Planned Early Delivery in High-Risk Pregnancies

Timing of delivery is a significant part of childbirth. 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 performs a quick delivery if the baby is showing signs of fetal distress.

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

• Hypoxic ischemic encephalopathy (HIE)
• Neonatal encephalopathy
• Permanent brain damage
• Seizure disorders
• Cerebral palsy (CP)
• Intellectual disabilities
• Developmental delays
• Motor disorders and low muscle tone
• Microcephaly
• Periventricular leukomalacia (PVL)

The American College of Obstetricians and Gynecologists (ACOG) published a recent committee opinion explaining that there are some fetal or maternal complications that necessitate a late-preterm or early term delivery (1). If indications are present for late-preterm or early term delivery, then the baby should be delivered at that time regardless of the results of lung maturity tests.

High-risk pregnancy and early delivery

There are a multitude of pregnancy and birth complications that can cause serious harm to the baby if the medical team fails to follow standards of care. These are called high-risk pregnancy complications. In certain cases of high-risk pregnancy, early delivery of a baby is required in order to avoid birth injuries, such as hypoxic-ischemic encephalopathy (HIE) and cerebral palsy.

The following are some examples of common high-risk pregnancy conditions and the time for delivery they each require:

Preeclampsia

Preeclampsia is a condition characterized by high blood pressure and protein in the urine after 20 weeks of pregnancy. It affects roughly 5-8% of pregnancies (2).

Mild preeclampsia: Women with mild preeclampsia after 37 weeks may have safe vaginal deliveries. If a woman has mild preeclampsia before 37 weeks, her doctor will want to monitor her closely and plan for an early delivery (3).

Severe preeclampsia: Women with severe preeclampsia may need to be hospitalized (3). They may be given antenatal corticosteroids, a common medication administered to help a baby’s lungs mature in the womb; this helps to prevent respiratory distress and subsequent complications. At-risk mothers may also be given medications to help lower their blood pressure and prevent seizures (3). 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 intrauterine growth restriction (IUGR/FGR), an earlier delivery may be indicated. The delivery would be done via induction or C-section (3).

Placental Issues

Placenta previa: Placenta previa occurs when the placenta grows so close to the opening of the uterus that it partially or completely blocks the mother’s cervix. It can lead to severe bleeding and hemorrhage if mismanaged. If placenta previa doesn’t resolve during pregnancy, the baby will need to be delivered by C-section (4). If the mother experiences bleeding, her doctor may suggest delivery between 36-37 weeks (4).

Placenta accreta: Placenta accreta occurs when the placenta grows too deeply into the uterine wall that it does not separate naturally from the uterus during labor and delivery. This can lead to very severe complications, including maternal hemorrhage, HIE, premature delivery, intracranial hemorrhage, and others (5). Placenta accreta usually requires a planned cesarean delivery, but doctors will normally try to get the patient as close to term as possible.

Previous placental abruption: Women who have experienced placental abruption in their first pregnancy have an increased risk of experiencing it again in later pregnancies (6). Elective induction is recommended after 37 weeks in these cases if the abruption occurred at term in the first pregnancy (6).

Previous C-section

For women with a prior classical C-section delivery, risk of uterine rupture is 4-9% during labor. A woman with a prior classical C-section delivery should deliver at 36-37 weeks gestation via C-section (7).

Multiple previous C-sections

Women who have had more than one previous cesarean delivery should have a C-section delivery, and that delivery should usually occur early (7).

Prior myectomy

A myectomy is a surgery to remove pelvic tumors. Myectomy poses a risk of uterine rupture during subsequent pregnancies (7). 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, delivery may need to take place even earlier.

Intrauterine Growth Restriction (IUGR)

Intrauterine Growth Restriction, also called Small for Gestational Age or Fetal Growth Restriction, occurs when the fetal weight is below the 10th percentile for gestational age. IUGR increases the risks of hypoxic-ischemic encephalopathy (HIE), meconium aspiration syndrome, hypoglycemia, hyperviscosity, motor and neurological disabilities, and many other conditions (8). Most growth-restricted fetuses can be monitored with serial ultrasonography every 3-4 weeks (9). The exact time of delivery for a growth-restricted fetus depends on the etiology of the growth restriction. The American College of Obstetricians and Gynecologists (ACOG) recommends that, in cases of isolated fetal growth restriction (no presence of comorbidities), the fetus be delivered between 38 and 39 6/7 weeks (9). ACOG recommends that, in cases of fetal growth restriction with additional risk factors for adverse outcome, the fetus be delivered between 34 and 37 6/7 weeks (9). If the delivery in cases of IUGR is anticipated before 34 weeks gestation, it should be planned with consultation of a maternal-fetal medicine (MFM) specialist and in a facility with a NICU prepared for immediate IUGR care.

Multiple gestation

Uncomplicated dichorionic/diamniotic (twins in separate sacs): Delivery is suggested to occur between 38 weeks and 38 and 6/7 weeks gestation (10). If there are additional complicating factors, such as (IUGR/FGR), preeclampsia, etc., delivery may need to take place at an earlier date.

Uncomplicated monochorionic/diamniotic (twins with the same placenta, but different amniotic sacs): Delivery is suggested to occur at between 36 weeks 36 and 6/7 weeks gestation (10). If there are additional complicating factors, such as (IUGR/FGR), preeclampsia, etc., delivery may need to take place at an earlier date.

Complicated monochorionic/monoamniotic (twins with the same placenta and the same amniotic sac): Delivery is suggested to occur at between 32 weeks and 34 weeks gestation because of the high risk of stillbirth (10). If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc., delivery may need to occur at an earlier date.

Gestational diabetes

Uncomplicated gestational diabetes: Late preterm birth or early term birth is not recommended for uncomplicated gestational diabetes (11). However, if additional complicating issues exist, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.

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 (11). If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc., 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 38-39 (11). If additional complicating issues are present, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be necessary.

Gestational diabetes that are poorly controlled on medication. This scenario requires that delivery take place at 34 – 38 6/7 weeks, with specific timing individualized to the mother’s situation (11). If there are additional complicating issues, such as IUGR/FGR, preeclampsia, etc., an earlier delivery may be indicated.

Oligohydramnios: Oligohydramnios occurs when the amniotic fluid volume is less than it should be for the gestational age of the fetus. This can affect the baby’s growth, movement, and protection during pregnancy. The baby needs to be closely monitored if oligohydramnios is present, and it is common for the baby to be delivered early. Indications for delivery include non-reassuring fetal testing as well as reaching 37-38 6/7 weeks gestation (12).

Premature Rupture of Membranes (PROM): PROM occurs when the amniotic sac ruptures (“water breaks”) before labor begins. Losing this layer of protection put the baby at risk for various health issues, including hypoxic-ischemic encephalopathy (HIE), cerebral palsy, periventricular leukomalacia (PVL), and others. If PROM occurs before 34 weeks, the situation is complex and requires diligent monitoring (13). If signs of infection aren’t present, your doctor may wait to deliver. If it occurs after 34 weeks, however, the doctor will likely induce labor within 24 hours.

Previous stillbirth

It has been found that women who have experienced a stillbirth have up to a fourfold increased risk of having a stillbirth in their next pregnancy (14). These pregnancies need to be closely monitored. An early delivery may be necessary.

Previous premature birth

Previously having a premature baby puts you at risk of another premature birth (15). Because of this risk, doctors should monitor the pregnancy closely and address concerns as soon as they arise.

Fetal congenital malformations

A baby who has any of the following conditions should be delivered at 34 – 39 weeks (16):

• A delivery that should occur prior to the onset of labor
• Suspected worsening fetal organ damage
• Potential for brain bleeds / intracranial hemorrhages (such as Vein of Galen aneurysm, neonatal alloimmune thrombocytopenia)
• A previous fetal intervention
• Concurrent maternal disease, such as preeclampsia
• The potential for adverse maternal effect from the fetal condition

Immediate delivery is required regardless of gestational age if the intervention is expected to be beneficial, fetal complications develop, or maternal complications develop.

Obstetricians must be aware of these guidelines and follow the 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), cerebral palsy, seizures, and intellectual and developmental disabilities.

Preventable medical error is an epidemic, and these errors are responsible for over 250,000 deaths a year and millions of injuries annually (17). 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.

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 pain or back pain) can give important information regarding impending or current fetal distress, as well as the mother’s own health status. When a baby is showing signs of distress on the fetal heart rate monitor, it means they are experiencing a lack of oxygen in the 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.

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. ABC Law Centers (Reiter & Walsh, P.C.) is a national birth injury law firm that has been helping children with birth injuries since its inception in 1997.

1. ACOG Committee Opinion No. 764 Summary: Medically Indicated … : Obstetrics & Gynecology. (2013, April). Retrieved October 22, 2019, from https://journals.lww.com/greenjournal/pages/articleviewer.aspx?year=2019&issue=02000&article=00035&type=Fulltext.
2. Preeclampsia: Symptoms, Risks, Treatment and Prevention. (2019, July 16). Retrieved from https://americanpregnancy.org/pregnancy-complications/preeclampsia/
3. Preeclampsia. (2017, December). Retrieved from https://www.marchofdimes.org/complications/preeclampsia.aspx 
4. Placenta previa. (2018, March 6). Retrieved from https://www.mayoclinic.org/diseases-conditions/placenta-previa/symptoms-causes/syc-20352768  
5. What Is Placenta Accreta?: Legal Help for Birth Injuries. (n.d.). Retrieved October 21, 2019, from https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/maternal-medical-conditions/placenta-accreta/.
6. Ruiter L, Ravelli ACJ, de Graaf IM, et al. Incidence and recurrence rate of placental abruption: a longitudinal linked national cohort study in the Netherlands. Am J Obstet Gynecol 2015;213:573.e1-8.
7. Publications & Guidelines: SMFM.org – The Society for Maternal-Fetal Medicine. (n.d.). Retrieved from https://www.smfm.org/publications/78-prior-non-lower-segment-uterine-scar-when-to-plan-cesarean-delivery
8. Intrauterine growth restriction: Small for Gestational Age. (2019, July 16). Retrieved from https://americanpregnancy.org/pregnancy-complications/intrauterine-growth-restriction/
9. American College of Obstetricians and Gynecologists. (2013, May). ACOG Practice bulletin no. 134: fetal growth restriction. Retrieved November 15, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/23635765.
10. Chasen, S. T., & Chervenak, F. A. (2019, June 4). Twin pregnancy: Labor and delivery. Retrieved from https://www.uptodate.com/contents/twin-pregnancy-labor-and-delivery
11. Kalra, B., Gupta, Y., & Kalra, S. (2016). Timing of Delivery in Gestational Diabetes Mellitus: Need for Person-Centered, Shared Decision-Making. Diabetes therapy : research, treatment and education of diabetes and related disorders, 7(2), 169–174. doi:10.1007/s13300-016-0162-2
12. Beloosesky, R. G., & Ross, M. G. (2019, January 30). Oligohydramnios. Retrieved October 22, 2019, from https://www.uptodate.com/contents/oligohydramnios.
13. Premature Rupture of Membranes (PROM): Birth Injury. (n.d.). Retrieved October 22, 2019, from https://www.abclawcenters.com/practice-areas/prenatal-birth-injuries/maternal-medical-conditions/premature-rupture-of-membranes/.
14. Women have up to a fourfold increase in risk of stillbirth following a previous stillbirth. (2015, June 24). Retrieved from https://www.sciencedaily.com/releases/2015/06/150624210343.htm
15. Preterm labor and premature birth: Are you at risk? (n.d.). Retrieved from https://www.marchofdimes.org/complications/preterm-labor-and-premature-birth-are-you-at-risk.aspx
16. Spong, C. Y., Mercer, B. M., D’alton, M., Kilpatrick, S., Blackwell, S., & Saade, G. (2011). Timing of indicated late-preterm and early-term birth. Obstetrics and gynecology, 118(2 Pt 1), 323–333. doi:10.1097/AOG.0b013e3182255999
17. Ray Sipherd, special to C. N. B. C. (2018, February 28). The third-leading cause of death in US most doctors don’t want you to know about. Retrieved October 22, 2019, from https://www.cnbc.com/2018/02/22/medical-errors-third-leading-cause-of-death-in-america.html.