Giving Birth with Confidence, Safe & Healthy Birth
When Pregnancy is Complicated - ACOG Recommendations for Delivery
Cara Terreri
Lamaze International’s first Healthy Birth Practice is “Let Labor Begin on Its Own” and for a normal, healthy pregnancy with both a parent and baby who have no complications or concerns, that is a great rule of thumb to follow. Labor goes smoother, less interventions are needed and outcomes are better for all involved.
There are, of course, times when a situation is present prior to pregnancy or develops during the pregnancy that require a deviation from this birth practice. When circumstances like that occur and using best practice and current evidence, either parent or baby will do better if the baby was born sooner rather than later, parents are then faced with making decisions.
After consulting with your provider, you may want to use a decision-making tool called “BRAIN” to gather information, take time to discuss privately, and make a decision that feels right for you. This shared decision making model is a respectful and appropriate way to decide how to move forward.
The decision to induce or plan a cesarean is not one to be taken lightly, especially before term and should be considered when the health of the baby or the parent is at risk, rather than for non-medical reasons.
The American College of Obstetricians and Gynecologists, in collaboration with the Society for Maternal Fetal Medicine, recently updated their recommendations on the timing of medically indicated late-preterm and early-term deliveries. The recommendations are based on placental, fetal and maternal complications. Late-preterm or early term refers to a birth before 39 weeks and 0 days gestation.
Pregnancy complications require evaluation through a different lens in order keep both the baby and the pregnant person safe and healthy, and there are many conditions that require and early delivery, including gestational or chronic hypertension, placental complications and many others.
ACOG acknowledges that a) “decisions regarding timing of delivery always should be individualized to the needs of the patient” and b) the decision should take into account “patient preferences.”
Here are the current recommendations, in Committee Opinion 831 based on placental, fetal and maternal conditions (courtesy of the OBG Project):
Placental Indications
- Previa (otherwise uncomplicated): 36w0d – 37w6d
- Accreta, increta, percreta (otherwise uncomplicated) : 34w0d – 35w6d
- Vasa previa: 34w0d – 37w0d
- Prior classical cesarean: 36w0d – 37w0d
- Previous uterine rupture: 36w0d – 37w0d
- Prior myomectomy requiring cesarean: 37w0d – 38w6d
- May require delivery similar to classical section (see above) if surgery was more extensive and complicated
- With less extensive surgery, delivery may be considered as late as 38w6d
- ACOG states:
Timing of delivery should be individualized based on prior surgical details (if available) and the clinical situation
Fetal Conditions
- Oligohydramnios (DVP <2cm) isolated and uncomplicated : 36w0d – 37w6d (or at time of diagnosis if later)
- Polyhydramnios (otherwise uncomplicated): 39w0d – 39w6d
- Fetal growth restriction (FGR) – singleton
- Uncomplicated and EFW between 3rd and 10th percentile: 38w0d – 39w0d
- Uncomplicated and EFW <3rd percentile: 37w0d (or at time of diagnosis if later)
- UA Doppler decreased end diastolic flow without absent end diastolic flow: 37w0d (or at time of diagnosis if later)
- UA Doppler absent end diastolic flow: 33w0d – 34w0d (or at time of diagnosis if later)
- UA Doppler reversed end-diastolic flow: 30w0d – 32w0d (or at time of diagnosis if later)
- Note: Concurrent condition (e.g., oligohydramnios, preeclampsia, hypertension): 34w0d – 37w6d
- Multiple gestation – uncomplicated
- Di-di twins: 38w0d – 38w6d
- Mono-di twins: 34w0d – 37w6d
- Mono-mono twins: 32w0d – 34w0d
- Note: Triplets and higher: Individualize
- Alloimmunization
- At-risk and not requiring intrauterine transfusion: 37w0d – 38w6d
- Note: Requiring intrauterine transfusion: Individualize
Maternal Conditions
Chronic hypertension
- Uncomplicated, no meds: 38w0d – 39w6d
- Uncomplicated, controlled on meds: 37w0d – 39w6d
- Difficult to control: 36w0d – 37w6d
Gestational hypertension
- Without severe BP: 37w0d (or at time of diagnosis if later)
- With severe BP: 34w0d (or at time of diagnosis if later)
Preeclampsia
- Without severe features: 37w0d (or at time of diagnosis if later)
- With severe features
- Stable maternal-fetal status: 34w0d (or at time of diagnosis if later)
- Unstable or complicated by HELLP: Soon after maternal stabilization (guided by maternal/fetal status and gestational age)
- Before viability: Soon after maternal stabilization (guided by maternal/fetal status and gestational age)
Diabetes
- Pregestational diabetes
- Well-controlled: 39w0d – 39w6d
- With vascular complications, poor control, or prior stillbirth: 36w0d – 38w6d
- Gestational diabetes
- Well-controlled on diet: 39w0d – 40w6d
- Well-controlled on meds: 39w0 – 39w6d
- Note: Poorly-controlled: Individualize
HIV
- Intact membranes & viral load > 1,000 copies/mL: 38w0d
- Viral load <1,000 copies/mL and antiretroviral therapy: ≥39w0d
Intrahepatic cholestasis of Pregnancy
- Bile acids ≥100 micromol/L: 36w0d
- Bile acids <100 micromol/L: 36w0d to 39w0d | Delivery <36 weeks may be required depending on clinical findings and lab values
PROM and Stillbirth
- Ruptured membranes
- Preterm PROM (PPROM): 34w0d to 36w6d
- PROM (≥37w0d): Generally, deliver at time of diagnosis
- Previous stillbirth: Individualize
- Early term birth not routinely recommended
- “…maternal anxiety with a history of stillbirth should be considered and may warrant an early term delivery (37 0/7 weeks to 38 6/7 weeks) in women who are educated regarding, and accept, the associated neonatal risks”
Sometimes during pregnancy, families need to make difficult decisions about medical interventions that are indeed necessary in order to keep everyone as healthy as possible. A good childbirth education class that includes preparation and practice for asking the questions you need to ask in order to make a decision that feels right to you is critical.
References
Medically indicated late-preterm and early-term deliveries. ACOG Committee Opinion No. 831. American College of Obstetricians and Gynecologists. Obstet Gynecol 2021;138:e35–9.
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