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After years of unsuccessfully trying to conceive a child, Virginian attorneys Gene (Michael Woods) and Karen (Faye Grant) York adopt a newborn from a nun-owned orphanage. As little Delia (Asia Vieira) grows, Karen notices that she has a mean streak, difficulty making friends, and unusual psychic powers, so Karen hires private investigator Earl Knight (Michael Lerner) to search out her birth parents.

Omen IV is the fourth and final film in The Omen series that started with The Omen (1976), which was based on an original screenplay by American screenwriter David Seltzer. The story and teleplay for Omen IV was written by American screenwriter Brian Taggert and American film producer Harvey Bernhard. Other films in the series include Damien: Omen II (1978) and Omen III: The Final Conflict (1981).

Delia's biological mother is not revealed in the film. Viewers have suggested two possibilities: (1) Sister Yvonne (Megan Leitch), and (2) Kate Reynolds (Lisa Harrow), whom Damien was dating in The Final Conflict (1981).

Fetus papyraceous aka vanishing twin is a condition in which one fetus in a multiple birth dies while still in the womb. Depending upon the stage of pregnancy, the body of the dead fetus may be partially or completely reabsorbed by the remaining fetus. In the film, however, Alexander is not dead; he's merely "hibernating" inside Delia until Dr Hastings removes him and transplants him into Karen.