Understanding the Importance of a Planned, Early Delivery When the Pregnancy is High-Risk

Going through pregnancy, labor and delivery is a very exciting experience. During this joyous time, parents hope that nothing occurs that can affect the health of their baby. Most of the time, babies are born healthy. But when something goes wrong around the time of a child’s birth, the consequences can be devastating. Birth injuries can be caused by many different types of complications that occur around the time of delivery. Often, these complications involve umbilical cord problems, such as the cord being wrapped around the baby’s neck (nuchal cord), a placental abruption or uterine rupture, or brain bleeds caused by vacuum extractor use. Birth injuries and birth trauma can usually be avoided if the medical team follows standards of care, closely monitors the baby’s heart rate, and quickly delivers the baby when she is in distress.

When mismanaged, however, birth complications can cause the baby to experience a lack of oxygen in her brain (birth asphyxia), which can cause the following birth injuries:

Delivering a Baby Before Term to Prevent Birth Injuries

We have written extensively about pregnancy and birth complications that can cause serious harm to the baby if the medical team fails to follow standards of care. In certain cases, early delivery of a baby is required in order to avoid birth injuries, such as hypoxic ischemic encephalopathy (HIE) and cerebral palsy.

Under the following circumstances, standards of care require early delivery:

  • Placenta previa: This is when the placenta grows so close to the opening of the uterus it partially or completely blocks the mother’s cervix (or “cervical os”), which is the opening to the birth canal.  This can lead to severe bleeding and hemorrhaging if mismanaged.  Due to the risks associated with placenta previa, delivery should take place when the baby’s gestational age is 36 – 37 weeks. If there are additional complicating factors, such as intrauterine (fetal) growth restriction (IUGR/FGR), preeclampsia, etc., delivery may need to occur earlier.
  • Suspected placenta accreta, increta, or percreta with placenta previa. Placenta accreta, increta and percreta are abnormalities of placental implantation. When these conditions are present, the baby should be delivered at 34 – 35 weeks, and if additional complicating factors are present, such as IUGR/FGR, preeclampsia, etc., the baby may need to be delivered closer to week 34, maybe sooner.
  • The mother had a prior classic C-section, with an upper segment uterine incision. In this case, the baby should be delivered at 36 – 37 weeks. If there are other complicating issues, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be required.
  • Prior myomectomy necessitating C-section delivery. A myomectomy is surgery to remove pelvic tumors. Myomectomy is associated with an increased risk of uterine rupture during a subsequent pregnancy. As such, most experts recommend a C-section delivery. Delivery should occur at weeks 37 – 38. Earlier delivery may be required in situations where the mother had a more complicated or extensive myomectomy. Also, if the mother has other pregnancy complications, such as IUGR/FGR or preeclampsia, etc., delivery may need to take place even earlier.
  • Intrauterine (fetal) growth restriction (IUGR/FGR) when mother is pregnant with one baby. When IUGR/FGR is present and there are no other complicating factors, delivery should occur at weeks 38 – 39. If additional complications exist (oligohydramnios, abnormal Doppler studies, maternal risk factors, the presence of 2 or more chronic conditions), delivery should take place at weeks 34 – 37. Immediate delivery is indicated regardless of gestational age if there is persistent abnormal fetal testing suggesting imminent fetal jeopardy.
  • Intrauterine (fetal) growth restriction (IUGR/FGR) when mother is pregnant with twins. When the mother is pregnant with dichorionic-diamniotic twins and there is isolated IUGR/FGR, the baby should be delivered at 36 – 37 weeks. If the mother is pregnant with monochorionic-diamniotic twins with isolated IUGR/FGR OR has additional complications (oligohydramnios, abnormal Doppler studies, maternal risk factors, the presence of 2 or more chronic conditions), delivery should occur at 32 – 34 weeks. Expeditious delivery is indicated regardless of gestational age if there is persistent abnormal fetal testing suggesting imminent fetal jeopardy.
  • Fetal congenital malformations:
    • A baby who has any of the following conditions should be delivered at 34 – 39 weeks:
      • Suspected worsening fetal organ damage
      • Potential for brain bleeds / intracranial hemorrhages (e.g., vein of Galen aneurysm, neonatal alloimmune thrombocytopenia)
      • A delivery that should occur prior to the onset of labor (e.g., EXIT procedure)
      • A previous fetal intervention
      • Concurrent maternal disease (e.g., preeclampsia, chronic hypertension)
      • The potential for adverse maternal effect from the fetal condition
    • Immediate delivery is required regardless of gestational age if 1.) intervention is expected to be beneficial, 2.) fetal complications develop (abnormal fetal testing, new-onset hydrops fetalis, progressive or new-onset organ injury, or 3.) Maternal complications develop (mirror syndrome).
  • Multiple gestations: dichorionic – diamniotic. In this situation, the baby should be delivered at 38 weeks. If there are additional complicating factors, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Multiple gestations: monochorionic – diamniotic. In this scenario, delivery should take place at 34 – 37 weeks. If there are additional complicating factors, such as (IUGR/FGR), preeclampsia, etc., delivery may need to take place at an earlier date.
  • Multiple gestations: dichorionic – diamniotic or monochorionic – diamniotic with single fetal death. If the death occurs at or after week 34, consider delivery. This recommendation is limited to pregnancies at or after week 34; if the fetal death occurs before the 34th week, delivery is individualized based on concurrent maternal or fetal conditions. If there are additional complicating factors, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Multiple gestations: monochorionic – monoamniotic. In this situation, the baby should be delivered at weeks 32 – 34. If there are additional complicating issues, such as (IUGR/FGR), preeclampsia, etc., delivery may need to occur at an earlier date.
  • Multiple gestations: monochorionic – monoamniotic with single fetal death. In this case, delivery should be considered, with timing individualized according to gestational age and concurrent complications. If additional complicating issues exist, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Oligohydramnios (low amniotic fluid). If the condition is isolated and persistent, delivery at 36 – 37 weeks is indicated. If there are additional complicating issues, such as (IUGR/FGR), preeclampsia, etc., delivery may need to occur at an earlier date.
  • Chronic maternal high blood pressure (hypertension) & the mother is not being treated with medication. In this situation, delivery should occur at week 38 – 39. If additional complicating issues are present, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Chronic maternal hypertension controlled with medication. This condition requires a delivery at weeks 37 – 39. If there are additional complicating issues, such as (IUGR/FGR), preeclampsia, etc., delivery may need to occur at an earlier date.
  • Chronic maternal hypertension that is difficult to control (requires frequent medication adjustments). In this case, delivery should take place at weeks 36 – 37. If additional complicating issues exist, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Gestational hypertension (hypertension that begins during pregnancy). When a mother has this condition, delivery should occur at weeks 37 – 38.
  • Severe preeclampsia. Preeclampsia is a multi-system disorder characterized by hypertension and either protein in the urine or end-organ dysfunction that occurs in the last half of pregnancy. This condition requires that delivery take place as soon as the mother is diagnosed, as long as the pregnancy is at 34 weeks or later. If additional complicating issues exist, such as (IUGR/FGR), an earlier delivery may be indicated.
  • Mild preeclampsia. When the mother has mild preeclampsia, the baby should be delivered at 37 weeks. If there are additional complicating issues, such as (IUGR/FGR), an earlier delivery may be indicated.
  • Diabetes that the mother had prior to becoming pregnant (pregestational) that are well-controlled. Late preterm birth or early term birth is not recommended. However, if additional complicating issues exist, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Pregestational diabetes coupled with vascular disease. These conditions require that the baby be delivered at weeks 37 – 39. If additional complicating issues are present, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be necessary.
  • Pregestational diabetes that are poorly controlled. This situation requires that delivery take place at 34 – 39 weeks, with specific timing individualized to the mother’s situation. If there are additional complicating issues, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Gestational diabetes that are well-controlled either with diet or medication. Late preterm birth or early term birth is not recommended for this situation. However, if additional complicating issues exist, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • Gestational diabetes that are poorly controlled on medication. This scenario requires that delivery take place at 34 – 39 weeks, with specific timing individualized to the mother’s situation. If there are additional complicating issues, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • The mother had a previous unexplained stillbirth. Late preterm birth or early term birth is not recommended for this situation. Amniocentesis for fetal lung maturity should be considered if delivery is planned at less than 39 weeks. If additional complicating issues exist, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • The mother had a previous spontaneous preterm birth and is currently experiencing preterm premature rupture of the membranes. When this occurs, the baby can be delivered if her gestational age is 34 weeks or older. If there are additional complicating issues, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.
  • The mother had a previous spontaneous preterm birth and is currently experiencing active preterm labor. Delivery is indicated if there is progressive labor or an additional maternal of fetal indication. If additional complicating issues exist, such as (IUGR/FGR), preeclampsia, etc., an earlier delivery may be indicated.

Obstetricians must be aware of these guidelines and follow these standards of care. Failure to deliver a baby before term when there are maternal or fetal complications necessitating an early delivery can cause the baby to have birth injuries, such as hypoxic ischemic encephalopathy (HIE), periventricular leukomalacia (PVL), permanent brain damage, cerebral palsy, seizures, and intellectual and developmental disabilities.

In addition to being aware of conditions that require an early delivery in order to prevent birth injuries, expecting parents should ask potential obstetricians certain questions in order to further ensure a safe and healthy pregnancy and birth.

How to Choose a Doctor and Hospital for Delivery

Preventable medical error is an epidemic and these errors are responsible for over 400,000 deaths a year and millions of injuries annually. In order to help ensure a safe pregnancy, labor and delivery, it is very important to choose a hospital that has protocols in place to help ensure the health of each mother and baby. Equally important is choosing an obstetrician and medical team that have skill and experience.

Questions expecting mothers should ask potential obstetricians include the following:

  1. Will my baby have continuous electronic fetal heart rate monitoring? Continuous heart rate monitoring will help the medical team be aware of any distress the baby is experiencing.
  2. Are you skilled in fetal heart rate tracing interpretation, and how many years of experience do you have?
  3. Is there at least one other person involved in my labor and delivery that is skilled at fetal heart rate interpretation?
  4. If my baby shows signs of distress or impending distress, do you have the ability to deliver her very quickly by emergency C-section?
  5. How many years of experience do you have in performing emergency C-sections?
  6. Is there an additional physician immediately available in the event that multiple dangerous conditions occur simultaneously, such as my baby and I having difficulty at the same time?
  7. Is there proper resuscitation equipment (and a team if necessary) immediately available in case my baby needs to be resuscitated and/or intubated at birth? Intubation is when a tube is placed in the baby’s upper airway to help her breathe.

In addition to proper fetal monitoring, the mother must also be properly monitored. A mother’s blood pressure, heart rate, and physical signs (such as abdominal and back pain and lack of fetal movement) can give important information regarding impending or current fetal distress. When a baby is showing signs of distress on the fetal heart rate monitor, it means she is experiencing a lack of oxygen in her brain. When this occurs, the baby must be delivered quickly by emergency C-section (in most cases) to prevent brain damage and HIE.

Informed consent must be given by the mother for all procedures. This means that the use of risky delivery instruments, such as forceps and vacuum extractors, as well as the potentially dangerous labor drugs Pitocin and Cytotec, must be fully explained to the mother. The option of a C-section must also be explained. Thorough explanations include the risks and benefits of – as well as the alternatives to – each procedure.


Trusted Legal Help for Pregnancy, Delivery and Newborn Injury Cases

If you are seeking the help of a medical malpractice lawyer for your child, it is very important to choose a lawyer and firm that focus solely on birth injury cases. Reiter & Walsh ABC Law Centers is a national birth injury law firm that has been helping children with birth injuries since its inception in 1997.

If your child was diagnosed with a birth injury, such as cerebral palsy, a seizure disorder or hypoxic ischemic encephalopathy (HIE), the award winning Michigan medical malpractice lawyers at ABC Law Centers can help. We have helped children throughout the country obtain compensation for lifelong treatment, therapy and a secure future, and we give personal attention to each child and family we represent. Our national birth injury firm has numerous multi-million dollar verdicts and settlements that attest to our success and no fees are ever paid to our firm until we win your case.

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SOURCES:

  • Spong, Catherine Y., et al. “Timing of indicated late-preterm and early-term birth.” Obstetrics and gynecology 118.2 Pt 1 (2011): 323.
  • Graham EM, Ruis KA, Hartman AL, et al. A systematic review of the role of intrapartum hypoxia-ischemia in the causation of neonatal encephalopathy. Am J Obstet Gynecol 2008; 199:587.