Making the Best Decisions Possible

I recently posted about being called to a birth-in-progress on New Year's Eve, and mentioned that mom was admitted for low amniotic fluid based on an AFI of 4.5 (0.5 of a point below the 'low' assessment rankings).

It's sort of been bugging me, and I wanted to see what research was out there about this kind of testing. So, I pulled out my handy A Guide to Effective Care in Pregnancy and Childbirth and did a little reading.

Effective Care mentions the AFI somewhat obliquely in chapter 12, section 5.5:

5.5 Fetal biophysical profile
The ‘biophysical profile’ was derived from a study of serial ultrasound examinations and antenatal cardiotocography (non-stress test) in high-risk pregnancies. Combining five biophysical ‘variables’ considered to be of prognostic significance (fetal movement, tone, reactivity, breathing, and amniotic fluid volume) into a score, reduced the frequency of false-positive and false-negative results compared to the non-stress test alone. An additional advantage of the biophysical profile over the nonstress test is that it permits assessment of the possibility of major congenital anomalies. This may be important, as detection of a serious anomaly may on occasion help to avoid a cesarean section when the baby is clearly abnormal.

Only two controlled trials of biophysical-profile testing have been performed. Both were conducted in women referred to units specializing in fetal biophysical assessment. They compared care based on biophysical score results with that based on non-stress test results, following a management protocol. In both studies, the biophysical profile score was a better predictor of low 5-min Apgar scores than the non-stress test. The biophysical profile was both more sensitive and more specific in predicting overall abnormal outcome than the nonstress test.

Despite the better predictive value of the biophysical score than the non-stress test, its use did not result in any improvements in outcome for the baby. Outcomes measured included perinatal death, fetal distress in labor, low Apgar score, and low birth weight-for-gestational age. Compared with cardioiocography alone, biophysical-profile testing showed no obvious effect (either beneficial or deleterious) on these outcome measures. The available evidence provides no support at all for the use of biophysical profile as a test of fetal well-being in high risk pregnancies. However, the number of women included in these studies is so small that any estimates of effect are extremely imprecise.

Basically, what I took from that was, researchers believe the biophysical profiling approach is an effective means by which to see how mom and baby are faring, but the research may be flawed or incomplete when one reviews it, and so Effective Care authors believe it's difficult to say whether it's an effective method or not.

I think this is another instance where care providers try to lump all women into categories, like making an IF/THEN/ELSE statement. (Well-Rounded Mama is dealing with a similar situation with her health care, so it's not unfair to say that this sort of thing happens all the time in other instances of health care.) It makes me wonder what my last client's experience would have been like if she had made different decisions, and decided to place her trust more in her (very healthy) body than in (uncertain) risk assessment testing.

Humanity is on the search for "true indicators", but life isn't always consistent in its outcomes and occurrences. So, here's the approach I'll have when I'm a pregnant mom: I'll make the best decisions possible with ALL of the information available and won't forget to listen to intuition and feelings as well as intellect.

Exploring Your Options

Our friendly, neighborhood Birth Activist blogged recently about how some future moms tell themselves (or are told, in many cases) that, at the end of labor, the manner of birth is not as important as having a healthy baby in arms. She goes on to make an analogy about how planning for big events allows us to reap the best from the event. (It's a good read, go check it out.)

Telling oneself or a new mom, "At least you have a healthy baby," is a sticky thing. Yes, the desired result for anyone who chooses to give birth is for a baby with all the appropriate working parts. But that's only one part of the equation. If mom births a healthy baby but her care provider convinced her to have an intervention she felt was unnecessary or that she feels she was coerced into, how will that affect her interaction with care providers in the future? How will the experience shape her ideas about birth and about herself as a mother?

Using the compass rose as a model, imagine that each cardinal direction represents the four major parts of our human experience: physical, mental, emotional and spiritual. Bearing a child is an intense experience which shapes all of these aspects of ourselves. The body changes; the mind is challenged to make decisions for the benefit of a new being; emotions are finely-tuned and sensitive. And birth can be influential to those for whom spirituality is an important part of life.

Planning means exploring one's options. Families have choices in childbirth. They can pick where they give birth, who will attend them, what interventions (if any) are acceptable. The design of a birth experience is farther reaching than just the day a baby emerges from its mother's body; birth is a touchstone experience, and can shape our ideas about what life is and means in a long term way.

In childbirth, there's a balance to be achieved between what can and cannot be planned. Sometimes the way things turn out doesn't match the hopes or expectations of the family - and even if the birth was its absolute ideal, often moms feel that their lives are in upheaval from the act of bringing life into the world. Being at peace with a birth experience can take time; it is an act of respect to be gentle with a mother while she processes her experience.

For more information and different approaches to crafting a birth plan:

• Melissa @ the Bradley Babies blog, Tips for Creating a Birth Plan, part 1 & part 2
• Chapter 17 in Pam England's book, Birthing From Within
• Janine DeBaise's Birth Plan (published by Midwifery Today)
• Christine Kane's guide to building a vision board
• Birth plan tips from an (awesome and supportive) L&D nurse, part 1 & part 2