Original Paper
Received: October 8, 2000
Gynecol Obstet Invest 2002;53:1–5
A Diminished Intrapartum Amniotic Fluid Index
Is a Predictive Marker of Possible Adverse
Neonatal Outcome when Associated with
Prolonged Labor
Noriyoshi Kawasaki a Hiroshi Nishimura a Toshihiro Yoshimura b
Hitoshi Okamura b
Departments of Obstetrics and Gynecology, a Shimonoseki Kosei Hospital, Shimonoseki, and
b Kumamoto University School of Medicine, Kumamoto, Japan
Key Words
Amniotic fluid index W Intrapartum amniotic fluid W Labor
duration W Adverse neonatal outcome
Abstract
Objective: To determine whether a diminished intrapar-
tum amniotic fluid volume represents a risk of adverse
neonatal outcome when it occurs in conjunction with
prolonged labor. Methods: The intrapartum amniotic
fluid index (iAFI) was measured in 242 parturients over
35 weeks of gestation during 1st-stage labor, and the
umbilical artery blood gas was analyzed at delivery. The
subjects were divided into group A (n = 99), having a
diminished amniotic fluid volume (iAFI ^8.0 cm) and
group B (n = 143), having a normal amniotic fluid volume
(iAFI 8.1–20.0 cm), and selected antenatal, delivery, and
neonatal variables were compared. In addition, the two
groups were subdivided according to the duration of
labor. Statistical analysis was performed using indepen-
dent Student’s t test, Mann-Whitney U test, chi-square
analysis, and Fisher’s exact test where appropriate. p !
0.05 was considered significant. Results: The patient
characteristics and pregnancy outcomes were similar in
groups A and B, as were the incidences of an umbilical
artery blood pH ! 7.20 and/or an Apgar score ! 7
(group A 9.5%, group B 10.1%). In group A, however, the
© 2002 S. Karger AG, Basel
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Accepted after revision: July 12, 2001
incidence of an adverse neonatal outcome was 23.5% in
cases in whom the duration of labor was longer than 8 h
which was significantly higher than in cases in whom the
duration of labor was 8 h or less (2.8%; p ! 0.01). In
group B, the incidence of an adverse neonatal outcome
was similar in the two subgroups. Conclusions: The risk
of an adverse neonatal outcome is higher in patients
with diminished amniotic fluid volume if labor is pro-
longed. Consequently, determination of the iAFI could be
a useful admission test.
Copyright © 2002 S. Karger AG, Basel
Introduction
Fetal admission tests were developed to screen partu-
rients for significant risks of such adverse peripartum out-
comes as cesarean section for presumed fetal distress, low
Apgar scores, and neonatal acidosis [1–4]. The use of
these tests could improve patient triage, utilization of
labor and delivery resources, and the timeliness of inter-
ventions for compromised fetuses. Intrapartum assess-
ment of the amniotic fluid index (AFI) had been consid-
ered the ideal admission test because, regardless of the
cause of oligohydramnios, an AFI ^5.0 cm in early labor
was associated with a poor perinatal outcome [1–5]. More
recently, however, the associations between an intrapar-
Noriyoshi Kawasaki, MD
Department of Obstetrics and Gynecology
Shimonoseki Kosei Hospital, Kamishinchi 3-3-8
Shimonoseki 750-0061 (Japan)
Tel. +81 832 31 5811, Fax +81 832 23 3077, E-Mail nori-kawasaki@hkg.odn.ne.jp
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Table 1. Descriptive variables of women
undergoing intrapartum amniotic fluid Variable AFI p
assessment ^8 cm (n = 99) 8–20 cm (n = 143)

Age, years 27.8B4.2 27.9B4.5 NS

Gravidity, median (range) 1 (1–6) 2 (1–5) NS
Parity, median (range) 0 (0–4) 0 (0–4) NS
Gestational age, weeks 39.5B1.1 39.5B1.1 NS
Amniotic fluid index, cm 6.1B1.5 12.0B2.7 ! 0.01

Table 2. Delivery outcome variables in

women undergoing intrapartum amniotic Variable AFI p
fluid assessment ^8 cm (n = 99) 8–20 cm (n = 143)

Duration of labor, h 7.45B5.13 8.44B6.34 NS

Delivery route, %
Vaginal spontaneous 64.6 71.3 NS
augmentation 16.2 14.7 NS
vacuum extractor 17.2 10.5 NS
Cesarean section 2.0 2.8 NS

Table 3. Neonatal outcome variables from

pregnancies undergoing intrapartum Variable AFI p
amniotic fluid assessment ^8 cm (n = 99) 8–20 cm (n = 143)

Birth weight, g 3,023B313 3,106B364 NS

! 2,500 g, % 3.0 4.2 NS
Apgar score, median (range)
1 min 9 (7–10) 9 (4–10) NS
! 7, % 0 1.3 NS
5 min 9 (8–10) 9 (7–10) NS
! 7, % 0 0 NS
Umbilical artery blood pH 7.296B0.075 7.295B0.078 NS
! 7.20, % 9.1 9.8 NS

tum AFI (iAFI) ^5.0 cm and intrapartum complications
have been disputed [6, 7]. We, therefore, considered
whether assessing the iAFI in the context of the duration
of labor would be more predictive of adverse perinatal
outcomes.
Patients and Methods
Patients delivering at the Shimonoseki Kosei Hospital between
May 1, 1996, and December 31, 1999, in whom an iAFI was deter-
mined and an umbilical artery (UmA) blood gas analysis was per-
formed, were entered into the study (n = 242). Patients with a rup-
tured membrane were included in the study, but those with multife-
tal gestations, or having an elective cesarean section, those in whom
delivery was imminent, those with polyhydramnios (AFI 1 20 cm),
chronic hypertension, preeclampsia, diabetes mellitus, and intrauter-
ine growth restriction, or those in whom no AFI or UmA blood gas
analysis was performed because of staff unavailability were ex-
cluded.
The AFI was determined with a linear 3.5-MHz transducer on a
Sonovista SL (Mochida Pharmaceuticals, Tokyo, Japan) using the
four-quadrant AFI technique [8]. All AFI determinations were per-
formed on admission, when the patients were in the first stage of
labor. At delivery, the umbilical cord was clamped at two places, and
an UmA blood sample was obtained in a preheparinized syringe and
placed on ice. All blood gas analyses were done within 30 min of
delivery.

2 Gynecol Obstet Invest 2002;53:1–5 Kawasaki/Nishimura/Yoshimura/Okamura

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 Fig. 1. Distribution of the duration of labor and the intrapartum AFI. Open squares represent the cases with good
neonatal outcomes (UmA pH 67.20 and 1-min Apgar score 67) and closed symbols represent the cases with adverse
neonatal outcomes: $ = UmA pH ! 7.20 and 1-min Apgar score 67; j = UmA pH ! 7.20 and 1-min Apgar score ! 7;
d = UmA pH 67.20 and 1-min Apgar score ! 7.
The patients were divided into two groups: group A patients (n =
99) exhibited iAFIs ^8.0 cm and included 20 oligohydramnios
patients (iAFI ^5.0 cm) and 79 borderline oligohydramnios patients
(iAFI 5.1–8.0 cm) and were designated as having diminished am-
niotic fluid: group B patients (n = 143) exhibited iAFIs 8.1–20.0 cm
and were designated as having normal amniotic fluid. Group A was
compared with group B with respect to the following data abstracted
from each patient’s medical record: maternal age, gravidity, parity,
gestational age, duration of labor, delivery route, neonatal birth
weight, pH in the UmA, and Apgar score at 1 or 5 min after birth.
Labor onset was defined as that time when regular painful contrac-
tions began, occurring every 10 min, leading to cervical change. This
time was determined by patient history.
Statistical analyses were performed with an independent Student
t test, Mann-Whitney U test, chi-square analysis, and Fisher’s exact
test where appropriate. p ! 0.05 was considered significant. Contin-
uous data are reported as mean values B SD and nonparametric data
as a median and range.
Intrapartum AFI, Duration of Labor, and
Neonatal Outcome
Results
Groups A and B were similar with respect to maternal
age, gravidity, parity and gestational age (table 1). As
shown in table 2, duration of labor and route of delivery
were also similar in the two groups.
The mean birth weights in group A and B were similar,
as were the incidences of adverse neonatal outcomes,
defined as UmA pH !7.20 and/or Apgar score !7
(group A 9.5%, group B 10.1%). The median Apgar scores
at 1 and 5 min were similar in the two groups, and there
were no differences in the incidences of low 1- or 5-min
Apgar scores. The mean pH in the UmA and the inci-
dence of the lower UmA pH (!7.20) were also similar (ta-
ble 3). All infants with low UmA pH and/or a low 1-min
Gynecol Obstet Invest 2002;53:1–5 3
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Table 4. Incidence of adverse neonatal outcomes from pregnancies
undergoing intrapartum amniotic fluid assessment
AFI Duration of labor
^8 h 18 h
^8 cm 2.8% (2/68) 23.5% (7/31)
8–20 cm 6.5% (6/89) 16.4% (9/54)
Apgar score (!7) soon improved, and the 5-min Apgar
scores were all 7 or more.
Duration of labor, iAFI, and neonatal outcome are
shown in figure 1 and table 4. When the groups were
divided into two subgroups each, the incidence of an
adverse neonatal outcome was 23.5% among patients in
group A with a labor duration 18 h which was significant-
ly higher than among group A patients with a labor dura-
tion ^8 h (2.8%, p ! 0.01). On the other hand, the dura-
tion of labor had no significant effect on the incidence of
adverse neonatal outcomes among patients in group B,
though the incidence tended to be higher among patients
with a labor duration 18 h (16.4 vs. 6.5%, NS). Six cases
of emergent cesarean section were included in the sub-
group with a labor duration 18 h; the decision to perform
a cesarean section was made after 18 h of labor. The indi-
cations for cesarean section were malrotation (n = 3) and
fetal distress (n = 3), and in each case abdominal delivery
prevented the development of an adverse neonatal out-
come.
Discussion
Because up to 20% of antepartum low-risk patients
develop complications during labor, separation of the
high- and low-risk patients during the intrapartum period
is important. Fetal admission tests were, therefore, devel-
oped to screen parturients for significant risks of such
adverse peripartum outcomes as cesarean section for pre-
sumed fetal distress, low Apgar scores, and neonatal aci-
dosis [1–4]. In this regard, the AFI was described by Phe-
lan et al. [8] as a semiquantitative means of assessing
amniotic fluid volume during pregnancy. As ultrasound is
becoming increasingly available in labor and delivery
units, its utilization for screening intrapartum patients is
now certainly feasible; indeed, determination of the AFI
is a simple and rapid procedure that does not require
extensive training [9].
4 Gynecol Obstet Invest 2002;53:1–5
The clinical appeal of the AFI is that oligohydramnios
(AFI ^5.0 cm) is associated with significantly higher inci-
dences of abnormal fetal heart rate tracings, cesarean sec-
p
tion for fetal distress, and low 1- and 5-min Apgar scores
[3, 5]. Recently, however, some investigators have been
unable to confirm that an iAFI ^5.0 cm is the critical val-
! 0.01
NS ue associated with a significant risk of abdominal delivery
for fetal distress [4]. By contrast, Jeng et al. [10] reported
that an AFI !8.0 cm was associated with a significant risk
of abnormal fetal heart rate tracings and emergency cesar-
ean section for fetal distress, and in a separate study,
Grubb and Paul [11] found that an iAFI !2 cm was pre-
dictive of similar adverse outcomes. The reason for the
disparity among these findings is that the critical value for
the amniotic fluid volume associated with adverse out-
comes was empirically chosen, and the outcome may vary
among clinicians in different practices.
Our study population was at low risk, with few cases
(8.7%) of oligohydramnios (iAFI !5.0 cm). Nonetheless,
we still had a 6.3% incidence of adverse neonatal out-
comes. The placental hemodynamic alterations result in
fetal heart rate abnormalities and hypoxia [12]. The best
evidence of intrapartum fetal hypoxia at birth, however,
is considered to be the UmA acid-base status rather than
abnormal fetal heart rate patterns [13]. For these reasons,
we included borderline oligohydramnios (iAFI !8.0 cm)
in our analysis, and we used a low pH in the UmA or low
Apgar scores, not cesarean section rate, for the evaluation
of the perinatal outcome.
We found that the incidence of adverse neonatal out-
comes could not be predicted by iAFI alone which is con-
sistent with the findings of Chauhan et al. [14]. However,
in the cases where patients exhibiting low iAFI also expe-
rienced prolonged labor, the incidence of the adverse neo-
natal outcomes was significantly higher than in the nor-
mal iAFI group. One possible explanation could be that,
when there is less fluid around the fetus, the reduction in
cushioning normally provided by the fluid may have
increased the degree of compression of the fetal head or
umbilical cord. If this situation is prolonged, compensato-
ry mechanisms may eventually fail, even in fetuses doing
well otherwise. Alternatively, decreased amniotic fluid
may be a sign of chronic fetal hypoxia that only becomes
apparent after prolonged labor stress. However, it should
be mentioned also that, in patients with labor duration
18 h, the incidence of adverse neonatal outcomes was not
different between patients with iAFI !8 cm and 8–20 cm.
And 1 case with low UmA pH and low Apgar score was
found in the group with normal iAFI (9 cm) and pro-
longed labor (fig. 1).
Kawasaki/Nishimura/Yoshimura/Okamura
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 The critical duration of labor was seen at 8 h which is
generally considered the mean duration of labor of multi-
paras [15]. The purpose of this study was not to determine
the critical labor duration with respect to iAFI, as a pro-
spective study would be more appropriate for the pur-
pose.
In conclusion, the results of the present study indicate
that the risk of adverse neonatal outcomes in patients
with diminished iAFI increases when labor is prolonged.
Consequently, measurement of the iAFI should be a use-
ful admission test.

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Neonatal Outcome
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