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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 3  |  Page : 228-235

The effect of oral versus intravenous fluid therapy on maternal and neonatal outcomes for women with oligohydramnios


1 Women’s Health and Maternity Nursing, Faculty of Nursing, Kafr El-Sheikh University, Kafr El-Sheikh, Egypt
2 Maternal and Newborn Health Nursing, Faculty of Nursing, Helwan University, Helwan, Egypt

Date of Submission22-Nov-2017
Date of Acceptance07-May-2018
Date of Web Publication28-Dec-2018

Correspondence Address:
Hala Abd El-fttah Ali
Women’s Health and Maternity Nursing, Faculty of Nursing, Kafr El-Sheikh Unive rsity, Kafr El-Sheikh
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_43_17

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  Abstract 


Background Oligohydramnios may increase the perinatal morbidity and mortality rate and is associated with adverse fetal outcomes.
Aim The aim of this study was to assess the effect of oral versus intravenous fluid therapy on maternal and neonatal outcomes for women with oligohydramnios.
Study design This was a quasi-experimental study model.
Setting Th study was conducted at a high-risk pregnancy department at a specific private hospital in El-Mansoura City, Egypt.
Participants and methods A purposive sample of 45 pregnant women with oligohydramnios was included in the study, and the women were divided equally into three groups, with 15 women per each group: the first group was administered intravenous (i.v.) isotonic solution, second group was administered i.v. hypotonic solution, and the third group was administered oral water. Data were collected during the period of 6 months from the first of December 2016 to the end of August 2017.
Tools Four tools were used to conduct this study: maternal characteristics questionnaire, sonographic report for measuring amniotic fluid index (AFI) in oligohydramnios women before and after hydration, fluid chart, and maternal and neonatal assessment sheet.
Results The AFI was significantly increased from 0.35±0.07 to 1.7±0.5 in the i.v. isotonic group whereas the AFI was significantly increased from 0.37±0.08 to 1.9±0.9 in the i.v. hypotonic group. Moreover, the AFI was more markedly increased from 0.37±0.07 to 2.7±0.8 in the oral water group. The maternal and neonatal outcomes did not differ significantly among the groups but were more markedly increased in the oral water group.
Conclusion Oral hydration is as effective as intravenous hydration in significantly increasing the AFI in the third trimester oligohydramnios. The AFI was more markedly increased in the oral water. Maternal and neonatal outcomes did not differ significantly among the groups.
Recommendations Oral hydration is recommended for pregnant women with oligohydramnios till delivery.

Keywords: amniotic fluid index, intravenous fluid, maternal and neonatal outcomes, oligohydramnios, oral mother hydration


How to cite this article:
Ali HA, Ahmed SR. The effect of oral versus intravenous fluid therapy on maternal and neonatal outcomes for women with oligohydramnios. Egypt Nurs J 2018;15:228-35

How to cite this URL:
Ali HA, Ahmed SR. The effect of oral versus intravenous fluid therapy on maternal and neonatal outcomes for women with oligohydramnios. Egypt Nurs J [serial online] 2018 [cited 2019 Jan 17];15:228-35. Available from: http://www.enj.eg.net/text.asp?2018/15/3/228/248970




  Introduction Top


Normal amniotic fluid volume (AFV) changes with gestational age and ways of accurate estimation. Too little amniotic fluid (AF) represents oligohydramnios. Moreover, oligohydramnios has been defined as follows: AFV is less than 500 ml at 32–36 weeks of gestation or maximum vertical pocket is less than 2 cm from late mid-trimester or AFI is less than 5 cm or less than the 5th percentile, from late mid-trimester (Morris et al., 2014). Excretion of urine by the fetus is the major source of AF production in the second half of the pregnancy. Moreover, fluid secreted by the fetal respiratory tract contributes to AFV. Fetal swallowing is the major pathway of AF clearance in the last half of gestation. Fetal skin is highly permeable in the first half of pregnancy but becomes keratinized at 22–25 weeks of gestation, significantly reducing transfer. The mother’s fluid balance (and also therefore the fetus) has a major effect on the AFV. Increased maternal fluid intake has been shown to increase the AFV in women with oligohydramnios (Patient: Making Lives Better, 2017).

Oligohydramnios is usually associated with premature rupture of membrane (PROM), fetal congenital anomalies, intrauterine growth retardation (IUGR), postmaturity, hypertension, diabetes mellitus, autoimmune disorders, hypovolemic states and iatrogenic states. The incidence of idiopathic types represents ∼7% of oligohydramnios. It complicates 4.0–5.5% of pregnancies and is associated with adverse fetal outcomes. The perinatal morbidity and mortality rates may increase to 56.5% with oligohydramnios. Furthermore, it increases the cesarean section (CS) rates by five to seven times. Additionally, oligohydramnios is more common in pregnancies beyond term, as the AFV normally decreases at term. It complicates as many as 12% of pregnancies that last beyond 41 weeks (Cunningham et al., 2010; Jagatia et al., 2013; Ülker, 2014; Bhat and Kulkarni, 2015; Madhavi1 and Chandrasekhar, 2015; Patient: Making Lives Better, 2017).

The maternity and newborn health nurse plays an energetic role in management of oligohydramnios based on gestational age. Planned birth in an obstetric unit is recommended. Transfer to a tertiary referral center may be appropriate if oligohydramnios is severe. Before term, expectant management is often the most appropriate course of action, depending on maternal and fetal condition. Ongoing antepartum surveillance (including assessment of fetal growth and follow-up monitoring of AFV) is necessary. Continuous fetal heart rate monitoring during labor has been advocated for all pregnancies complicated by oligohydramnios. However, maternal rest in the left lateral position significantly increases the AFV. At term, delivery is often the most appropriate management with reassuring fetal testing; delivery may be safely delayed on the basis of the parity, the gestational age, the mother’s cervix dilatation and the severity of the oligohydramnios. After term, isolated oligohydramnios in the post-term patient has no greater risk for CS delivery and there is insufficient evidence to support induction for women with oligohydramnios. The treatment of maternal dehydration with oral or intravenous (i.v.) rehydration has been shown to increase the AFV by 30% (Akter et al., 2012; Ulker et al., 2012).

Significance of the study

The importance of AFV as an indicator of fetal status is a relatively recent development. It plays a major role in the development of fetus. AF allows proper growth and development of fetal long bones and musculoskeletal system; it has bacteriostatic and anti-inflammatory properties (Pásztor et al., 2014). Oral hydration therapy is a cheap and feasible method and devoid of serious adverse effects; thus, we suggest this method of hydration in women with oligohydramnios, as our results demonstrated it is the most effective method for oral maternal hydration. Several studies have previously been conducted to determine the effect of maternal hydration of amniotic fluid index (AFI) in women with oligohydramnios. However, most of these studies were limited by sample sizes and examined pregnant women at near-term (>35 weeks gestational age) but did not study the maternal and neonatal outcome. Therefore, this study was carried out to assess the effect of oral versus i.v. fluid therapy on maternal and neonatal outcomes for women with oligohydramnios. In addition, it was done to focus the attention of researchers toward developing a hydration management strategy for women with oligohydramnios for the next risky pregnancy, and for those with new incidence of oligohydramnios, that provides the greatest chance for appropriate safe delivery with the least maternal, fetal, and neonatal risk.


  Aim Top


The aim of this study was to assess the effect of oral versus i.v. fluid therapy on maternal and neonatal outcomes for women with oligohydramnios.

Research hypothesis

To fulfill the aim of this study, the following research hypothesis was formulated: women with oligohydramnios are more likely to cure with oral water therapy than i.v. fluids, and those on oral water therapy would achieved more markedly better maternal and neonatal outcomes than the other groups.


  Participants and methods Top


Research design

This was a quasi-experimental study design.

Setting

The study was conducted at a high-risk pregnancy department at a specific private hospital in El-Mansoura City, Egypt.

Sampling

A purposive sample of women with oligohydramnios was recruited, and their data were collected during the period from the first of December 2016 to the end of August 2017.

Inclusion criteria were as follows:

  1. AFI of less than or equal to 5 cm.
  2. Well-established gestational age 37 and more weeks.
  3. Intact membranes.
  4. Maternal age ranging 15–38 years.
  5. Women with 1–4 parity.


Exclusion criteria were as follows:

  1. Maternal complications such as hypertension, diabetes mellitus, cardiovascular disease, and hyperthyroidism.
  2. Any evidence of pre-eclampsia.
  3. Any evidence of fetal structural abnormality on ultrasonographic study.
  4. Rupture of the membranes.


A sample size

The target variable in this study is to explore the effect of oral versus i.v. fluid therapy on women with oligohydramnios. Considering the level of significance of 5%, and power of study of 80%, the sample size can be calculated using the following formula: n={(/2+)×2×[2(SD)×2]}/effect size×2=[(1.96+0.84)×2×2(0.7)×2]/0.5×2. Based on this formula, 15 participants are needed in each group.

Group assignments

In the arrangement of study groups, a purposive sample was used. A study sample of 45 pregnant women was divided equally into three groups, with 15 women in each group. Fifteen women were allocated to i.v. isotonic solution group, 15 women to i.v. hypotonic solution group, and 15 women to oral water group. The allocation started on admission for labor, where each woman was randomly allocated into three groups.

Tools of data collection

Data collection obtained by using the following tools:
  1. Tool I (maternal characteristics questionnaire): it consists of five items and was originally designed to collect maternal characteristics such as maternal age, gestational age, parity, gravidity, and BMI. It was reviewed by the supervisors in the field of maternity nursing and implemented by researchers.
  2. Tool II: sonographic report for amniotic fluid index in women with oligohydramnios, before and after ultrasonography, were recorded on prepared data collection form.
  3. Tool III was the fluid chart recommended by Lorzadehet al.(2008) as follows.
    1. Oral intake of water for 2 l/2 h.
    2. i.v. infusion of isotonic fluid (normal saline) for 2 l/2 h.
    3. i.v. infusion of hypotonic fluid (Ringer’s solution) for 2 l/2 h.
  4. Tool IV (maternal and neonatal assessment sheet): it consists of eight items and was originally designed to assess maternal and neonatal outcomes such as completed weeks’ gestation, mode of delivery, postpartum hemorrhage (PPH), weight of neonate, small for gestational age, stillbirth, Apgar score, and special care baby unit admission. It was reviewed by supervisors in the field of maternity nursing and was implemented by researchers.


Validity of the tools

The three tools used in this study were reviewed by a panel of three experts in the maternity nursing specialty before introducing them to the participants to ensure its validity, and their comments were considered.

Administrative design

Official permission was obtained from the director of the Specific Private Labour and Delivery Hospital in El-Mansoura City, Egypt.

Ethical consideration

Ethical approval was granted by the Ethics Committee of the Nursing Faculty. Permission and written consent to carry out the study were obtained from parturient women. The researcher introduced herself to all health care providers and parturient women, and the aim of the study was explained before their participation to obtain their acceptance and cooperation.

Pilot study

A pilot study was conducted on 10% of the total sample. It aimed to assess the required time for each team to perform the task and to assess clarity, feasibility and applicability of the tools. The results of the pilot indicated that the task needs 20–30 min to be completed and statements of the tools were clear and applicable. The pilot sample was excluded from the study.

Research procedure

Preparation phase

The researcher introduced herself to eligible women and briefly explained the nature of the study, and then written consent was obtained from them. The researcher visited the Specific Private Labour and Delivery Hospital 3 days/week (Thursday, Friday, and Saturday) for 12 h/ daily to obtain the study sample. The interview took from 20 to 30 min with each woman in intervention groups. Specific issues were addressed and documented, including maternal characteristics, which were talked out by the researcher.

Randomization of parturient women into the three intervention groups was continued. A study sample of 45 pregnant women was included in the study. Of them, 15 women were allocated into i.v. isotonic solution group, 15 women into i.v. hypotonic solution group, and 15 women into oral water group. This was done once labor was established, which had been confirmed by vaginal examination. Labor was confirmed if there was (i) effacement of the cervix, (ii) cervical dilatation of 3 cm or more, and (iii) regular uterine contractions occurred every 5 min, lasting at least 20 s.

Data sheets were completed for all pregnant women. Before analysis, data collection tools were reviewed after testing for validity.

Implementation phase

After obtaining written informed consent as well as evaluation of inclusion and exclusion criteria and matching for confounding factors, patients were randomly allocated to three groups, with 15 women in each group (the first group was administered i.v. isotonic solution, the second group was administered i.v. hypotonic solution, and the third group was administered oral water). The recommended fluid chart was as follows:
  1. i.v. infusion of isotonic fluid (normal saline) for 2 l/2 h.
  2. i.v. infusion of hypotonic fluid (Ringer’s solution) for 2 l/2 h.
  3. Oral intake of water for 2 l/2 h.


Application follow-up form: a table was used for registration of fluids, including the duration and frequency of administration of fluids. All patients were admitted and ultrasonography for measuring AFI was performed twice, one before oral or i.v. rehydration therapy, and the second, 1 h after oral or i.v. rehydration therapy. The AFI was rechecked after 2 days and followed up regularly and were recorded on prepared data collection form. Maternal vital sign and any sign of overhydration during fluid therapy were monitored.

The researcher, nurses, and midwives in the intrapartum practices monitored labor and early detection of labor complication. If the cervix was not fully dilated within 2 h, operative treatment was indicated, and cesarean section (CS) was done.

Outcome phase

Two outcomes were assessed in this study:
  1. Primary outcome was AFI in pregnant women with oligohydramnios before and after hydration.
  2. Secondary outcomes were maternal and neonatal outcomes following hydration.


Limitations of the study

The type of intervention was difficult to randomize and there was no control group to compare the effectiveness of the interventions.

Statistical analysis

Statistical analysis of the data was performed using the SPS version 20.0 program (SPSS Inc., Chicago, Illinois, USA). Continuous data were expressed as mean±SD, whereas categorical data were expressed as number and percent. The comparisons of the continuous data were made by Student’s t-test, whereas comparisons between the categorical data were made by chi-square test. The level of significance was set at P less than 0.05.


  Results Top


The current results include the following three parts: maternal characteristics, comparison of the AFI in women with oligohydramnios before and following hydration, and comparison of the maternal and neonatal outcomes among the three groups. A study sample of 45 pregnant women was divided equally into three groups, with 15 women in each group. Fifteen women were allocated into i.v. isotonic solution group, 15 women into i.v. hypotonic solution group, and 15 women into oral water. Their age ranged between 15 and 38 years, with 1–4 parity. According to the study aim and hypotheses, the following findings will support the study hypotheses and achieve the study aim.

As shown in [Table 1], the average age of the mothers in the i.v. isotonic group was 26.2±2.5 years, in the i.v. hypotonic group was 27.2±2.5 years, and in the oral water group was 26.3±2.3 years. The average gestational age in the i.v. isotonic group was 38.2±2.5 weeks, in the i.v. hypotonic group was 40.2±2.5 weeks, and in the oral water group was 39.3±2.3 weeks. The average gravidity in the i.v. isotonic group was 2.2±1.2, in the i.v. hypotonic group was 2.1±1.2, and in the oral water group was 2.7±0.8. The average parity in the i.v. isotonic group was 2.1±0.7, in the i.v. hypotonic group was 2.0±0.7, and in the oral water group was 2.5±0.9. The average BMI of the mothers in the i.v. isotonic group was 28.1±3.0 kg/m2, in the i.v. hypotonic group was 30.1±3.0 kg/m2, and in the oral water group was 29.2±2.8 kg/m2.
Table 1 Maternal characteristics (N=15)

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The AFI was significantly increased from 0.35±0.07 to 1.7±0.5 in the i.v. isotonic group (mean difference was 1.35, P<0.001), whereas the AFI was significantly increased from 0.37±0.08 to 1.9±0.9 in the i.v. hypotonic group (mean difference was 1.53, P=0.010). On the contrary, the AFI was more markedly increased from 0.37±0.07 to 2.7±0.8 in the oral water group (mean difference was 2.33, P<0.001) ([Table 2] and [Figure 1]).
Table 2 Comparison of the amniotic fluid index in women with oligohydramnios before and after hydration (N=15)

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Figure 1 Comparision of the amniotic fluid index in women with oligohydramnios before and following hydration.

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Regarding pregnancy outcome, the gestational age at delivery, mode of delivery and the occurrence of PPH did not differ significantly among the groups, but the oral water group achieved more markedly better maternal and neonatal outcome results than the other groups ([Table 3]).
Table 3 Comparison of the maternal and neonatal outcomes among the three groups (N=15)

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Moreover, regarding the neonatal outcome, the neonatal body weight at delivery, the occurrence of stillbirth, being small for gestational age, Apgar score at 5 min, and the admission to special care baby unit did not differ significantly among the groups, but the oral water group achieved more markedly better results than the other groups ([Table 3]).


  Discussion Top


Pregnancy is an exciting time when women face the unknown experience of motherhood and watch the profound changes their bodies undergo in preparation for the child birth. For many women, oligohydramnios is a time of reappraisal of behavior, nutrition, and lifestyle to ensure that their fetus has the best and healthiest start in life. Most pregnant women are likely to pay more attention to living healthily and eating a healthy diet than they did before pregnancy, but there is a chance that they may still overlook a key element in antenatal well-being; hydration. Adequate hydration is especially important during and after pregnancy to help meet the physiological changes that occur during these important phases of the life cycle. Water is needed to form AF that surrounds the baby, support the increase in blood plasma volume, and produce breast milk (Derbyshire and Natural Hydration Council, 2016).

Therefore, this study aimed to assess the effect of oral versus i.v. fluid therapy on maternal and neonatal outcomes for women with oligohydramnios. Accordingly, the study hypothesis is accepted ‘Women with oligohydramnios are more likely to cure with oral water therapy than intravenous fluids and has achieved more markedly better maternal and neonatal outcome than the other groups’. The results of the current study showed that both oral and i.v. hydration significantly increased the AFI in the oligohydramnios. These results were similar to those of Nada (2015) who studied oral and i.v. maternal hydration in the third trimester. These results may be related to the increase of the uterine placental perfusion (Patrelli et al., 2012), or owing to the acute reduction of maternal plasma osmolality and increasing the urine production rate in the near-term human fetus (Oosterhof et al., 2000). Fortunately, most studies, if not all, based on after oral hydration (Oosterhof et al., 2000; Magann et al., 2003; Ghafarnejad et al., 2009; Akter et al., 2012; Patrelli et al., 2012; Nada, 2015) or after i.v. hydration (Umber and Chohan, 2007; Yan-Rosenberg et al., 2007; Patrelli et al., 2012; Shahnazi et al., 2012; Nada, 2015), correspond with our findings. In the same line, the AFI was more markedly increased from 0.37±0.07 to 2.7±0.8 in the oral water group (mean difference was 2.33, P<0.001) in the present study. On the contrary, this result is in contrast to the study results of Nada (2015) who mentioned that neither oral nor i.v. hydration appeared advantageous one over the other.Although oligohydramnios causes the mother and the fetus to experience many complications, a study on the effects of i.v. hydration on AFI in pregnant women with preterm premature rupture of membranes did not find significant effect of hydration on AFI as a prophylactic method on oligohydramnios in pregnant women with preterm premature rupture of membranes, but hydration of the mother is a low-cost method with no complications for the fetus and the mother (Shahnazi et al., 2013). Moreover, the investigators studied the effect of ZamZam water intake during labor on maternal and neonatal outcome, and the study presented significant decreased CS deliveries among ZamZam water group. This result may indicate the maintenance blood glucose at normal level owing to ZamZam water treatment, which leads to decreased incidence of both maternal and fetal distress. In other words, hunger and thirsty during labor cause stress, and stress leads to an increase in adrenaline and noradrenaline levels, owing to decreased competence of the uterine contractions, which may in turn adversely affect fetal heart rate and increase the need for medical intervention (Ghani, 2012).

In Egypt, the results of a study concerning duration of active phase calculated by hour reported that it was less in the group that received i.v. fluids of 1500 ml (4.02±0.99) than the 1000 ml group and the 1250 ml group (6.82±1.00 and 5.34±0.52, respectively), and there was a statistically significant difference among the three groups in relation to the duration of the active phase and amount of fluid received through labor, as the duration become shorter when the i.v. fluid amount progress from 1000, 1250 to 1500 with duration of 6.82, 5.34, and 4.02, respectively. However, there were statistically significant differences between time during third stage calculated by minutes and the amount of i.v. fluid especially on 1000 and 1500 ml amount (Ghonemy and Kotob, 2017). These results reflect maternal outcome complications as mode of delivery and PPH. However, these results were not proved by our study, which revealed the pregnancy outcome, the gestational age at delivery, mode of delivery, and the occurrence of PPH, as complications, did not differ significantly among the study groups. These results were confirmed from 2426 laboring women, as researchers could not see any significant differences related to forceps deliveries or CS rates between women who were allowed to eat lightly or have just water during labor (Parson, 2009).

Regarding the neonatal outcomes, the positive result may reveal the nourishment effect of hydration which prevents maternal ketosis and in turn affects intrauterine fetal condition and umbilical artery pH favorably. In addition, once the umbilical artery pH is less than 7.2, the chances of having an Apgar score less than 7 at 5 min is higher. Furthermore, the odds of requiring NICU admission is 2.3 times higher than if the pH is more than 7.0 (Granger, 2009). The present result is congruent with the recommendations in the National Institute of Clinical Excellence guidelines, which state that women should be informed that having isotonic drinks during labor prevents ketosis without a concomitant increase in gastric volume and ensures a better effect on maternal and fetal well-being (Lui et al., 2007). In addition, the WHO points out that, because labor requires enormous amounts of energy to ensure fetal and maternal well-being, the health care providers should not interfere with the woman’s wish for food and drink during labor (World Health Organization WHO, 1997). The present study confirmed these results as the neonatal outcome, the neonatal body weight at delivery, the occurrence of stillbirth, being small for gestational age, Apgar score at 5 min, and the admission to NICU, were good, as approximately half or more of the participants’ neonates had an Apgar score of 7 or less at 5 min. Moreover, three neonates, four neonates, and also one neonate in the IV isotonic, IV hypotonic, and oral water groups respectively were admitted to NICU, although the neonatal outcomes statistically did not differ significantly among the groups. The mechanism of these results is not clear but may be because of the small number of each group in the study sample.

Fortunately, pregnant women can meet their body’s requirements from other drinks; water is one of the healthiest ways to hydrate as it has no calories, sugar, or caffeine (Derbyshire and Natural Hydration Council, 2016). Finally, there are many experiments done on water. These tested the healing ability water possesses. All proved that we do not know yet the potential energy of the water. Hence, we can safely say again that as water carries and brings life to plants and if the earth vibrates when the water pours down on it, the human body’s cells would also be affected and vibrated when water enters these cells.


  Conclusion Top


The AFI was significantly increased in the i.v. isotonic group, whereas the AFI was significantly increased in the i.v. hypotonic group. Fortunately, the AFI was more markedly increased in the oral water group. The mode of delivery and the occurrence of PPH did not differ significantly among the groups. Moreover, the Apgar score at 5 min and the admission to NICU as the neonatal outcomes did not differ significantly among the groups. There shows the good effect of oral hydration over i.v.. Women with oligohydramnios are more likely to cure with oral water therapy than i.v. fluids and have achieved more markedly better maternal and neonatal outcomes with oral water treatment than the other groups.

Recommendations

Determination of AFI should be used as an adjunct to other fetal surveillance methods. It helps to identify those infants at risk of poor perinatal outcome and is a valuable screening test for predicting fetal distress in labor requiring CS in oligohydramnios women. Continuous antepartum monitoring and intrapartum monitoring are mandatory for every women diagnosed with oligohydramnios to reduce the maternal and neonatal risks associated with oligohydramnios. The advantageous effect of maternal hydration is temporar so oral hydration may be recommended for pregnant women with oligohydramnios till delivery. Therefore, more studies with large sample size and wide range of gestational age are needed to verify the validity of this method in pregnant women with gestational age of less than 35 weeks having oligohydramnios, to avoid preterm labor induction and to prevent its serious consequences for mother and newborn baby. In most of the pregnant women, the effect of hydration lasts 2 days. So, extended period of hydration is recommended, i.e., 2.5 l/day every 2 days till the time of delivery. Nurse’s knowledge about care provided to women having oligohydramnios must be periodically upgraded through scientific conferences, meetings, seminars, and workshops because nurses have a significant role and profound effect in antepartum and intrapartum monitoring of this high-risk group.[27]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interesting.



 
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