What Happens If Your Pregnancy Becomes Higher Risk?

Author: Igel Cudiera

If your pregnancy becomes higher risk, your care team will look closely at what changed and adjust your care to match, which can mean more frequent visits, extra tests or monitoring, input from a physician or specialist, and sometimes a change in where you plan to give birth. Being called higher risk does not mean something will go wrong; it means your pregnancy needs closer attention, and the right plan depends on your specific situation and your care team's assessment.

This guide walks through what high-risk pregnancy care can involve, from common tests to how midwives work with specialists, how birth center eligibility is decided, and which symptoms need care right away.

What Does "Higher Risk" Mean in Pregnancy?

A high-risk pregnancy is one in which the pregnant person, the fetus, or both have a higher chance of health problems than in a typical pregnancy, according to the National Institute of Child Health and Human Development (NICHD) and MedlinePlus. Some people are higher risk from their first visit because of an existing health condition. Others become higher risk later; the American College of Obstetricians and Gynecologists (ACOG) gives the example of a pregnancy that became high risk after a routine ultrasound.

Does higher risk mean something is wrong?

Not on its own. NICHD states that a pregnancy being considered high risk "does not mean that a problem will occur," and the Society for Maternal-Fetal Medicine (SMFM) notes that many people with high-risk pregnancies go on to have healthy pregnancies and babies, especially with close monitoring and coordinated care. The label exists so your care team can watch for problems early and plan ahead.

Higher risk is a spectrum

An ACOG article by a maternal-fetal medicine specialist describes high-risk pregnancy as a spectrum, from a somewhat greater chance of complications to pregnancy itself being risky. That's why, as NICHD notes, the care needed depends on the specific risk factors and overall health.

What Can Make a Pregnancy Higher Risk?

NICHD groups these factors into existing health conditions, age, lifestyle, and conditions of pregnancy, and stresses that each pregnancy is different. The examples below aren't a complete list, and having one doesn't automatically decide your care or where you give birth. A baby in breech position is covered in its own section below.

Health conditions from before pregnancy

According to NICHD, long-term conditions such as high blood pressure or diabetes can make a pregnancy high risk even when they are well controlled. NICHD also lists kidney disease, autoimmune disease, thyroid disease, polycystic ovary syndrome (PCOS), and obesity, and MedlinePlus includes a problem from a previous pregnancy that could happen again.

Conditions that can develop during pregnancy

• High blood pressure and preeclampsia. ACOG defines gestational hypertension as blood pressure of 140/90 or higher that first appears after 20 weeks in someone whose blood pressure was normal before, and says it is usually monitored weekly for signs of preeclampsia. Preeclampsia is a serious disorder that usually develops after 20 weeks and can also develop after birth; with severe features, it may be treated in the hospital.
• Gestational diabetes. ACOG says everyone should be screened, usually at 24 to 28 weeks, or earlier with risk factors. Care can include more frequent visits, tracking blood sugar, and sometimes tests of the baby's well-being. ACOG notes that most people with controlled gestational diabetes can complete a full-term pregnancy.
• Bleeding. ACOG advises contacting your provider about any bleeding. Later in pregnancy it can be more serious, because it may come from a placenta problem such as placenta previa or placental abruption, or signal preterm labor.
• Preterm labor. Labor that starts before 37 weeks needs medical attention right away, though ACOG notes it does not automatically mean a preterm birth. NICHD lists a previous preterm birth among the factors that raise risk.

Changes involving the baby or the pregnancy

• Twins or more. ACOG says you will likely have more frequent prenatal visits and, starting in the second trimester, may have ultrasound exams every 4 to 6 weeks. Preterm birth is the most common complication, and preeclampsia and gestational diabetes are more likely.
• Going past your due date. ACOG calls 41 weeks up to 42 weeks "late term" and longer than 42 weeks "postterm." Problems occur in only a small number of postterm pregnancies, but testing may be recommended and induction discussed at 41 weeks.
• Concerns about the baby's growth or health. ACOG lists fetal growth problems and decreased fetal movement among the reasons for extra monitoring, and NICHD includes fetal congenital or genetic conditions.

Does being 35 or older make a pregnancy higher risk?

Age is one factor, not a switch that flips at a birthday. ACOG explains that age-related risks "do not increase all at once," some not until 40 or later, and that older age by itself does not mean you need a cesarean birth. NICHD adds that most older first-time mothers have normal pregnancies, and notes that pregnant teens are more likely to develop pregnancy-related high blood pressure and anemia and to have preterm labor.

What Happens After Your Pregnancy Becomes Higher Risk?

Care depends on the specific concern, but the process often follows a similar pattern:

1. A conversation about what changed. Your midwife or other prenatal care provider explains what was found and what it could mean.
2. A plan matched to the specific concern. NICHD notes that care depends on the specific risk factors. A blood pressure concern and a breech baby lead to very different next steps.
3. Closer follow-up. ACOG and SMFM describe more frequent visits, more ultrasounds, and for some pregnancies regular monitoring of the baby, along with blood pressure checks, lab work, or home monitoring.
4. Input from another clinician, if needed. Your midwife may ask a physician for advice, share your care with one, or refer you, sometimes to a maternal-fetal medicine specialist. These approaches are explained below.
5. A review of your birth plan and setting. SMFM notes that specialist care includes time to talk about your pregnancy and birth plans, including where you can safely give birth.
6. Ongoing reassessment. ACOG and SMFM call for continuous risk assessment, and ACOG notes that how often tests are repeated depends on whether the condition stays stable. Your plan can be updated as your situation changes.
7. Knowing when to call. Make sure you know which symptoms to report and how to reach someone after hours.

What Extra Monitoring or Testing Might You Have?

According to ACOG, special tests of the baby's well-being usually start between 32 and 34 weeks, or earlier if problems are particularly serious, and may be repeated weekly or twice weekly depending on the condition. The table explains what common tests are; your care team will explain your own results.

When Might a Specialist Become Involved?

What a maternal-fetal medicine specialist does

According to SMFM, maternal-fetal medicine specialists (MFMs), also called perinatologists, are obstetricians with extra training in complex, high-risk pregnancies who work with obstetricians, nurses, midwives, and other specialists. A referral "doesn't always mean something is wrong," SMFM says; it means your team wants closer monitoring and expert support. ACOG adds that a specialist who already treats a pre-existing condition, such as a cardiologist, should also be involved, and that pediatric specialists and the neonatal intensive care unit (NICU) may help plan if the concern involves the baby.

Will a specialist take over your care?

Not necessarily. SMFM describes MFM subspecialists as working alongside other obstetric care providers through consultation, co-management, or transfer of care. In a consultation, an MFM may give advice about a particular problem or perform special testing. In co-management, you see both your regular provider and an MFM, which SMFM notes many patients do. For certain patients, an MFM provides all of the pregnancy care. Whether an MFM is involved at all, and in which role, depends on your condition and your care team's assessment, so ask what the specialist's role will be and who to call with questions.

Can You Keep Seeing Your Midwife?

Often, at least for part of your care, but it depends on the condition. Becoming higher risk doesn't automatically end midwifery care; it can change the midwife's role.

How collaborative care works

The American College of Nurse-Midwives (ACNM) describes three ways certified nurse-midwives work with physicians, and ACOG and ACNM jointly describe the two professions as collaborating according to the patient's needs. New York law requires midwives to have collaborative relationships that provide for consultation, collaborative management, and referral.

How this works at Birthing Center Long Island

This section describes Birthing Center Long Island specifically, using the center's own published pages. It is not general guidance for all birth centers.

The center's midwifery services page says its midwives "consult with or refer to physicians when a pregnancy needs that level of care," and that "some pregnancy histories and conditions make a hospital the safer setting. That is a clinical conversation rather than a checklist... If your circumstances change during pregnancy, the plan changes with them." Its page on planned hospital birth with our midwives adds: "Because the same midwives attend births in each setting, your care continues with people you know."

These pages don't spell out which conditions lead to consultation, shared care, or referral, so ask your midwife directly what your change means for who cares for you.

How Your Birth Plan Might Change

ACOG reminds families that a birth plan doesn't guarantee how labor will go. Its article on high-risk pregnancy notes that a higher-risk pregnancy can affect the birth plan; for example, a serious heart condition may lead your care team to recommend a scheduled cesarean birth. Your preferences still matter, so ask which of them can still be honored.

Can you still give birth at a birth center?

It depends. ACOG and SMFM describe birth centers as caring for low-risk pregnancies with one baby, at term, head-down, expected to have an uncomplicated birth. New York's regulations for midwifery birth centers (10 NYCRR Part 795), which apply to facilities licensed in New York as midwifery birth centers and are described here as general information, allow only patients at low risk to be admitted, with risk judged by standardized, written criteria. ACOG and SMFM note that risk definitions should be individualized by facilities and regions, and the Commission for the Accreditation of Birth Centers notes, for example, that accredited centers may choose whether to offer a trial of labor after a previous cesarean. So the answer depends on:

• The specific condition or finding
• How it develops over time
• The birth center's written risk criteria and protocols
• Your care team's clinical assessment

Whether a particular finding affects birth center care is decided by applying the center's criteria to your situation. If your pregnancy no longer meets them, your care setting may need to change, and your care team may recommend hospital-based care. Our guide to licensed and unlicensed birth centers explains why these standards matter.

When hospital birth may become the safer option

Some care is not provided in a birth center. New York's regulations say midwifery birth centers do not use forceps or vacuum extraction, give general or regional anesthesia (including epidurals), or induce or speed up labor with medication. Centers must refer or transfer patients for care outside their resources and risk criteria "at any point during the course of care," must start a transfer in labor for situations such as prolonged labor, fetal distress, a need for an epidural, or a possible cesarean, and must have transfer agreements with perinatal centers.

Some situations point to a hospital birth from the start. The Commission for the Accreditation of Birth Centers says accredited centers transfer people known to have a breech baby, or twins or more, to a hospital obstetric unit. Our guide to choosing where to give birth on Long Island explains hospital levels of care in New York. A change to a hospital birth is a safety decision, not a failure.

If your baby is breech late in pregnancy

A breech baby is positioned to come out buttocks or feet first, which ACOG says happens in 3 to 4 percent of full-term births. Beyond 36 weeks, your provider may suggest external cephalic version (ECV), an attempt to turn the baby head-down from the outside, usually done near a delivery room. More than half of ECV attempts succeed, though some babies turn back. If the baby stays breech, most are born by planned cesarean, and planned vaginal breech birth may be considered in some situations after a detailed discussion of risks. Ask your midwife about your options and where ECV would happen if it's offered.

When circumstances change again

Because care teams keep reassessing risk, a plan can change as the situation does, and plans can also change during labor. Our guide to birth center care in the Five Towns describes the center's approach to hospital transfer, and our third trimester checklist includes making a transfer plan.

It's Okay to Feel Unsettled

Hearing that your pregnancy is higher risk can bring worry or disappointment, especially if you were looking forward to a particular kind of birth. In ACOG's article, a maternal-fetal medicine specialist writes that patients are "understandably nervous" about the term and that "all those appointments and tests can feel stressful and time-consuming." It can help to write down questions before each visit, bring a support person, and, as MedlinePlus advises, tell your provider if something is bothering or worrying you. If you have thoughts about harming yourself or your baby, the CDC lists that as an urgent warning sign: seek medical care immediately.

Questions to Ask Your Care Team

• What exactly changed, and what does it mean for me and my baby?
• Could this change again?
• What extra visits, tests, or monitoring do you recommend, and how often?
• Do I need a specialist? Is that a consultation, shared care, or a transfer of care?
• Who is my main provider now, and can I keep seeing my midwife?
• Does this change whether I can give birth at the birth center? What would have to change for that answer to change?
• If a hospital birth is recommended, which hospital, and who would attend my birth?
• Which of my birth preferences can still be part of the plan?
• Which symptoms should I report right away, and how do I reach someone after hours?
• Will this affect my care after birth or in a future pregnancy?

Risk Factors vs. Warning Signs: When to Get Care Right Away

A risk factor is a reason your care team watches more closely. A warning sign is a symptom that needs medical attention now. They aren't the same: warning signs can appear in pregnancies considered low risk, and ACOG notes, for example, that preterm labor can happen to anyone without warning.

The CDC's urgent maternal warning signs apply during pregnancy and in the year after birth. The CDC says to seek medical care immediately if you have any of these:

• Headache that won't go away or gets worse over time
• Dizziness or fainting
• Changes in your vision
• Fever of 100.4°F or higher
• Extreme swelling of your hands or face
• Thoughts about harming yourself or your baby
• Trouble breathing
• Chest pain or fast-beating heart
• Severe nausea and throwing up
• Severe belly pain that doesn't go away
• Baby's movement stopping or slowing during pregnancy
• Vaginal bleeding or fluid leaking during pregnancy
• Vaginal bleeding or discharge after pregnancy
• Severe swelling, redness, or pain of your leg or arm
• Overwhelming tiredness

The ACOG Foundation's Quality in Action program advises contacting your provider right away for any of these symptoms, and going to the nearest emergency room if you can't reach your provider. Tell anyone who treats you that you are pregnant or were pregnant within the past year.

ACOG also advises calling your provider right away, or going to the hospital, for signs of preterm labor (cramps, a change in or more vaginal discharge, pelvic pressure, a constant low, dull backache, regular contractions or tightening, or your water breaking) or any bleeding late in pregnancy, and calling right away for symptoms of preeclampsia. On movement, the CDC notes there is no specific normal number; a change is what matters. Its list doesn't cover every symptom, so if something doesn't feel right or you aren't sure whether it's serious, contact your provider. Questions that aren't urgent can wait for your regular visits. After birth, see our guide to postpartum warning signs.

A Note From Our Midwifery Practice

Our published approach is to be straightforward with you when a hospital is the safer setting and to change the plan when your circumstances change. Bring your questions, and see our birth center FAQs for common ones.