Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Delivery of the preterm low birth weight singleton fetus

Authors
Jane Cleary-Goldman, MD
Julian N Robinson, MD

Section Editor
Charles J Lockwood, MD, MHCM

Deputy Editor
Vanessa A Barss, MD, FACOG

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2016. | This topic last updated: Jun 07, 2016.
INTRODUCTION Delivery of the preterm low birth weight (LBW) fetus is often necessitated by maternal and fetal
indications, including nonreassuring fetal status, intractable preterm labor, intraamniotic infection, placental
abruption, placental insufficiency, hypertensive disorders, and other maternal factors (see individual topic reviews on
these subjects). The prognosis for survival and long-term outcomes of these neonates continues to improve and can
be attributed, in part, to widespread use of antenatal corticosteroids in women at risk for preterm birth, liberal use of
cesarean delivery for fetal indications, improvements in neonatal resuscitation, use of surfactant therapy, magnesium
sulfate prophylaxis, and delivery at facilities with personnel experienced in neonatal intensive care. (See "Incidence
and mortality of the preterm infant".)
DEFINITION OF LOW BIRTH WEIGHT Low birth weight neonates are subgrouped according to the degree of
smallness at the first weight determination after birth [1]:
Low birth weight (LBW): less than 2500 grams
Very low birth weight (VLBW): less than 1500 grams
Extremely low birth weight (ELBW): less than 1000 grams
In this topic, we will use the term LBW to encompass both fetuses and neonates in all of these estimated weight and
birth weight categories and only use the terms VLBW and ELBW when these subgroups are considered separately.
CHOOSING THE ROUTE OF DELIVERY
Cesarean versus vaginal In the absence of a standard indication for cesarean delivery (eg, breech presentation,
previous classical hysterotomy), we believe women with low birth weight (LBW) fetuses should undergo a trial of
labor. Elective cesarean delivery is associated with known risks for the mother and no proven benefits for the LBW
neonate in cephalic presentation.
The rationale for routine cesarean delivery of the LBW fetus when preterm delivery is necessary or inevitable is
based upon the hypothesis that avoidance of active labor and vaginal delivery might improve survival by reducing
hypoxic stress, asphyxia, and intraventricular hemorrhage (IVH) [2-4]. However, there is no strong evidence
supporting this hypothesis and available evidence suggests that the route of delivery is not a significant independent
factor affecting perinatal mortality or neurodevelopment.
In a 2013 Cochrane review of four randomized trials (n = 116 women) comparing cesarean versus attempted
vaginal delivery for preterm singletons, there were no statistically significant differences in perinatal morbidity or
mortality between groups [5]. However, the small number of pregnancies precluded making any conclusions
about the optimal route of delivery. The authors observed that one in six babies did not deliver by the method to
which they were allocated, in part due to precipitous deliveries and to nonreassuring fetal heart rate patterns.
In a 2013 systematic review of case-control and cohort studies that analyzed the association between
cesarean delivery and cerebral palsy, cesarean delivery (elective or emergency) was not associated with a
significant reduction in risk of cerebral palsy in preterm infants (OR 0.81, 95% CI 0.47-1.40; six studies, n =
2416 deliveries) [6]. The gestational age range for the preterm deliveries varied widely among the included
studies.
In addition, most evidence from retrospective studies performed worldwide has not demonstrated significant
improvement in perinatal morbidity or mortality for the vertex fetus delivered by cesarean, particularly when the
primary indication for operative delivery was LBW [7-21]. Although a few studies have observed an increased risk of

IVH or death among LBW newborns delivered vaginally [22-24], a consistent limitation of these studies is the marked
differences in baseline characteristics between the cesarean and vaginal delivery groups. Obstetric complications
that favor delivery by one method over the other are important confounders. Carefully accounting for maternal and
fetal factors tends to eliminate route of delivery as a significant factor in risk of either mortality or IVH [8]. A longerterm study found that mode of delivery of periviable fetuses made no detectable difference in Bayley II scores at age
two years [25]. (See "Clinical manifestations and diagnosis of intraventricular hemorrhage in the newborn", section
on 'Delivery'.)
The LBW newborn may be preterm or small for gestational age, although most studies have not distinguished
between these two subgroups when evaluating outcome. There are limited observational data suggesting a survival
advantage for some preterm growth-restricted fetuses delivered by cesarean compared with those delivered
vaginally [12,14,26]. This finding should be interpreted cautiously because of the limitations of observational data
and because no studies have compared outcomes of prelabor cesarean delivery versus planned vaginal delivery.
Some authors have hypothesized that labor has a deleterious effect on the preterm fetal brain and have suggested
that cesarean delivery may only reduce neonatal morbidity if it is performed before the fetus is exposed to labor.
However, elective cesarean delivery performed in an attempt to avoid exposing the fetus to the potentially
deleterious effects of labor might lead to unnecessarily early delivery, since expectant management of many
pregnancy complications can lead to significant prolongation of pregnancy with further fetal growth and maturation.
Furthermore, preterm labor itself is the most common cause or contributing factor to delivery of LBW neonates and
thus cannot be avoided in most cases.
An additional factor when considering the route of delivery is that cesarean delivery of LBW fetuses, especially those
that are very low birth weight (VLBW) or extremely low birth weight (ELBW), is more likely to require a vertical or
classical hysterotomy incision. This places the mother at increased risk of serious complications, such as placenta
accreta and uterine rupture, in future pregnancies. Even a low transverse incision may be associated with an
increased risk of future uterine rupture when compared with the same incision at term (4/228 [1.8 percent] versus
36/9558 [0.4 percent] in one study [27]).
In addition, a classical hysterotomy commits her to cesarean delivery by 37 weeks of gestation for all future
pregnancies, which increases the risk of neonatal morbidity compared with 39 weeks, the usual gestation age for
scheduled repeat cesarean in women with a low transverse cesarean delivery. (See "Cesarean delivery:
Postoperative issues", section on 'Complications'.)
Also of note, classical hysterotomy is associated with a high rate of serious postpartum complications in the index
pregnancy. In one study, 23 percent of women who delivered preterm by a classical hysterotomy had serious
postpartum complications (hemorrhage, infection, ICU admission, death) [28].
Spontaneous vaginal versus assisted vaginal Compression of the fetal head increases cerebral venous
pressure, which theoretically could promote IVH. There is no strong evidence that reducing maternal soft tissue
compression of the fetal head during vaginal delivery is an important factor in preventing development of IVH in
fetuses without a bleeding diathesis. For example, in a study that performed neonatal ultrasound on 288 neonates
2000 grams delivered from vertex presentation either spontaneously or by low forceps, no correlation between early
periventricular or IVH and delivery method was observed [29]. Another study of 101 infants weighing 500 to 1500
grams reported that factors believed to affect head compression, such as use of episiotomy and forceps, did not
correlate with the frequency of IVH [30].
INTRAPARTUM ISSUES
Neonatology consultation Neonatal providers should have an opportunity to talk to and assess the patient
before delivery, if possible. This discussion should include potential neonatal mortality and morbidity, and a
discussion about the extent of care, when appropriate.
(See "Incidence and mortality of the preterm infant".)
(See "Short-term complications of the preterm infant".)
(See "Long-term complications of the preterm infant".)
(See "Limit of viability".)
Ideally, preterm births should occur in hospitals with nurseries able to provide an appropriate level of care. This is

particularly important for very low birth weight (VLBW) infants and very preterm infants. In a 2010 meta-analysis of
studies of the association between nursery level at birth and neonatal mortality, VLBW infants born in hospitals with
level I or II nurseries had higher mortality than those born in hospitals with level III nurseries (38 versus 23 percent;
OR 1.62, 95% CI 1.21-1.98) [31,32]. When analyzed by gestational age, infants 32 weeks of gestation born in
hospitals with level I or II nurseries had higher mortality than those with level III nurseries (12 versus 7 percent; OR
1.42, 95% CI 1.06-1.88).
Intrapartum fetal monitoring Continuous intrapartum fetal heart rate monitoring of the LBW fetus is indicated if a
nonreassuring fetal heart rate pattern would prompt intervention. The immature fetal cardiovascular and nervous
system of the preterm fetus results in fetal heart rate patterns that are normal for gestational age, but slightly different
from the typical patterns seen later in gestation. For example:
Baseline fetal heart rate gradually decreases across gestation, but remains within the normal range (110 to 160
beats/minute). Before 25 weeks the mean fetal heart rate is 150 to 155 beats/minute, falling to 130 to 140
beats/minute at term [33-36].
Before about 30 weeks of gestation, the frequency, amplitude, and duration of accelerations are reduced.
Nonhypoxic, nonacidotic preterm fetuses under 30 weeks may exhibit few accelerations and the peak may be
only 10 beats/minute above baseline and the acceleration may last only 10 seconds. After about 30 weeks,
accelerations become more frequent in the healthy fetus; the peak should be 15 beats/minute and the
acceleration should last 15 seconds [33,37].
Healthy fetuses between 20 and 30 weeks of gestation may have occasional fetal heart rate decelerations
unassociated with contractions [34].
A reduction in baseline variability before about 28 weeks has been described, but not clearly quantified [33,37].
Fetal ST segment analysis (STAN) is not recommended prior to 36 weeks of gestation [38], as available data in
preterm fetuses are not sufficient to determine whether the device is reliable.
These issues are described in more detail separately. (See "Intrapartum fetal heart rate assessment" and "Umbilical
cord blood acid-base analysis at delivery".)
Maternal analgesia/anesthesia The choice of maternal analgesia/anesthesia for labor and/or delivery should be
guided primarily by maternal needs and the specific clinical scenario, given the absence of adequate data on the
optimal approach for women with a LBW fetus. Although a large prospective epidemiologic study (EPIPAGE)
reported an increased risk of neonatal mortality in very preterm infants undergoing cesarean delivery under spinal
anesthesia compared with general anesthesia or epidural anaesthesia, this study had several limitations (eg,
confounding, nonstandardized anesthetic techniques) that preclude making a change in clinical practice [39].
The benefits and risks of various analgesic and anesthetic techniques are reviewed separately. (See "Pharmacologic
management of pain during labor and delivery".)
Use of episiotomy, vacuum, and forceps Prophylactic use of episiotomy for delivery of the LBW fetus does not
appear to be associated with improved neonatal outcome [40-42]. Selective use of episiotomy is reasonable when
clinically indicated, such as deliveries with a high risk of severe perineal laceration or need to facilitate delivery of a
possibly compromised fetus. (See "Approach to episiotomy".)
Vacuum-assisted delivery is contraindicated before 34 weeks of gestation because it may increase the risk of
intraventricular hemorrhage (IVH) in the preterm LBW fetus. Forceps should be used when an instrument-assisted
delivery is necessary before 34 weeks of gestation. (See "Operative vaginal delivery", section on 'Contraindications'.)
As discussed above, the bulk of observational data suggest that the risk of IVH is not reduced by use of low forceps
compared with no forceps (see 'Spontaneous vaginal versus assisted vaginal' above); therefore, prophylactic use of
low forceps should be avoided. Use of low forceps when clinically indicated seems reasonable, since the risk of harm
to the LBW fetus does not appear to be higher than in term fetuses whose weight is appropriate for gestational age.
Two forceps are available which are smaller in dimension than standard forceps and are intended for use in a LBW
or VLBW delivery. "Baby" Elliot and "baby" Simpson forceps are among these instruments. We were unable to
identify any published studies or manufacturer guidelines regarding the estimated fetal weights or gestational ages at

which these instruments might be most useful. The evidence for these conclusions is reviewed separately. (See
"Operative vaginal delivery", section on 'Minimum and maximum estimated fetal weight'.)
Optimal cord clamping Optimal (formerly called "delayed") cord clamping is recommended, when feasible,
because it appears to improve several neonatal outcomes compared with early cord clamping [43,44].
In a 2012 meta-analysis of 15 randomized trials of late versus early cord clamping in 738 preterm infants [45],
late cord clamping resulted in fewer infants requiring transfusion for anemia (24 versus 36 percent; RR 0.61,
95% CI 0.46-0.81; seven trials, 392 infants), less risk of necrotizing enterocolitis (21 versus 32 percent; RR
0.62, 95% CI 0.43-0.90; five trials, 241 infants), and fewer infants with any grade of IVH on ultrasound (14
versus 20 percent; RR 0.59, 95% CI 0.41-0.85; 10 trials, 539 infants). Peak bilirubin level was significantly
higher with delayed cord clamping, but there was no significant increase in the need for treatment of jaundice.
A 2014 meta-analysis restricted to randomized trials of interventions to promote placental transfusion (delayed
cord clamping, cord milking) in pregnancies <32 weeks of gestation also reported significant neonatal benefits
compared with early cord clamping: reduced mortality (RR 0.42, 95% CI 0.19-0.95, 3.4 versus 9.3 percent),
reduced rate of transfusion (RR 0.75, 95% CI 0.63-0.92, 49.3 versus 66 percent), reduced rate of IVH (RR
0.62, 95% CI 0.43-0.91, 16.7 versus 27.3 percent) [43]. The delayed clamping group also had 3.24 mmHg
higher blood pressure at four hours of life and a strong trend toward higher peak bilirubin levels.
Higher infant iron stores is advantageous for infants of mothers with low ferritin levels, breastfed infants not receiving
iron supplements or fortified formula, and preterm infants, but the increased need for phototherapy is an important
disadvantage for infants who are at low risk of developing anemia. Late cord clamping may also be disadvantageous
for growth restricted neonates who are at risk of polycythemia.
Techniques for atraumatic cesarean delivery Extremely low birth weight (ELBW) infants (premature or growth
restricted) present many challenges at cesarean delivery. The uterus is less distended than with a term fetus and the
lower uterine segment is less well-developed (thicker myometrium, smaller area). Thus, the hysterotomy incision is
deeper and bloodier, and an adequate transverse incision to allow atraumatic extraction of the fetus may not be
possible. It is also easy to inadvertently lacerate the fetus if the deepest layers if the myometrium are not incised
carefully, especially in the setting of preterm premature ruptured membranes.
Since these fetuses are premature and/or smaller, their bones and soft tissues are more delicate and prone to injury.
To avoid iatrogenic injury, the pressure applied to grasp and extract them should be much less than that used for a
normal term fetus.
Also, because of the markedly reduced fetal size, the uterus is significantly smaller and occupies less of the
abdomen and pelvis than larger, term pregnancies. As a result, the mother's intestines, which are usually confined to
the upper abdomen in a cesarean delivery, may descend into the operative field and may need to be manually
displaced with either retractors or packing.
To address all of the issues during the cesarean delivery of the extremely premature or growth restricted fetus,
obstetricians should carefully consider their choice and size of skin and uterine incisions. Although a low transverse
skin incision (Pfannenstiel) is still a reasonable choice, surgeons should make sure that the skin incision length is
adequate to provide the exposure requirements one might encounter; in particular, the skin incision should not be
prorated smaller to adjust for the smaller size of the fetus.
While some deliveries can be accomplished safely via a low transverse uterine incision, the lack of development of
the lower uterine segment often precludes this option. A vertical uterine incision may be a more prudent choice and
guarantees adequate access to the fetus without the risks of head entrapment or injury to the uterine arteries. In one
study, 50 percent of cesareans in singleton pregnancies 26 weeks of gestation were performed using a classical
hysterotomy; the rate was lower in twin pregnancies [46]. As with any incision, the surgeon's best judgment should
ultimately dictate the choice.
MANAGEMENT AT THE LIMIT OF VIABILITY The American College of Obstetricians and Gynecologists and the
Society for Maternal-Fetal Medicine have published a consensus statement about clinical management of
pregnancies with threatened or imminent delivery at 200/7ths to 256/7ths weeks of gestation (table 1) [47,48].
Pediatric organizations have published generally similar statements, which are reviewed separately. (See "Limit of

viability".)
SUMMARY AND RECOMMENDATIONS
For the cephalic low birth weight (LBW) fetus, we suggest avoiding elective (prophylactic) cesarean delivery
(Grade 2C). A policy of elective cesarean delivery is associated with known risks to the mother, but the benefits
to the LBW neonate in cephalic presentation are uncertain. Standard obstetrical care aimed at avoiding a
depressed neonate seems to be a better strategy than routine cesarean delivery for preventing asphyxia,
intraventricular hemorrhage (IVH), and death in these fetuses. (See 'Cesarean versus vaginal' above.)
Delivery of the breech fetus is a separate issue. (See "Delivery of the fetus in breech presentation".)
Ideally, preterm births should occur in hospitals with nurseries able to provide an appropriate level of care. (See
'Neonatology consultation' above.)
Continuous intrapartum fetal heart rate monitoring of the LBW fetus is indicated if a nonreassuring fetal heart
rate pattern would prompt intervention. The immature fetal cardiovascular and nervous system of the preterm
fetus results in fetal heart rate patterns that are normal for gestational age, but slightly different from the typical
patterns seen later in gestation. (See 'Intrapartum fetal monitoring' above.)
Head compression by maternal soft tissues in the vertex LBW fetus is not a major determinant of IVH. For this
reason, we suggest avoiding elective (prophylactic) episiotomy and elective low forceps delivery (Grade 2C).
(See 'Spontaneous vaginal versus assisted vaginal' above and 'Use of episiotomy, vacuum, and forceps'
above.)
Vacuum-assisted delivery is contraindicated before 34 weeks of gestation because it may increase the risk of
IVH in the preterm LBW fetus. (See "Operative vaginal delivery", section on 'Contraindications'.)
Choice of maternal analgesia should be guided primarily by maternal needs. (See 'Maternal
analgesia/anesthesia' above.)
Obstetricians should carefully consider their choice and size of skin and uterine incisions. Although a low
transverse skin incision (Pfannenstiel) is a reasonable choice, the skin incision should not be prorated smaller
to adjust for the smaller size of the fetus. (See 'Techniques for atraumatic cesarean delivery' above.)
We suggest optimal (formerly called "delayed") rather than early cord clamping, when feasible (Grade 2B).
(See 'Optimal cord clamping' above.)
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Topic 4444 Version 21.0

GRAPHICS
Obstetric management of threatened or imminent delivery of
pregnancies at a periviable gestational age
Recommendations for periviable birth
Recommendations

Grade of recommendations

Based on anticipated neonatal or maternal complications,

antepartum transport to a center with advanced levels of
neonatal or maternal care is recommended when feasible and

Best practice

appropriate.
Prenatal and postnatal counseling regarding anticipated shortterm and long-term neonatal outcome should take into

Best practice

consideration anticipated gestational age at delivery, as well as

other variables that may alter the likelihood of survival and
adverse newborn outcomes (eg, fetal sex, multiple gestation,
the presence of suspected major fetal malformations, antenatal
corticosteroid administration, birth weight, and response to
initial newborn resuscitation).
Family counseling should be provided by a multidisciplinary
team that includes obstetrician-gynecologists and other
obstetric providers, maternal-fetal medicine specialists, if

Best practice

available, and neonatologists who can address their individual

and shared considerations and perspectives. Maternal and
neonatal outcomes should be considered. Follow-up counseling
should be provided when there is relevant new information
about the maternal and fetal status or the newborn's evolving
condition.
A predelivery plan, made with the parents, family, or both,
should be recognized as a general plan of approach, which may

Best practice

be modified as the neonate's condition and response is

evaluated by the neonatal providers. A recommendation
regarding assessment for resuscitation is not meant to indicate
that resuscitation should always either be undertaken or
deferred, or that every possible intervention need be offered. A
stepwise approach concordant with neonatal circumstances and
condition and with parental wishes is appropriate. Care should
be reevaluated regularly and potentially redirected based on the
evolution of the clinical situation.
Recommendations regarding specific interventions, tailored to gestational age and other clinical
data, and taking into account individual family preferences and values, are summarized below.

General guidance regarding obstetric interventions for threatened and

imminent periviable birth by best estimate of gestational age*
20 0/7
weeks to
21 6/7
weeks

Neonatal
assessment for

Not
recommended

22 0/7
weeks to
22 6/7
weeks

Consider 2B

23 0/7
weeks to
23 6/7
weeks

Consider
2B

24 0/7 weeks
to 24 6/7

25 0/7 weeks
to 25 6/7

weeks

weeks

Recommended
1B

Recommended
1B

resuscitation*

1A

Antenatal
corticosteroids

Not
recommended

Not
recommended

1A

1A

Tocolysis for
preterm labor

Not
recommended

Not
recommended

to allow for
antenatal
corticosteroid

1A

1A

Magnesium
sulfate for

Not
recommended

Not
recommended

neuroprotection

1A

1A

Antibiotics to
prolong latency
during

Consider 2C

Intrapartum
antibiotics for

Consider
2B

Recommended
1B

Recommended
1B

Consider
2B

Recommended
1B

Recommended
1B

Consider
2B

Recommended
1B

Recommended
1B

Consider 2C

Consider
2B

Recommended
1B

Recommended
1B

Not
recommended

Not
recommended

Consider
2B

Recommended
1B

Recommended
1B

group B
streptococci
prophylaxis

1A

1A

Cesarean

Not

Not

Consider

Consider 1B

Recommended

delivery for
fetal

recommended
1A

recommended
1A

2B

administration

expectant
management of
preterm PROM
if delivery is
not considered
imminentt

indication

1B

PROM: premature rupture of membranes.

* Survival of infants born in the periviable period is dependent on resuscitation and support. Between 22
weeks and 25 weeks of gestation, there may be factors in addition to gestational age that will affect the
potential for survival and the determination of viability. Importantly, some families, concordant with
their values and preferences, may choose to forgo such resuscitation and support. Many of the other
decisions on this table will be linked to decisions regarding resuscitation and support and should be
considered in that context.
Group B streptococci carrier, or carrier status unknown.
For example, persistently abnormal fetal heart rate patterns or biophysical testing, malpresentation.
Reproduced from: American College of Obstetricians and Gynecologists, Society for Maternal-Fetal
Medicine. ACOG/SMFM Obstetric Care Consensus: Periviable birth. Am J Obstet Gynecol 2015. Table
used with the permission of Elsevier Inc. All rights reserved.
Graphic 104945 Version 1.0

Contributor Disclosures
Jane Cleary-Goldman, MD Nothing to disclose. Julian N Robinson, MD Nothing to disclose. Charles J
Lockwood, MD, MHCM Consultant/Advisory Boards: Celula [Aneuploidy screening (No current products or drugs in
the US)]. Vanessa A Barss, MD, FACOG Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
by vetting through a multi-level review process, and through requirements for references to be provided to support
the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of
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