INTRODUCTION: Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. METHODS AND ANALYSIS: Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is <10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. ETHICS AND DISSEMINATION: The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. TRIAL REGISTRATION NUMBER: Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200.

Centre for Trials Research Cardiff University Cardiff UK

Department of Clinical Sciences and Community Health Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano ltaly

Department of Gynecology and Obstetrics Katholieke Universiteit Leuven Leuven Belgium

Department of Neurosciences Reproductive and Dentistry Sciences Federico 2 University Hospital Napoli Italy

Department of Obstetrics Amsterdam Vrije Universiteit Amsterdam Noord Holland Netherlands

Department of Obstetrics and Fetal Medicine University Medical Center Hamburg Eppendorf Hamburg Germany

Department of Obstetrics and Fetomaternal Medicine Medical University of Vienna Vienna Austria

Department of Obstetrics and Gynaecology Amsterdam University Medical Centres Amsterdam The Netherlands

Department of Obstetrics and Gynaecology Charles University Praha Czech Republic

Department of Obstetrics and Gynaecology General University Hospital and 1st Faculty of Medicine Charles University Prague Czech Republic

Department of Obstetrics and Gynaecology Stavanger University Hospital Stavanger Norway

Department of Obstetrics and Gynaecology Università degli Studi di Brescia Brescia Italy

Department of Obstetrics and Gynaecology University of Bern Bern Switzerland

Department of Obstetrics and Gynaecology University of Nottingham City hospital Nottingham UK

Department of Obstetrics and Gynecology Hospital Oost Limburg Genk Belgium

Department of Obstetrics and Gynecology Klinikum rechts der Isar Technical University of Munich Munich Germany

Department of Obstetrics and Gynecology Lund Skanes universitetssjukhus Lund Skåne Sweden

Department of Obstetrics and Gynecology Medical University of Graz Graz Austria

Department of Obstetrics and Gynecology University Hospital of Innsbruck Innsbruck Austria

Department of Obstetrics and Gynecology University of Parma Parma Italy

Department of Obstetrics and Gynecology Vittore Buzzi Hospital University of Milan Milan Italy

Department of Obstetrics Charite Humboldt University of Berlin Berlin Germany

Department of Obstetrics Children's and Women's Health St Olavs Hospital University Hospital Trondheim Norway

Department of Obstetrics University Medical Center Utrecht University Utrecht The Netherlands

Department of Women's and Children's Health Uppsala University Uppsala Sweden

Division of Obstetrics and Gynaecology Policlinico Casilino Roma Italy

Division of Obstetrics and Gynecology Department of Clinical Science Intervention and Technology Karolinska Institutet Stockholm Sweden

Division of Obstetrics and Maternal Fetal Medicine Medical University of Graz Graz Austria

Elizabeth Garrett Anderson Institute for Women's Health University College London London UK

Fetal medicine Unit Leeds Teaching Hospitals NHS Trust Leeds UK

Fetal Medicine Unit St George's University Hospitals NHS Foundation Trust London UK

High Risk Pregnancy Unit University Hospital Careggi Firenze Italy

Imperial College London Obstetrics and Gynaecology Queen Charlotte's and Chelsea Hospital London London UK

Institute for Care of Mother and Child Prague Czech Republic

Klinik für Geburtsmedizin Universitätsklinikum Jena Jena Germany

Medicine and Surgery University of Parma Parma Italy

Molecular and Clinical Sciences Research Institute St George's University of London London UK

National Medical Research Center for Obstetrics Gynecology and Perinatology Moscow Russia

Obstetrics and Gynaecology East Suffolk and North Essex NHS Foundation Trust Colchester Hospital Colchester UK

Obstetrics and Gynaecology Faculty of Medicine Lunds Universitet Lund Sweden

Obstetrics And Gynaecology Princess Alexandra Hospital NHS Trust Harlow UK

Obstetrics and Gynecology Hannover Medical School Hannover Germany

St Olav's Hospital Trondheim Norway

Unit of Fetal Medicine and Prenatal Diagnosis RCCS materno infantile Burlo Garofolo Dipartimento di Pediatria Trieste Italy

University College London Hospitals NHS Foundation Trust London UK

Vivantes Network for Health Clinicum Neukoelln Clinic for Obstetric Medicine Berlin Germany

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