The need to understand the psychology of couples who have been through ART, and the impact that this has on both them and their maternity team is vital. Undergoing fertility treatment is physically, psychologically and financially demanding and not unlike being on an “emotional rollercoaster” [1]. Recognition of the potential for significantly increased psychological and emotional needs of couples is helpful to those involved in care [2, 3]. Women with IVF pregnancies have been shown to be more anxious throughout pregnancy [4]. Patients who have conceived through IVF present with antenatal complaints earlier and more frequently, increasing personal and medical anxiety [5]. This has also been shown to have a “knock-on” effect on medical intervention [6, 7]. They are more likely to be admitted when presenting with problems and may need more reassurance that normal symptoms of pregnancy, such as backache, are not something more serious [8].

There is evidence that obstetricians and midwives view patients who conceive through ART differently with regard to how they manage birth. Elective caesarean section (CS) rates for maternal request are higher in most countries in pregnancy after ART, with rates of 50 % or more being seen in some countries.

This protective attitude is especially evident in older women who may have had multiple attempts to conceive and in whom achieving another pregnancy may prove challenging. Concern about minimising adverse fetal outcomes and fear of litigation lead to a lower threshold for intervention, induction of labour, or operative delivery.

The mental well-being and psychological coping strategies of women who conceive with ART are also different from spontaneously conceived pregnancies. Some studies [9] cite that the emotionally demanding aspects of fertility treatment positively prepares some women to deal with the unexpected complications of childbirth whereas other authors state that these same factors can lead to anxiety about delivery [10]. Interestingly parents of both IVF and naturally conceived pregnancies find parenthood similarly stressful [11].

In the UK national guidance on antenatal care advises that women conceiving with ART do not have to be booked under an obstetrician unless there are additional risk factors [12]. However, before deciding on whether consultant led care is required, it is important that a full assessment of the obstetric risks associated with non-spontaneous conception is undertaken. Antenatal assessment of risk factors is discussed in other chapters.

The clinician managing labour may not have been involved in the delivery of antenatal care and so a thorough understanding of those risks that will be pertinent to labour is important.

Data from two large robust systematic reviews [13, 14] concluded that singleton IVF pregnancies compared to naturally conceived pregnancies, were more likely to have preterm (<37 weeks), very preterm (<32 weeks), low birth weight (<2500 g), very low birth weight (<1500 g) and small for gestational age babies. Recent data from Australia suggest that the larger part of this risk appears to be related to the infertility itself rather than the assisted conception, as risks were actually highest in pregnancies conceived spontaneously after a period of prolonged infertility [15]. Few studies have examined actual outcomes in labour for women after assisted conception compared to control groups. On large study from the Netherlands where pregnancies were very carefully matched at booking showed that the outcomes for labour were not significantly different except that delivery occurred approximately 3 days earlier on average in the IVF group amongst women who spontaneously laboured. There were more elective CS in the IVF group and slightly more assisted vaginal deliveries in the control group. Induction rates were no different. Birthweight centiles were slightly lower for babies born after IVF but neonatal outcomes for term babies were similar [16].

Pre-birth planning should be undertaken with every woman, regardless of method of conception. The appropriate professional to undertake this may be the midwife in the UK, if the pregnancy has progressed normally and there are no additional fetal or maternal risks identified. Conversely the obstetric team may have to fulfil this role, where midwives are not available or where complications or risks have been identified or where a couple wish to discuss alternative birth options to those offered by the midwife. Many women who have conceived after ART but are otherwise well are keen to avoid medicalisation and want to feel and be treated as normal, equally others feel that their journey to pregnancy has been complex and they need to discuss at length what choices they have with regard to birth, to minimise any risk to the baby.

The clinician should be able to present choices and the rationale for why some options may be recommended. In order to be in a position to provide appropriate information, maternal and fetal surveillance should have been undertaken according to identified risk factors, to ensure that issues such as fetal growth problems, placental issues, maternal medical problems and psychological needs have been identified prior to a final planning discussion.

Where complications have developed these should be managed in line with national guidelines where available. In the UK the most pertinent guidelines are: National Institute for Health and Clinical Excellence (NICE): Hypertension in pregnancy [17], Diabetes in pregnancy [18], Management of multiple pregnancies [19] and the Royal College of Obstericians and Gynaecologists (RCOG) guideline on Placenta praevia, accreta and vasa praevia with the National Patient Safety Agency care bundle for the management of placenta praevia after previous CS [20].

The key aspects for birth planning will include: