFI so low. I thought she should learn to forgive herself for her wise choice and that, sure, a VBAC was a given, but this cesarean seemed absolutely warranted. Angry, she has barely spoken to me since.

In the years since, as earlier, I have watched women be told they had low AFI/AFV and birth babies on waves of amniotic fluid. The woman’s cesarean was, in all likelihood, unnecessary as she knew and I didn’t hear. I was humbled by her knowledge. And embarrassed.

If I, a “knowledgeable” care provider, an alternative one at that, believed in the information from a BPP, then how vulnerable are women at the end of their pregnancies? Very.

(This woman went on to HBAC!)

Tori returned for her BPP, bringing her husband along and, after another NST and then the BPP, she “passed” and was asked to return in 2 days. She isn’t sure she will.

As with all prenatal tests, reading as much as you can, pros and cons, from a variety of sources - medical, midwifery, and consumer – can help formulate the decisions you make regarding your own care. Read wisely. Listen to your gut and intuition.

Then step forward with surety and clarity.

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