Expert High-Risk Pregnancy Care Gets Mom to the Vital 23-Week Mark

Compassionate in-depth fetal counseling helps family make the best decision for them

When Emily Van became pregnant with her third child, she expected an easy time. After all, she had had smooth courses with her first two sons, who were born healthy at 37 and 38 weeks. Yet, after five weeks of pregnancy, she realized something was off.

“My body felt different, and I know my body well,” says Emily. “I started bleeding at five weeks, and I knew something was wrong.”

The little voice that kept insisting that something was amiss, despite hearing that all was well, continued to play in her head. She decided to transfer care to Stanford Medicine Children’s Health, where her older children had been born.

“Before my first appointment at Stanford Children’s Health, they sent me for my 19-week anatomy scan [ultrasound],” Emily says.

Emily’s care team made a thorough investigation during her scheduled ultrasound to identify any potential source of bleeding, and her cervix and placenta looked normal. The Stanford Children’s obstetric care team made a standard recommendation then that she repeat the ultrasound at 22 weeks to get a better view of the fetus. This time, Erica Wu, MD, maternal-fetal medicine specialist, diagnosed Emily with cervical insufficiency—when the cervix (the lower part of the uterus) is at risk for holding the fetus. She recommended that Emily check into Labor and Delivery immediately.

“We were going to go on vacation that week to Mexico, so of course that got canceled,” Emily says.

With cervical insufficiency, obstetricians can sometimes stitch up the cervix, but Emily’s pregnancy was too advanced for that solution. It couldn’t be done without breaking her amniotic sac (bag of water), which had traveled beyond her cervix—a condition referred to as bulging membranes.

Being admitted for a preterm birth

Emily was immediately admitted to the Johnson Center for Pregnancy and Newborn Services at Stanford Children’s. She was just 22 weeks along. Twenty-two weeks is nearly always too soon for a baby to survive.

That was when she met maternal-fetal medicine (MFM) specialist Charlotte Conturie, MD, and Stanford Medicine MFM fellow Hayley Miller, MD. Maternal-fetal medicine doctors are high-risk pregnancy specialists who provide the most advanced care for mothers who develop complications that affect them or the baby during pregnancy.

Emily’s maternal-fetal medicine and neonatology teams felt another week was needed for her baby to reach the possibility of a successful resuscitation. That single week—from 22 weeks to 23 weeks—can make a huge difference. According to a Stanford Medicine study, 55% of babies born at 23 weeks survive, compared with close to 28% babies born one week earlier.

“Survival is possible [for babies born between 22 and 23 weeks], but there is still a high risk of a baby not making it or having long-term complications,” Dr. Conturie adds. “It was a complex situation, one we see a lot of here at Stanford Children’s.”

When born early, babies often have chronic lung disease and need oxygen to survive. That’s because the lungs are one of the last organs to develop. They can also be burdened with other health and developmental problems. Typically the younger a baby is at birth, the more challenges he or she will have.

Giving the couple personalized fetal counseling

Emily and her husband, Christian, had to make one of the hardest decisions of their lives. Should they have the baby, knowing he might have chronic health problems or not survive?

“We resuscitate after our families receive counseling and understand the high rates of neonatal morbidity [ongoing health issues] and mortality [death] of premature babies at these very early gestational ages,” Dr. Conturie says.

From the beginning, Emily was clear that she wanted to hear the outlook of her baby son straight up. She wanted her doctors to be open and transparent.

“I asked them to tell it to me straightforward. I didn’t want them to sugarcoat it. And our MFM team did just that. Whether it was good or bad, they let me know, and I needed that,” Emily says.

Such a big decision requires careful counseling by a multispecialty team of maternal-fetal medicine specialists, neonatologists (newborn and preemie experts), and family planning experts to help couples understand their pregnancy options and what they can expect for their premature newborn and future pregnancies.

“Parents have choices. They decide at what level they want us to intervene on the part of mom or the baby. Some choose to not continue the pregnancy; others choose to continue. We had multiple conversations with Emily and Christian, because it’s a very complex, emotional decision,” Dr. Conturie says.

The Stanford Children’s team made themselves available to Emily and Christian continually and were there no matter what the time of night or day. Because Stanford Children’s specializes in caring for complex, high-risk pregnancy patients, they are able to share highly informed knowledge tailored to every couple’s unique needs.

“We meet families where they are at, and we take the time to sit together with patients like Emily. Nonbiased, nonjudgmental counseling is really helpful for our patients,” Dr. Miller says.

Armed with answers to all of their questions and ones they didn’t even know to ask, the couple made their decision. They wanted to try to reach 23 weeks—the point when the Neonatal Intensive Care Unit (NICU) could offer an attempt at neonatal resuscitation. “I told Christian that if the universe takes our baby naturally, then let’s accept it. But I could not give up. We knew there would be complications with our baby, that he could even be disabled, but we accepted that,” Emily says.

The MFM care team admired how the couple worked as a team, asked good questions, dove into deep topics, and had tough conversations to make the best decision for their family.

Getting Emily to 23 weeks’ gestation

The high-risk pregnancy team did everything they could to keep Emily pregnant, counting each day as a major victory. Throughout the 22nd week, they discussed the level of neonatal intensive care that Emily wanted for her baby, as well as the care she wanted for herself, such as whether or not to have a cesarean birth.

“We did everything we could to satisfy her goals of care,” Dr. Conturie says.

Finally, the week passed. Emily had made it to 23 weeks! Everyone felt a huge sense of relief.

Yet the next day was a new chapter. Emily felt fine all day, but during the night she told the nurse that something was wrong.

“I didn’t have an appetite, and in the middle of the night I woke up with spotting. I felt pretty sure he was coming,” Emily says.

Welcoming baby Alexander into the world

It was 23 weeks and one day. Emily continued to bleed, and her high-risk pregnancy care team watched her carefully for other complications. They discovered that the baby was in a breech position, where the baby’s feet are bottom-first in the cervix (as opposed to headfirst). At that point, Emily changed her mind on a planned cesarean section (C-section).

“I told my husband, ‘If we lose our baby, the healing process of the C-section will be hard on me.’ I had to think about both myself and my baby,” Emily says.

The care team prepared for an urgent vaginal delivery.

“I saw the realities of what could happen, and I loved the fact that everyone on the care team was very open to my opinion and really listened to me. They let me make my own choices,” Emily adds.

Emily naturally went into preterm labor, and before she knew it, her new baby boy was in the world. She describes him as about the size of her hand. She was shocked at his small size, but she intuitively knew that everything was OK. It helped that baby Alexander (Alex) gave her a sign.

“He grabbed my finger and squeezed, so I knew he was OK,” she says.

Highly specialized neonatal intensive care in the Nest

Right after birth, Alexander was resuscitated, quickly intubated, and placed on oxygen. He was transferred to the Neonatal Intensive Care Unit, where Stanford Children’s Health’s nationally recognized neonatologists could provide advanced care for his prematurity.

“At 23 weeks and one day, Alex could be saved, but it was quite risky,” says Anoop Rao, MD, Alex’s neonatologist. “All preemies have their share of life-threatening events, and Alex checked all the boxes. He had many ups and downs.”

Several specialized teams jumped in to care for him. Heart and lung doctors from the Cardiac and Respiratory Care for Infants with Bronchopulmonary Dysplasia (CRIB) Program supported his underdeveloped lungs and treated him for pulmonary hypertension—high blood pressure of the lungs. Pediatric Ophthalmology treated him for retinopathy of prematurity, an eye problem that can occur in premature babies. And Pediatric Dermatology treated him for a hemangioma—a benign vascular tumor. As Alex grew, he was also cared for by our neonatal developmental follow-up team to ensure that he was working toward his developmental milestones.

“Everyone at Stanford is great—from the MFM team to the neonatologists and everyone in between. I really appreciated having a team of multiple specialists who shared their opinions and decided together, with us, the very best care for Alex,” Emily says.

Alex was cared for in a specialized part of the NICU called the Nest, where specially trained nurses, therapists, and neonatologists care for the tiniest babies. In the Nest, he received continuous monitoring to ensure that he was always getting adequate oxygen to his brain and advanced lung support in a quiet, healing environment that mimics the womb.

“The Nest helps us keep a unified focus on needs unique to very young premature babies. This sustained focus lets us learn the intricacies of each baby and provide highly tailored care,” Dr. Rao says.

Emily gives extra praise and thanks to the NICU nurses who cared for Alex. She called them his “best friends in the NICU.” She felt they played a very important role in his healing and helped her and Christian to stay positive.

Living up to his warrior name

Alex was discharged home from the NICU after 120 days—just two days after his actual due date. The happy 15-month-old loves cuddling with his mama and playing with his dad and two older brothers. Alex is great at cruising around, and he’s just attempting to walk. The good support that he gets from his family is helping him to thrive.

Even though the family had to push through difficult times—when it didn’t seem like he would make it—Alex proved his will to live. And he’s lived up to his name.

“We named him after Alexander the Great. It means warrior, and he showed his strength,” Emily says. “At the hardest of times, he let us know that he wanted to stick around. And with his smile, he would tell me everything was going to be OK.”

Learn more about our maternal-fetal medicine care for high-risk pregnancies and specialized care for premature newborns .