My first pregnancy was relatively uneventful. My daughter was delivered by an OB/GYN in hospital at 41 weeks. For my second pregnancy, four years later, I decided to get a midwife. Everything was going great until 16 weeks in.
After a routine visit with my dermatologist, I was diagnosed with lupus, which totally derailed my birth plan. Antibodies from lupus can cause fetal complications, so my midwife referred me to a physician specializing in maternal-fetal medicine. Within weeks, my prenatal team ballooned to six MDs (including four specialists) and I had non-stop appointments.
While the majority of pregnancies in Canada are considered low risk, around five to 10 percent are categorized as high risk. This classification is usually given when either the mother or the baby are at an increased risk of health problems before, during or after delivery.
Typically, a pregnancy will be classified as high risk if the person expecting has a specific underlying medical condition, such as hypertension, diabetes or, in my case, an autoimmune disorder. There may also be a risk identified with the baby or concerns with the development of the placenta.
“Getting a high-risk classification doesn’t automatically mean you will have a bad outcome,” says Julia Kfouri, a maternal-fetal medicine specialist at Mount Sinai Hospital in Toronto, “but it may change the course of your care.”
Kfouri says that high-risk patients should expect increased surveillance and more investigations, including extra blood work and ultrasounds, during the pregnancy and potentially postpartum as well.
“Depending on the reason for your high-risk classification, you’re likely going to be working with a number of other specialists from various departments, which could include internal medicine, paediatrics, radiology, anaesthesia, genetics or general surgery,” she says.
According to the College of Midwives of Ontario, midwives can provide care for individuals during normal pregnancy, where “normal” refers to “low risk or uncomplicated.” Some midwives will work with high-risk patients as a secondary care provider, but this typically happens only when high-risk classification comes later in the pregnancy.
That was the case for Chelsea Luciani, a mom of two from Toronto who had been seeing a midwife up until her 20-week ultrasound, when she learned that her placenta was partially covering her cervix. At a 28-week follow-up, she was sent to the hospital and told she was dilated and her cervix was funnelling, a condition that can lead to preterm birth. She was put on bed rest and referred to an OB/GYN; however, she was still able to keep her midwife for basic monitoring.
“I chose to keep my midwife for appointments and only transfer to the OB if the baby decided to come before 38 weeks,” says Luciani.
If your pregnancy is deemed high risk from the start, a doula can provide additional care. Megan Ewing, a mother of two in Toronto, was classified as high risk for both of her pregnancies because of her type 1 diabetes. “I would have loved to work with a midwife but was not able to because of my diabetes,” says Ewing. “My doula provided excellent pre-birth, birth and postpartum care.”
If you’re deemed high risk, your healthcare provider might ask you to make some changes to your lifestyle. For example, women with hypertension, which is exacerbated by a stressful work environment, may need to stop working sooner and get additional support, says Kfouri. You may also need to alter your diet or workout routine.
While bed rest is typically not recommended in pregnancy, you may not be able to resume all of your normal activities. For Luciani, she wasn’t allowed to stand for more than 10 minutes at a time, which made it hard to care for her three-year-old. “Basic things like getting him in and out of the car seat or bath and cooking meals were a challenge,” she says. Her husband ended up taking time away from work to help out.
It’s a good idea to let your employer know your situation so that you can work out a plan or determine whether it may be necessary to take a leave of absence or short-term disability, if those are options for you.
Women with high-risk pregnancies may also need additional emotional support. Once my care shifted, I was referred to a reproductive life stages psychiatrist, who helped me to manage my fears and anxieties about my high-risk pregnancy and monitored me for signs of postpartum depression (PPD). Similarly, Ewing’s team for her second pregnancy set her up with a social worker to help work through some PPD she had experienced with her first pregnancy.
With any pregnancy, a vaginal birth, if safe, is preferred, says Kfouri. “Our goal is always to aim for a vaginal birth unless there’s an absolute contraindication to this,” she says. “We reserve C-sections for cases where a trial of a vaginal delivery would not be safe.”
My OB/GYN suggested I induce at 39 weeks after additional complications had developed with my placenta and the fetus growth had slowed down; however, I was able to deliver vaginally without difficulties.
Depending on why your pregnancy is deemed high risk, it’s possible that this won’t be the case in subsequent pregnancies. For both myself and Luciani, our first pregnancies were low risk.
“If a patient has experienced a preterm birth or has had a complication like pre-eclampsia in her first pregnancy, it’s likely she would be at risk to have a recurrence with her subsequent pregnancies,” says Kfouri. “But in other pregnancies, for example, if the baby was affected by a congenital malformation that was sporadic, then future pregnancies could be considered low risk.”
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