Amniotic Fluid Volume: too much, too little, or who knows?

This post is in response to readers asking me to cover the topic of induction for low amniotic fluid volume (AFV). Most of the content is available in textbooks, in particular Coad and Dunstall 2011 and Beall and Ross (2011), and I have provided references/links for research where I have stepped outside the textbook sources. I use the word ‘may’ quite a bit in this post because little is known about AFV, therefore a lot of the available information is theoretical. In fact, this post probably raises more questions than answers! Also note that I am focussing on AFV at term.

Amniotic fluid volume regulation

Amniotic fluid is in a constant state of circulation. In the second half of pregnancy the main sources of fluid production are from the baby:

  • urine (700mls per day)
  • lung secretions (350ml/day)

And the main sources of fluid clearance are:

  • the baby swallowing fluid and passing it back into mother’s blood stream
  • direct flow across the amnion (placental membrane) into placental blood vessels

The balancing act required to maintain a healthy AFV may be influenced by hormones (prolactin and prostaglandins), osmotic and hydrostatic forces, and the baby. Maternal hydration is also associated with AFV (Patrielli et al. 2012). From day to day there is little change in AFV, however volume decreases towards term. This is normal. Perhaps this reduction reflects reduced lung secretions as the baby nears term?

The amniotic sac and fluid play an important role during pregnancy and birth – you can read more about that in an earlier post.

Abnormalities in AFV occur when there is an imbalance between fluid production and clearance. Too much fluid is called ‘polyhydramnios’ and too little fluid is called ‘oligohydramnios’. However, measurement and thresholds of normal/abnormal are not clear.

Accurate Measurement?

Here is the first problem… there is no accurate method for measuring AFV. The two ultrasound tests aimed at assessing AFV are:

  • Amniotic Fluid Index: four ‘pockets’ of fluid are measured by ultrasound and added up resulting in an Amniotic Fluid Index (AFI) eg. AFI = 10cm.
  • Maximum Pool: The ‘single deepest vertical pocket’ of fluid is identified by ultrasound and measured in centimetres.

Neither of these methods are supported by research (that I can find). However, studies comparing the two conclude that the ‘maximum pool’ measurement is the ‘better choice’ (Nebhan & Abdelmoula 2008Magann et al. 2011). The reasoning for this is interesting… AFI increases the detection of oligohydramnios resulting in increased rates of induction without improving outcomes for babies. So the best method is the one that does not detect the ‘problem’ you are looking for?

Measurement of AFV by AFI or ‘maximum pool’ is part of the Biophysical Profile assessment which aims to identifying babies with inadequate oxygenation via the placenta. However, it is unclear whether there is any benefit to this test. Indeed, an umbilical artery doppler test may provide a better assessment of placental function, and therefore how well oxygenated the baby is (Alfirevic, Stampalija & Gyte 2010) – which is what everyone is worried about.

There is of course the old fashioned method of assessment, also not well researched. Abdominal palpation is usually carried out during antenatal visits. In addition to working out what position the baby is in, a midwife assesses the amniotic fluid volume. When you have palpated lots of pregnant bellies, ‘real’ polyhydramnios and oligohydramnios are usually pretty obvious. Mothers are also experts regarding their own body/baby and notice differences themselves – particularly if they have been pregnant before and can compare pregnancies. What you may find:

  • Oligohydramnios: baby is very easy to feel – in some cases you can see limbs; the uterus is smaller than expected; the mother may notice reduced movements.
  • Polyhydramnios: baby is difficult to palpate and floats away as you apply pressure; the uterus is bigger than expected; the baby’s heart rate may sound muffled; the mother may notice breathlessness, vulval varicosities, oedema and gastric problems.

When you are working as a midwife in a continuity of care situation you get familiar with the individual woman’s bump over time, and it is easier to notice changes. Measuring (with a tape measure) is often used to assess uterine growth – particularly when care is spread between a number of practitioners. Whilst measuring can assist with identifying polyhydramnios, it is unreliable in identifying oligohydramnios (Freire et al. 2013).

Here is the second problem… there is currently no agreement about what constitutes ‘high’ or ‘low’ levels of AFV. Megann et al. (2011) conclude that: ‘high and low levels [of amniotic fluid] have yet to be established in the literature and are difficult to directly link to adverse pregnancy outcomes.’ So we are busy finding measurements that we don’t really understand the implications of?

Most of the time there is no known cause for the ‘high’ or ‘low’ volume of fluid, and there is are complications caused by it. However, there are some factors worth considering if you are labelled with oligohydramnios or polyhydramnios.

Oligoydramnios – too little

The definition of oligohydramnios is usually less than 500mls of fluid; <2cm maximum pool; or AFI <5. Around 3-5% of pregnant women are diagnosed as having too little fluid. Because of the complexities of measurement and the diagnosis of oligohydramnios, I have differentiated between what I believe are two types:

Physiological oligohydramnios

Most cases of ‘oligohydramnios’ are an outcome of 2 factors:

  1. The normal physiological changes that occur to AFV as term approaches (see chart above) and/or the ‘normal’ level for the individual mother/baby is comparatively low to the general ‘norm’.
  2. Women having routine scans for ‘post-dates’ which then identifies this normal ‘low’ AFV.

There is a lack of evidence supporting induction for oligohydramnios in ‘low risk’ pregnancies ie. when there is nothing else ‘abnormal’ going on with mother or baby (Quiñones et al 2012). Driggers et al. (2004) concluded that: “evidence is accumulating that in the presence of an appropriate-for-gestational age fetus, with reassuring fetal well-being and the absence of maternal disease, oligohydramnios is not associated with an increased incidence of adverse perinatal outcome.’’

A recent review of the literature (Rossi & Prefumo 2013) found that in term or post-term pregnancies oligohydramnios (with an otherwise healthy pregnancy/baby) was not associated with poor outcomes. However, it was associated with increased risk of obstetric interventions… probably because the diagnosis leads to intervention.

Pathological oligohydramnios

Pathological oligohydramnios is generally a consequence of reduced urine output (baby) which can indicate a redirection of blood flow away from the kidneys to the vital organs in response to reduced oxygenation. This usually occurs alongside pregnancy complications such as pre-eclampsia. In this case the low fluid volume indicates inadequate placental circulation to the baby. These babies often have significantly low AFV (easily identified by palpation), and are often growth restricted i.e. small and with limited glycogen supplies. These babies are at significant risk and further assessment and intervention should be offered. As a midwife there are few things more concerning than being able to see baby’s form though their mother’s abdomen.


Induction of labour is the usual management for oligohydramnios (regardless of type) because there is concern that the baby has inadequate placental circulation (which is correct in relation to pathological oligohydramnios). However, women need to consider that the induction procedure is associated with reducing placental circulation and causing hypoxia and fetal distress. In addition, if the baby is post-dates he may have already passed meconium, and/or will if he becomes hypoxic due to the induction process. Oligohydramnios = less fluid to dilute the meconium = increased risk of meconium aspiration. Therefore, it is very likely that the baby will become distressed during labour before birth occurs. This is why electronic fetal monitoring is important – in clinical practice I saw the inevitable fetal distress and rush to theatre resulting from induction for oligohydramnios over and over again. So, the mother must be prepared for, and informed of the likelihood of c-section. The other alternatives are planned c-section or awaiting spontaneous labour. Whilst spontaneous labour is more gentle on the baby than an induction, waiting for labour with a baby who is not being well supported by their placenta requires serious very consideration (and nerve) – time will not improve the situation, only worsen it. Even spontaneous labour is likely to result in fetal distress once contractions start – these babies are already struggling. Pathological oligohydraminios is a serious complication.

Polyhydramnios – too much

The definition of polyhydramnios is usually around 2000mls of fluid; >8cm maximum pool; or AFI >25cm. Around 1-3% of pregnant women are diagnosed with having too much amniotic fluid. In 60% of cases there is no known cause, but factors that increase fluid volume include:

  • The baby producing too much urine
  • Decreased fetal swallowing (baby)
  • Increased water transfer across the placenta by the mother

These factors may be influenced by the general well being of mother and baby ie. may occur if there are complications present such as diabetes, rhesus isoimmunisation, congential abnormalities, etc. But, usually no complication is present.

Complications associated with polyhydramnios

  • Preterm birth – as the uterus become over stretched with fluid.
  • ‘Unstable’ position of the baby – the baby can float about into helpful and not so helpful positions.
  • Cord presentation or prolapse – because the baby is floating about the cord can get between his head and the cervix.
  • Placental abruption – may occur with a sudden change in fluid volume and therefore size of uterus/placental site.


Tests may be suggested to see if a cause can be identified (although nothing can be done at this point). Induction of labour with a ‘controlled’ artificial rupture of membranes may be suggested to manage the risk of an unstable lie and/or cord prolapse. This involves breaking the waters whilst holding the baby in place… and with quick access to theatre as the procedure can result in a cord prolapse. Alternatively, the woman may choose to wait until labour begins, and assess her baby’s position once contractions have started. Either way – the risk is the woman’s therefore she must be the person to decide which risks are best for her – induction or waiting.

In Summary

  • The exact mechanisms involved in regulating AFV are still unknown.
  • AFV reduces significantly after 37 weeks – this is normal.
  • There are no accurate methods of measuring amniotic fluid.
  • There is no agreement about what measurements indicate ‘high’ or ‘low’ AFV.
  • The intervention used to manage polyhydramnios or oligohydramnios ie. induction also carries risks which need to be taken into consideration.

So, as you can see this topic creates more questions than answers which is why I previously avoided it!

Further Resources

Science & Sensibility – What is the evidence for induction for low amniotic fluid in a healthy pregnancy?

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90 Responses to Amniotic Fluid Volume: too much, too little, or who knows?

  1. Pingback: In Defence of the Amniotic Sac | MidwifeThinking

  2. Kate Dove says:

    Great thoughts echoing my own concerns…Kate mgp midwife

    Sent from my iPhone

  3. Tara says:

    This was a great piece of reading. So true in regard to your concerns about IOL for low AFI, growth restricted etc

  4. Claire says:

    Thank you for this post! Did you see the very recent EJOG article on oligohydramnios? It confirms your suspicions about the “pathology” of oligo at term:

  5. Adriana says:

    I wondered about this too. I was armed with knowledge and ready to refuse all medical interventions with my first pregnancy. I was 9 days past due but I was willing to continue to wait for my baby to decide when he was ready to be born. I went to a stress test and supposedly his amino fluid was too low and his heart rate kept taking small dips so they said my baby was stressed and that i needed to be induced. I refused because in my mind I thought, if my baby is in fact stressed and his heart is not stable why would I opt for an induction to cause more stress? It didn’t make sense to me so I told them that I wanted a c-section. I fought hard for a csection because they told me I had to try to deliver vaginally. Long story short, I did have a csection that same day and it turned out that there was meconium inside the sac. I know I made the right decision for my baby at the time, and I know that if I had opted for an induction my baby could have been born very sick because of the meconium and i would have probably wound up with a csection anyway but I still wonder if my baby was in fact stressed. I never got the chance to go into active labor…

  6. Rebecca says:

    Something I’ve often wondered about and not seen addressed is the question of time. Since AFL are not fixed, yet able to change, how long would a woman need to have Oligohydramnios/Polyhydramnios to receive a diagnosis? If she presented for a prenatal appointment and this was suspected, yet there were no other indicators of a problem- not even high blood pressure, would you see her again the next day or two before diagnosing a problem? Wouldn’t it be reasonable, if she presented with Poly, to examine her nourishment and activity, maybe suggest diet improvements and light exercise. Therefore, building up her osmotic pressure and moving her lymph fluid, then reevaluate. In my area, I have seen the low fluid diagnosis happen quite often, usually the high fluid question is raised by medical students and proven to be nothing. Thank you for this well presented information.

    • It would depend on the severity. With extreme poly or oligo I would offer a referral. With minor I would perhaps review. To be honest – if it is clearly detectable via palp then it is probably more severe.

  7. Kristine says:

    Still bitter about my first induction for “low fluid.” Thanks for exploring this because hopefully someone in a situation similar to mine will feel more empowered than I was at the time.

  8. Thank you so much for this information, I always knew instinctively that my baby was well at 42 weeks gestation and there was never anything wrong with the fetal ctg, however the public hospital where I had booked in as a back-up for our home birth used the scan for asserting amniotic fluid amounts to pressure me into agreeing to be induced the next morning. I realise that I was extremely lucky to have experienced a beautiful homebirth instead of a repeat hospital trauma. If I had refused to be induced the next day the hospital would have reported my midwife despite the fact that my baby and I were doing fine!

    Sent from my HTC Incredible S on Yes Optus network.

  9. Bree says:

    I was diagnosed as polyhydramnious at 41 + 5 with my second child after a biophysical profile. I was in a homebirth program (fabulous homebirth with my first) and the back up hospital was able to over rule homebirth based on the results of the ultrsound (that I should never have said yes to! I knew they were unreliable at that point of pregnancy). I was above the graph for my gestational point and they freaked out. Plus the measurements of the baby predicted an almost 5kg baby. The recommmended course of action (after telling me all the things listed in this blog as dangers) was an induction the following morning. I went home and labour became established. I had to go to the hospital for the birth (the homebirth program I was in is becoming more and more regulated) and 47 minutes after I got there my baby was born. No missed gestational diabetes, no hypoglycaemia, no weird body formation, no cord prolapse, water broke 10 minutes before birth, baby was 4.25kg and perfectly healthy.
    To read this blog and know that there was no scientific reasoning for overruling my homebirth and leaving me with birth trauma to deal with (the birth itself was stlll fabulous but I carried a lot of anger about the fear I was given to deal with just hours prior to birth and all for nothing). Not surprised, but still makes me angry right now!!

  10. Cate says:

    Women’s bodies are amazing! So clever to space out tightenings perfectly so that babies can cope! Just gotta trust

  11. Kim says:

    Thanks for this post. In my second pregnancy I was diagnosed with polyhydramnios at 33 weeks. My midwife felt there was an abundance of fluid on palpation, I was measuring 38cm, and then had a scan by an obstetric registrar which showed an AFI of 31 with a maximum pool of 10cm. I had suspected there was a lot of fluid because the baby was moving about very freely and my tummy skin had become crazy tight and itchy. The next day I had a formal scan and this showed an AFI of 21 with a maximum pool of 7cm! That is quite a difference – surely operator error should be less than that hey!
    Anyway the baby was growing normally, umbilical flow was fine and I passed a GTT, even though I had passed the routine GLT. So it was all a lot of worry and fuss that resulted in nothing different being done in regards to my care. I know that checking these things is sensible, but based on your post it does seem like a flimsy measurement to tell us how the baby is doing.
    I delivered my little boy at 41+2wks, 3915g, no PROM or any of the complications I’d been warned about. It would seem that some women just grow luscious babies in lovely big swimming pools of fluid!!

  12. Robyn says:

    I suspect the suspicion of oligo/polyhydramnios is as harmful as the suspicion of a large baby , and that the suspicion may be more harmful than the actual oligo/polyhydramnios especially in mild cases with no underlying pathology. I think therefore blanket management is inappropriate as each woman needs care provided based on her individual situation.

  13. Mama E says:

    I went in for a BPP at 41.5 weeks and they found my AFV to be a 3 or 4. The doctors were adamant that I check in immediately for an induction, but I knew enough to be wary. My husband and I resisted, and went home instead to read up on AFV. After doing our research, we were still extremely uncertain, but decided it would be best to refuse induction after all. (I had an otherwise uneventful pregnancy and the baby seemed fine.) We were very turned off by the doctors’ approach: they continued to use the threat of a “dead baby” and suggested that I was only being selfish in refusing induction. Even the midwife couldn’t understand why we would refuse; everyone believed that the baby was in imminent danger. We were terrified, but felt that induction had its own pitfalls. We didn’t trust the doctors because we know how induction-happy OB-Gyns are. Still, we were panicked (until the healthy delivery 4 days later) that the cord might get compressed by the baby (and we would lose him, as the doctors were warning). Thankfully, the birth went fine, but to this day, my husband and I look back at that time with horror. We don’t know if we made the best decision — I mean obviously it worked out fine, but how much of a risk did we take? We would like to do a LOT of reading on the subject before having baby #2. Any suggested leads are appreciated. I enjoyed the article, and everyone’s comments!

    • Hmmmm the concerns of the doctors seem strange. If they are worried about the risk of cord compression why would they suggest an induction (ie. more powerful contractions/squeezing) as an answer? Also, if OBs are so worried about cord compression why do they perform so many artificial ruptures of membranes ( In your case even IF there was ‘low’ fluid there was most likely more than if you waters had broken… and plenty of women labour with their waters broken – or have them broken during labour. So, the cord compression theory does not make sense.
      The concern with pathological oligohydramnios is the function of the placenta ie. the lack of fluid is a symptom or a poorly functioning placenta. Was your baby well grown and moving?
      From your description it seems that you were being coerced into an intervention to meet the needs/wishes of practitioners. I wonder if the risks of induction were also explained ( to assist you with your decision making?

  14. Erik says:

    My wife is 33 weeks pregnant. She had 2 ultras this week, and the readings were the same: 5.5 cm AFI and one pocket that was over 2×2. The baby is breech. The baby is also normal size, organ development. There is no visible issue with the kidneys or bladder. The Dr. wants to give the baby betamethasone, then induce and C-section THIS WEEK. We declined. What are your thoughts on the chances of death or mental problems due to cord compression over the next 7 weeks if we go to term. Oh yeah, and our midwife has now dropped us.

    • Hi Erik
      I can’t give individual advice. I’m sorry that you are having to work through this ‘change in circumstances’. If the dr is suggesting the baby needs to be born prematurely I am assuming the baby is in imminent danger… ie. they have assessed the placental function via umbilical artery doppler and are concerned. Low AFI alone is unlikely to create this amount of concern. I’m guessing the worry is not about cord compression as women labour when their membranes have ruptured and when the membranes rupture early (pre-term) everyone waits for the baby to mature before intervening. The worry may be about placental function. I suggest you get your dr to clarify exactly what the concerns are and based on what. Your midwife should be supporting you and providing information during this stressful time.

    • Rebecca says:

      What preceded the ultrasounds? What were they looking for?

  15. Cherie says:

    I had suspected something wasn’t right early in my pregnancy as I was showing rather early and seemed quite large for my dates. My concerns were dismissed as trivial and vain by the midwives and doctors and I was given an information sheet on diet and nutrition.

    I was eventually diagnosed with Poliohydramnios at 6 months after my full anatomy scan and monitored quite closely after that and referred to specialist care. Lots of investigations revealed my baby was healthy but the excess fluid was increasing. By 7 months I was admitted to hospital because of the risk of early labour and given steroid injections to strengthen my babies lungs incase I did deliver early. After 4 weeks confined to a hospital bed I was going nuts and begged to go home. I was allowed home at 8months on strict instructions of bed rest and being told that I could go into premature labour at any time and the risk of cord prolapse was extremely high and a medical emergency and to get to hospital ASAP at the first sign of labour.

    I was terrified that I would go into an early labour and didn’t dare to even walk to the corner shop and pretty much stayed confined home and to my bed. My only reassurance was “your baby is fine, it’s just that you have too much fluid”. The cause was idiopathic which is just a fancy word for I don’t know.

    At 37 weeks I attended my specialist appointment and was elated to be told that I needed to deliver immediately as my uterous was the size of a 2 week overdue woman carrying twins! It certainly felt like it too! I was booked in for a final scan and induction. I was so excited and relieved, I had successfully held on and carried my baby without going into early labour and my ordeal was soon over! The last thing on my mind was concerns about interventions or induction etc. I was about to deliver a healthy baby finally!

    I attended my scan at 37+3 weeks knowing i was about to have my baby. The sonographer noted my obvious fluid levels which were still excessive and then became very quiet before telling me there was no heartbeat. I wasn’t concerned, the baby was still breathing right? Looking back that was a silly thing to think but I was in complete shock. I went home that night preparing myself for the very worst. I was scheduled for induction the next day to deliver my dead baby. The labour was beautiful and easy and my grief and devastation was unimaginable when I held my son in my arms. My ordeal did not end there, I lost almost 2 litres of blood overnight and was rushed into emergency theatre. I almost died and by some miracle and medical intervention, I didn’t.

    I can’t help but think the irony is I was so scared of an early labour and determined to carry my baby to term but if I had delivered early or been induced just days earlier I would have my son now.

    Abnormal fluid levels should be taken seriously and I am at a loss to understand those who find interventions upsetting and dismiss medical advice. The most important outcome is a healthy baby and it was not that long ago that we did not have the advances in science and medicine that are now available and baby and mother mortality was high. I am all for having as natural a birth experience as possible, but if this is not the outcome, there are worse things that can happen.

    Even though things did not go as planned the last thing I was grieving was not having a water birth or being induced or having emergency surgery etc. Really it doesn’t matter, it’s the outcome weather good or bad that matters.

    Remember the hypocratic oath that health care providers take “first do no harm” and this may help you understand and appreciate treatment and advice that is offered to you.

    • Thank you for sharing your experience and I am sorry that lost your baby. Extreme polyhydramnios is not normal and should not be ignored… more importantly, your concerns were trivialised rather than listened to. It is so difficult with the power of hindsight. I am guessing your care providers were waiting until 37 weeks to induce because of the risks to the baby of a preterm birth… no one could have anticipated that those few days would make such an enormous difference. I agree that the way a baby is born is not the most important outcome. Thank you again for sharing.

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  17. Rachael says:

    Very interesting….I was diagnosed with Oligohydramnios at 32.5 weeks with a largest pool of 3cm and an index of 5.5…both above (albeit only by a little) the limits described as ‘acceptable’….my baby was delivered the next day by c section…I had been monitored from 28 weeks following midwives suspicion of a ‘small for dates’ baby which was confirmed by scanning….and again at 30 and 32….baby not on ‘correct curve’ but growing!? I wanted to wait obviously but was told it was not possible, especially after the Oligohydramnios diagnosis, which to them was now too much to just ignore and proceed with…almost immediate CSection was my only option… chance of induction…..asked for another week or two….told I was risking fetal death…

    Had a very distressing section (after natural birth with no pain relief two years previously)…baby in SCBU, after encouraging apgars of 9 and 9 at 1 and 5 mins after birth, she started to struggle, required intubation over night (after three failed attempts at suffactant delivery to help with breathing) and a long and traumatic time in hospital for my baby and my family, coming home after a month…

    I was very confused about the urgency applied to my babies delivery and started to question more and more if all of the ‘nastiness’ could have been avoided……I was asked several times by staff whilst in special care, why my baby was born early? This hightened my suspicion and so I applied for her notes…..Baby noted after birth as NOT IUGR (intra uterine growth restriction) on paperwork on several occasions……As this was also given for the reason that I had to have an ealy section (along with oligohydramnios)…..I was, ofcourse devastated and I tried to complain etc but was told they could only go by what the scans had told them and they had to adopt a ‘safe rather than sorry’ approach….

    I took it no further…not sure now if I should have or not!?

  18. Rachael says:

    Sorry cherie, I didn’t read any posts before posting….I am so sorry for your loss and apologise about my post complaining when at the end of the day I should be grateful I have my baby, no matter what happened x

  19. Tanya says:

    No body ever talks about 42 weeks plus. And no due date wasnt wrong. What do you do when midwife tells you to go to hosputal to have baby? You all focus on spontaneous labor, but what if labor never starts? And after it is all done, the placenta showed it was “dying”, it was old, baby shows up looking old because he is so late. Where are these articles?

  20. If oligo is there anything a mom is able to do (such as drink more water or certain tea) to increase AFV?

    • Dehydration can cause oligo – so hydrating will increase AFV if this is the cause :)

      • mani says:

        Hi my wife is 38 week pergnant , when we check the AFI is 4. But all the things are fine. And my wife is also health and she didnot have any small problem. But doctor is suggesting for seisserion, we are in confusion. Pls give some suggestion. My wife age 21.

        • Hi Mani
          I cannot give specific recommendations or suggestions for individuals. Your doctor should provide very clear reasons for suggesting a c-section in order to gain consent. Perhaps ask him/her whether the baby is in danger and why.

  21. ANJANEYULU.B says:

    Hi,My wife 24wk prgnt. On dt.21/12/2013-AFI – 16 and On dt.05/1/2014 AFI -20,Our doctor said that is polyhydramnios and problems in future what shall we do?

    • According to the definition of polyhydramnios an AFI of 20 is not polyhydramnios. There is nothing that you can do at the moment except continue to monitor the situation. The fluid may decrease as the pregnancy continues.

  22. ANJANEYULU.B says:

    Thank u

  23. ANJANEYULU.B says:

    What is the safe range of AFI & procedure for reduction of AFI within permissible limits for safe of mother & baby

  24. morgan says:

    i need some advice or help…..i am 33 weeks pregnant. i went to see my dr monday bc i though i had leaked water so she did a sono and had seen that my afi levels were at a 6.8. she ran a test to see if my water had broke but it came back negative. she had me come back wed. to check afi levels again, now it is at a 5.5. she is saying the baby looks very healthy, i had the steroid shots two weeks ago and she is going to give them to me again to make sure. i am really nervous and just wondering what happens if my levels go under 5.5 tomorrow when she checks me.?

    • Hi Morgan
      Hopefully they will do nothing if your AFI levels are under 5.5 and your baby is well. It would require a very compromised baby to justify any action at this point. I am surprised that your dr is not fully informing you about what they are looking for and what action would be proposed if x or y happens. Communication and information sharing is very important.

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  27. Rosalie says:

    Have you written any blog posts about the necessity of women with gestational diabetes to be induced if they pass their 40 week gestation mark? I am 38 weeks 4 days along and have gestational diabetes, my midwife just informed me that if the baby is not born by my due date that we will need to discuss induction. I am feeling skeptical but do not have very much information about whether this is really necessary. Thank you.

    • Hi Rosalie
      I haven’t written about GD yet. With abnormal blood sugars (ie. uncontrolled GD) there is an increased chance of stillbirth in the last weeks of pregnancy. That is why the usual recommendation is to induce before term. However, this risk is directly related to blood sugar stability and a woman with GD and normal blood sugars is at the same risk as any other woman.

  28. Lesa says:

    I am 33 weeks pregnant and my OB measured the fluid at 6.5 two days ago and then today got a measurement of 7.9. OB is forcing me to come in two times a week from now on to have this fluid monitored. Told me if it gets to 5 they usually take the baby. Told me about dangers of cord compression due to low fluid. I REALLY wanted to try to have this baby at home so I’m wondering about a couple of things. How low is too low and can I still aim for home birth? OB says this fluid “almost” puts me as high risk, yet there are no other issues at all with pregnancy or baby other than he is a bit smaller than we thought he’d be. My first pregnancy two years ago was very healthy and produced a very healthy 8lb. boy. At this point in that pregnancy that baby was in the 85th percentile for growth. Right now this baby is in the 20th percentile. Is this fluid related? He seems very healthy, just small. Also, with first baby my water broke then I went on to labor for 21 hours. So even if my fluid is on the low side right very near time of delivery and even if water breaks at beginning of labor lowering fluid levels even more so is it life threathening to baby to proceed with home birth?

    • Hi Lesa
      Firstly you OB cannot ‘take your baby’ without consent. Instead, he/she can recommend delivery… you then chose to follow the recommendation or not. I am reluctant to comment on individual cases that I am not involved in. However, some things you may wish to consider…
      Your fluid is low for your gestation. The fact that you previously had a good size baby and this one is small (if estimation correct) is another concern. These two factors may indicate that your placenta is not functioning as well this time. Did you have an assessment of placental function (see post)? Your OB is concerned that you have pathological oligohydramnios. Cord compression is not the only risk in labour if this is the case… many women labour after their water has broken = less fluid. The main risk is fetal distress once the placenta starts being ‘squeezed’ with contractions. Please read the information on pathological oligohydramnios in the post. The low fluid and small baby may be symptoms of problems with the placenta. If this is the case you may want to reconsider your birth plans. It would be great if you could return and let us know what happens.

      • Lesa says:

        Hi, I wanted to come back and let you know what happened. After a couple more weeks of seeing my OB twice a week to measure the fluid I decided it was pointless. My fluid had gone back up and was staying at 9. I believe it had only dropped temporarily due to a recent virus I’d had. I concluded my OB was handling my case as a “potential problem” when it clearly wasn’t. Very late in the game at 36 weeks I left the OB and started care with a wonderful and wise midwife. I had a wonderful labor and very easy and fast delivery at home three days before my due date. Baby weighed 7lbs.4oz. and was 20″ long. A very healthy and strong baby. At one month weighed 11 lbs. and almost 22″ long. Absolutely no issues whatsoever with labor, delivery or baby. I am so glad I trusted my body, my midwife, and God and opted for a normal delivery in my home instead of allowing the OB to make me fearful of any and all potential what-ifs that could have been. The female body is amazing and low risk pregancy, labor and birth goes best when not interfered with. I found that pain meds and other hospital interventions are far harder on the body than natural childbirth. As soon as the baby was out I had not another single second of pain. Never took anything not even ibuprofen postpartum. Also, not having to birth laying down on my back (hospital style) allowed for an easier birth with no tearing this time! I felt great afterwards!
        Home birth and midwife care was a wonderful experience!!

  29. maquillaje says:

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  30. Susan says:

    I’m 30 weeks and my OB measured the fluid is <50 AFI, he said it's too much
    Can you explain to me what is the risk for my baby and for me please and what i need to do?

    • That is a very high AFI. Read the information in the post about polyhydramnios for more information. Your OB should be fully explaining the findings of assessments and what it means for you/baby. Ask him/her for a full discussion at your next visit – it is their job to do this. I hope all goes well for you.

  31. Sarah says:

    Thank you for this informative post! I was diagnosed with oligo when I was 36 weeks pregnant with my daughter (now a healthy 2 year old). My AFI was 3 cm, and I delivered her by c-section a few hours after diagnosis (she was breech). Oligo was discovered by chance – I was having a doppler scan in preparation for a version, to hopefully turn her. I wasn’t given any information about possible causes – they just told me to drive to the hospital for delivery.

    I am now pregnant again, and am feeling nervous, because I am wondering if the low fluid level shouldn’t have been caught earlier last time. I had a scan at my midwife’s office two days before delivery, and no mention was made of low fluid. I had been measuring 2 weeks behind in fundal height for about 6 weeks. My daughter’s head was easily palpable on my belly for a week or two before diagnosis. No one ever mentioned the possibility of low fluid. Should I push for more careful monitoring this time? Or are these situations usually a fluke? I can’t help but wonder what would have happened if I hadn’t had that last optional ultrasound at the MFM.

    • Hi Sarah
      It depends on why you had oligo the first time as to whether it is likely to happen again… and you may not know. Usually it doesn’t happen again. If you would feel reassured by increased monitoring this pregnancy then that is what you should push for. Can you discuss this with your care provider? If they know this is something you are concerned about they should be able help you with it.

  32. Simran says:

    Hi there,

    Very interesting article and for once one that is understandable. I am currently 34 weeks and 3 days pregnant and I had a scan by chance yesterday as I thought my waters had broken, which they haven’t. The scan is showing high level of fluid and the deepest pool is 9 cm how severe is this? They also said that baby’s bladder was full with a longitudinal of 6 cm, they did another scan after about 30 mins and the bladder measurement had gone down to 4.8 cm. Could you please tell me if this is a case of Polyhydramnios? The baby is growing fine otherwise. I am already booked in for a planned C-section as I suffer from arrhythmia, I am really concerned if the high levels of fluid are harmful for my baby. I have to go for blood tests on Monday to check that I haven’t developed diabetes or an infection and then go back to my consultant in 2 weeks for another scan to monitor the fluid levels. Is the level of fluid too severe as I am going to be stressed for the next two weeks now.

    Many thanks

    • I can’t tell you if this is polyhydramnios… not sure what your AFI was and I don’t have access to your findings or full history. It always interests me that women who have cardiac issues are recommended to have planned c-sections… I can’t imagine how an operation is less stressful to the heart than a physiological birth.

  33. Hilary says:

    Thank you so much for this article! I am 36 weeks pregnant and have been recently diagnosed with polyhydraminos (AFI of 28), and am in the process of undergoing testing to attempt to identify the cause. This was the most reassuring article on the subject I’ve found online, especially the explanation of the risks and the possible complications. I’m glad that my doctors are looking so hard for a cause, but also knowing that no matter what they find I can expect the rest of pregnancy to continue roughly the same as it would have before the diagnosis is very helpful.

  34. gen says:

    Hi… My question is… At 40+weeks is the low amount of amniotic fluid (1cm) likely to be a main factor with a stillbirth? And if an ultrasound was conducted 24hours before onset of the labour, would the low amniotic fluid be detectable? And are there any ‘special’ procedures to be in place if so? Very important to me, need some information please

    • Low fluid does not cause stillbirth but is an indication that the baby has insufficient oxygenation from the placenta… and the reason for that may be unknown. It is unlikely that low fluid would suddenly occur over 24 hours, so an ultrasound would probably detect it. If it was detected then a medical review would be required to determine the best course of action for the individual in the individual’s circumstances.

  35. Chris says:

    Hello, I am 31 weeks pregnant. Yesterday I ha a Doppler and the AMFI is 8,8. Is this too low? I was prescribed to drink lots of water and rest as much as possible. Nobody has explained what is as much as possible. Should I bed rest or just take it easy. I have two daughters and I would love to be able to do things with them especially that now it is summer. We already cancelled our holiday plans but I am not sure exactly what I have to do. Baby is growing fine and there was no mention of any problems with the placenta. I would much appreciate your advice.

    • Is the AMFI the AFI… or is this a different measurement? An AFI of 5 or less is considered oligohydramnios (too low). It seems that your care provider has not adequately discussed your situation or their recommendations with you. I am unable to comment as I am not providing your care and do not know your entire history etc. Can you make an appointment to clarify what they mean? There are risks associated with overhydration.

      • Chris says:

        Sorry I meant AFI. I went back today for a Doppler. I am 33 w and 6 days. All the measurements of the baby we very good. His growth is very good and th estimated weight is 2250. Today the AFI was 8,57. The doctor saw that and he said I should bed rest and drink even more fluids. I do not think I am able to drink more fluids. The 2 lts a day of water that I drink, I think is my maximum. I really want to understand what if any are the complications of an AFI of 8,57 at 34 weeks. My doctor fails to explain things to me. I am a foreigner in the country I live in so it’s my first time with this doctor. I already have two healthy daughters whose pregnancies were without any complications at all. That was in my own country with the doctor that I know well. So if you please can you shed some more light in my situation so I understand more what it is happening? Thank you so much

        • I am a little confused as your AFI is not ‘low’… and drinking too much water i.e. over 2 litres is not good… Your baby seems to be healthy and growing well with no concerns re. placenta. I’m sorry – I can’t shed any light on your situation as it does not make sense.

          • Chris says:

            That was also my feeling. That it does not really make sense. I will continue with the 2lts a day but by no means more and will rest a lot but I will no bed rest. Thank you so much. You have boosted my confidence because the only thing that this doctor is making me is too feel scared and insecure. I have an appointment with another doctor also. Thanks again

          • Another doctor sounds like a good idea :)

  36. Kristin Lundell says:

    I am currently 40w 4d pregnant with my first baby, a boy. Yesterday I went to see my midwife and for the second week in a row she found my fluid to be borderline low, an AFI of a little over 6cm. As per her recommendation and routine procedure, I am getting a BPP done tomorrow morning. My midwife seems to be confident that everything is fine. I have had a very healthy pregnancy so far. Just wondering a couple of things–should I be worried? Can I refuse to be induced? How far should I be willing to take this pregnancy before labor begins on its own?

    • I am not sure how your midwife is measuring your AFI… ultrasound? What did your BBP report? Yes you can refuse to be induced under any circumstances. How far you are willing to take this pregnancy is your own personal decision and your care providers should share information with you and discuss your options with you. It is impossible for an ‘outsider’ to do this for you. I hope you have had your baby – let us know what happened.

      • Kristin Lundell says:

        Thank you for your response! No, unfortunately I still haven’t had my baby at 41w2d. My BPP was great, actually, I had no need to worry. His AFI measured around 9.6cm, so I guess my midwife’s ultrasound machine is not very accurate and caused me to worry for no reason. He got an 8/8 on his BPP. My midwife suggested taking castor oil this weekend, since I’ll be 42 weeks on Sunday. I got my second membrane sweep yesterday and had mild, 20-30 second contractions (felt in my lower back for the first time) for a couple of hours last night. They went away. I woke up this morning and had some blood on the sheets. Not sure if any of this was indicative of any progress, or just my cervical check/membrane sweep. Either way, my baby has descended to almost a 0 station which is great progression from last week, and my midwife also dilated me to 2cm and said I am 50% effaced. There is the update on me!! Going for another BPP today. NST yesterday said he is doing great in there. I am not so worried anymore, just anxious at when he will finally make his arrival!! Thank you again!!!!!!

  37. amrutha says:

    hi midlife
    my baby has 18weeks 6days. i going the anomaly scan AFI’s any aomplications

  38. Berenice says:

    3 1/2 years ago, my OB induced me because at 39w3 days, my AFI was 29. I did not have GD and my baby girl was born 3 days later, the induction did not work and I had to have a c-section. She was a healthy but very big baby, 9 lbs 12 Oz and 22 1/2 inches. Now I’m pregnant with my second, and because I’ve felt the baby move a lot since very early on and because my belly feels tight, I’ve suspected all along that I have too low amniotic fluid, also just a gut feeling. I asked for it to be checked at my anatomy scan but they said it was pointless to do so then. I had an U/S at 32 weeks (because I’m considered AMA at 36), and the fluid came back at 9.50, baby measuring fine. The doc said that was a good level. While it is OK, I’m concerned that it will start decreasing soon (I’m 34 weeks now), and that by 37-38 weeks it will be very low. From all that I’ve read fluid decreases near the end of pregnancy. I’m scheduled for a repeat C-section at 39w2d. I’ve asked my OB to have my fluid checked again but she says it’s not necessary. Should I keep pushing for more testing in the upcoming weeks? I’m also concerned that for one pregnancy I had too much fluid and now it’s not low but it’s at the bottom of the normal range. I feel my doc is just too hands-off as far as testing goes. Am I worrying for nothing? Thanks!

  39. Rebecca says:

    I’m 38.5 and went for a BPP yesterday (I have epilepsy so they’re doing these weekly). I was alerted my fluid level is at 26. I was told not to worry as everything else seems fine, and has been great all along. I use a midwife practice so they really don’t like to use interventions unless necessary. I have of course researched now and have myself absolutely terrified. I wanted a natural birth with no medical interventions, and my midwife said this can still happen, I’ll just need some pitocin after the birth. The midwives and even high risk OB don’t seem too concerned, what are your thoughts on mildly high levels in late pregnancy? I failed to mention to them that I had a lot of water (more than normal) preceding my ultrasound.

    • mildly high might be your ‘normal’. Your care providers are not concerned and they have ‘the full picture’ ie. how you and baby are doing. There is no reason that you cannot have a natural birth.

  40. Claire says:

    I have just had a scan at 29 weeks and been told that I am polyhydramnios with a max pool of 8.2cm.
    Please can you tell me what this means and if this is high risk. I am very worried as I already lost twins at 20 weeks last year (not for this reason) and have now read about the risks of cord prolapse and placental abruption as a result of this condition.
    Many thanks

    • Hi Claire
      I cannot comment on individual situations – this is the job of your care provider – so please discuss this with them. Your fluid is only slightly over the ‘normal range’ (<8cm). This could change. The concerns about cord prolapse or abruption are related to labour or your membranes breaking – which is unlikely for another 10+ weeks.

      • larbakium says:

        I am trying to understand AFI behaviour and impact ob baby.
        My case the women scan at 30wks showed AFI = 16.2cm.
        At week 34+5 she went to hospital due to slight blood found on discharge. During the routine scan her AFI was at 2.3cm. She was admitted to hospital and on rest.
        Week 35+4 AFI displays at 4.4cm
        Week 36+2 AFI displays at 7.8cm

        Baby is breeched and c-section was planned at 37wks as the baby is considered mature and this will reduce the risk of infection.

        But because AFI is returning to the normal index for that period there is consideration to delay c-section.

        Baby is active, heart avg. 140bmp. And seems not be highlighted and problems with baby.
        Placenta function is normal and ubilical flow as well.

        What could have caused such drop on AFI (16cm to 2cm)?
        Suspected from broken placenta causing leak.. but than we see a recovery on week 36.

        Second question. Could the low AFI period affected baby development?

        Third question: now that the AFI is slughly higher, us it same to assume that there less risk of infection?

        • “What could have caused such drop on AFI (16cm to 2cm)?
          Suspected from broken placenta causing leak.. but than we see a recovery on week 36.” – not sure… perhaps inaccurate measurement?

          “Second question. Could the low AFI period affected baby development?” – if it was a symptom of IUGR yes, or if it was so significant that parts of the baby were compressed against the uterus eg. feet = may develop abnormal positioning.

          “Third question: now that the AFI is slughly higher, us it same to assume that there less risk of infection?” – not sure what infection has to do with low AFI unless the low AFI was due to the amniotic membranes being broken – in which case there would have been fluid draining.

  41. Nicole Bruno says:

    Thank you for this article. As a doula and Bradley teacher, one of the things I run into a lot working in a big city is women approaching 40 who are considered ‘high risk’ due to age, and being induced due to low fluids. It would seem as though there is nothing else indicating a problem, but because women over 35 get late pregnancy ultrasounds this gets picked up a lot and generally leads to induction and often c-sections. My question is, should age automatically risk you out of ‘ There is a lack of evidence supporting induction for oligohydramnios in ‘low risk’ pregnancies ie. when there is nothing else ‘abnormal’ going on with mother or baby’? Thank you!

  42. sh says:

    Hi, I am currently in hospital 23 weeks pregnant wid an AFI of 5.they said its a ruptured membrane, On strict bedrest. Have had about 4 spontaneous bursts of red bleeding in around 3 mnths, which resolves thereafter. The deepest pocket of fluid was around 2.5 according to ultrasound is 610g. I have had 3 previous c-sections, the last being about a year and a half ago.. I am told I most probably will go into labour and pass the baby out. But I am feeling baby move and have stopped bleeding. Womb is closed, no being monitored. Thoughts and advise pls?

    • I hope all is going well for you and your baby. I can’t give you advice… only good wishes. I know women who have had ruptured membranes in early pregnancy and gone on to have a health baby. You will continue to make amniotic fluid and if the membranes reseal your AFI will increase.

  43. sh says:

    Also, is there any way to increase AFI?

  44. Umesh says:

    Hi, My wife is pregnant with 31 weeks. last week while U/S screening, she found AFI 24.1 cm. Not found any anamoly in baby. Heart beats are 142. Until last U/S (18th week) everything was normal. what could be the reason? what precaution we should take? Current DIPSY test (75 gm sugar test) was 136.

    • Your wife needs to discuss this with her care providers as they will have all of the information about her pregnancy tests. I can’t give individual advice or recommendations. I hope she gets the care, information and support she needs.

  45. Teena says:


    i am 38 weeks pregnant. I recently got an ultrasound scan done and the report says Polyhrdramnious with AFI = 23.5. The baby weighs 3.4 kg. Can you please advice if it is something i need to worry about? I am not diabetic.
    My previous scan at week 33.5 weeks dint show any such thing.

    • He Teena
      I am unable to give advice to individuals. Can you discuss this with your care provider who should have a good understanding of you individual situation? 3.4kg is a good weight for a 38 week baby – but ultrasounds are not very good at estimating weight. Your AFI is not technically polyhydramnios according to general definitions which = over 25. You seem to be having a lot of scans ie. one at 33.5 and at 38 weeks – so I am guessing there are concerns about your pregnancy as routine scanning at these gestations is not evidence based?

  46. Elizabeth says:

    Hi, I’m 33+3 for the last couple of months my bump has been hard and I have been measuring just above my dates. I’ve also been having a lot of discharge for which I had swabs and they came back clear. Last week I booked a private scan as I had a feeling something was not right and I wanted assurance. I was told I have a lot of fluid and to contact my midwife. I did so and was refered to see my consultant. On seeing him today and having a scan my AFI is 26cm and deepest pool 11cm, I also have leu 2+ protein 1+ ery 1+ . I am booked to have a gestational diabieties test and if that comes back clear then they will monitor me as normal but no other action. Should more be done, should I be concerned, something doesn’t feel right with the baby and I lack confidence that they are doing enough. I would appriciate any advice or information.

    • Hi Elizabeth
      You should always listen to your intuition. However, there are no other tests they can offer at the moment, or action to take – all they can do is ‘monitor’ until something becomes abnormal. Discuss your concerns with your midwife ie. ‘that something doesn’t feel right’ – it sounds like you need some additional emotional support.

  47. Elizabeth says:

    Thank you for your reply. I haven’t felt like I’ve had much support of my midwife at all in this pregnancy so your probably right. However I don’t see my midwife again until I am 37 weeks which feels so long away, I also can’t contact her via phone as her phone keeps breaking. My consultant is aiming to get me to at least 35 weeks so if I don’t make it to 37 which I don’t feel I will then I won’t see her again at all.

    • This is why every woman should have continuity of care by a named midwife ie. contactable. Not sure if your midwife is a private midwife ie. you have engaged her services, or if she is working for a public service. Either way – she should have a reliable phone! I am sorry that your care provider/system is letting you down :(

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