The impact of prenatal care on fetal and neonatal death rates for uninsured patients: a "natural experiment" in West Virginia.

A three-county program in southern West Virginia was developed by an obstetric practice to deliver prenatal care to a population of uninsured patients. Between January 1984 and December 1986, 1331 (29.4%) of 4534 patients were delivered at a level 2 hospital after prenatal care within the clinic program. The hospital-wide fetal death ratio declined from 11.8 to 7.2 per 1000 live births during the years of clinic operation, a statistically significant reduction (P = .02). Uninsured patients experienced a statistically significant reduction in fetal death ratio during the program, from 35.4 to 7.0 per 1000 live births (P = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1000 live births (P less than .001). The increasing operating expense, mainly due to rising malpractice insurance premiums, required suspension of the program in December 1986. The fetal death ratio returned to 10.3 deaths per 1000 live births in 1987. Factors that varied significantly during the "clinic" phase included: higher rates of cesarean, diagnosed maternal hypertension, and diabetes mellitus; and lower rates of premature rupture of membranes and non-white population. Other factors, including age over 35 years, postdatism, incidence of twins, incidence of lethal congenital anomalies, and single marital status, did not vary significantly before, during, or after the clinic program. This study identified a high-risk population of patients who did not qualify for medical assistance coverage and were de facto "uninsured." The results suggest that prenatal care for this high-risk population of uninsured patients can reduce the fetal death rate.     

Survey of Mode of Delivery and Maternal and Perinatal Outcomes in Canada

ObjectiveTo identify determinants of cesarean delivery (CD) and examine associations between mode of delivery (MOD) and maternal and perinatal outcomes.MethodsWe conducted a retrospective analysis of a Canadian multicentre birth cohort derived from provincial data collected in 2008/2009. Maternal and perinatal characteristics and outcomes were compared between vaginal and cesarean birth and between the following MOD subgroups: spontaneous vaginal delivery (VD), assisted VD, planned cesarean delivery (CD), and intrapartum CD. Multivariate regression identified determinants of CD and the effects of MOD and previous CD on maternal and perinatal outcomes.ResultsThe cohort included 264 755 births (72.1% VD and 27.9% CD) from 91 participating institutions. Determinants of CD included maternal age, parity, previous CD, chronic hypertension, diabetes, urinary tract infection or pyelonephritis, gestational hypertension, vaginal bleeding, labour induction, pre-term gestational age, low birth weight, large for gestational age, malpresentation, and male sex. CD was associated with greater risk of maternal and perinatal morbidity and mortality. Subgroup analysis demonstrated higher risk of adverse pregnancy outcomes with assisted VD and intrapartum CD than spontaneous VD. Planned CD reduced the risk of obstetric wound hematoma and perinatal mortality but increased maternal and neonatal morbidity. Previous CD increased the risk of maternal and neonatal morbidity among multiparous women.ConclusionsThe CD rate in Canada is consistent with global trends reflecting demographic and obstetric intervention factors. The risk of adverse pregnancy outcomes with CD warrants evaluation of interventions to safely prevent nonessential cesarean birth.     

Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery

OBJECTIVE: This study was undertaken to assess the safety of trial of labor after previous cesarean delivery. STUDY DESIGN: Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section. RESULTS: Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume (<500) than in high volume (> or =500 births per year) obstetric units. CONCLUSION: Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.     

Fetal death during labor: an epidemiologic indicator of level of obstetric care

The effect of level of perinatal care on rates of intrapartum fetal death was studied in births of infants weighing greater than 1000 gm in New York City in 1976 to 1978. With potential confounding by birth weight, gestational age, and several other variables controlled, intrapartum fetal death rates decreased as intensiveness of care increased. Compared with births in Level 3 maternity units (perinatal intensive care), births in Level 1 units (community hospitals) had a 61% excess risk of intrapartum fetal death (p less than 0.01) and births in Level 2 units (intermediate level of care) had a 35% excess risk (p = 0.06). The effect of hospital level on intrapartum fetal death rates could not be attributed to differences in the classification of fetal deaths during labor across hospital levels, since no compensatory differences in late antepartum fetal death rates were found. Our findings in a total population are compatible with several studies carried out in single hospitals that have reported declines in intrapartum fetal death rates, especially in births more closely attended during labor. Fetal deaths that occur in labor, as contrasted with fetal deaths occurring before labor, constitute a perinatal outcome that is especially sensitive to level of obstetric care.     

Elective induction vs. spontaneous labor associations and outcomes

OBJECTIVE: To determine factors and outcomes associated with elective medical induction of labor as compared with spontaneous labor in low-risk women. STUDY DESIGN: Using a birth certificate database including 11,849 low-risk, laboring women, univariate and multiple logistic regression was used to evaluate demographic and obstetric factors associated with elective labor induction. Low risk was defined as singleton, vertex, 37-41 weeks' gestation, no prior cesarean section, and no presenting medical/obstetric diagnoses considered indications for cesarean or induction. Adverse neonatal outcome was defined as 1- or 5-minute Apgar score < 7, neonatal intensive care unit admission or respiratory distress. Spontaneously laboring women (n = 10,608) were compared with women who underwent induced labor for no apparent medical/obstetric reason (n = 1,241). Interventions and outcomes during and after labor induction were adjusted for relevant associated variables. RESULTS: Odds ratios for epidural anesthesia, cesarean delivery and diagnoses of nonreassuring fetal heart rate patterns were independently increased following elective induction; odds ratios for cephalopelvic disproportion, instrumental delivery and adverse neonatal outcome were not. Maternal length of stay was 0.34 days longer with induction than with spontaneous labor (p < 0.0001). Slightly more induced labors ended before midnight. CONCLUSION: As compared with spontaneous labor, elective labor induction is independently associated with more intrapartum interventions, more cesarean deliveries and longer maternal length of stay. Neonatal outcome is unaffected.     

Evaluation of a feto-pelvic scoring system in the management of breech presentations

A feto-pelvic scoring system comprising maternal pelvimetric data, estimated fetal weight, type of breech presentation and previous obstetric history was used in selecting patients for cesarean section of vaginal delivery. A maximum score of 20 points was possible. Twelve points or less indicated cesarean section. During 1973-1975 224 singleton breech deliveries were evaluated. In 29.5% cesarean section was performed and in 83% of these it could be planned in advance. In 70.5% of cases, patients were allowed to deliver vaginally under continuous electronic monitoring of the fetal heart rate. There was one intrapartum death and only one early neonatal death of a small premature child. In two cases intrauterine death had occurred already in the antepartum period. The uncorrected perinatal mortality was 17.9 per 1000 but not significantly different from the uncorrected perinatal mortality of 8.0 per 1000 for all patients delivered at the Danderyd's Hospital during the period 1972-1975 (12832 births). The corrected mortality resulting from breech presentation was 8.9 per 1000. The infants exhibited similar and excellent 5 min Apgar scores whether delivered vaginally or by cesarean section or matched with a randomized control series of 1000 cephalic presentations.     

Balancing the risks of planned cesarean section and trial of vaginal delivery for the mature, selected, singleton breech presentation

The experience of mature, singleton, vaginal breech delivery over the last decade in our hospital is reviewed. This constitutes the largest series of breech delivery reported for over twelve years. Unlike all but two previous reports, we analyze our results by management policy; elective cesarean section, trial of vaginal breech delivery and cesarean section as soon as the diagnosis of breech delivery was made on labor ('expedite' cesarean operations). Six intrapartum or neonatal deaths occurred among 613 patients selected for trial of vaginal delivery--a rate of one per cent. There were none following 217 elective or 69 expedite cesarean sections. A detailed review of the literature over the last decade confirms that trial of vaginal delivery is more dangerous to the fetus and results in about one perinatal death of a normally formed infant in 200 deliveries. Apgar scores were slightly lower following trial of vaginal delivery and there were more irritable or injured babies in this group. The last intrapartum or neonatal death occurred in 1981. However, the elective cesarean section rate has increased from 14 to 33 per cent over this time period. Similarly the rate of failed trial of vaginal breech delivery has increased from 15 to 31 per cent. The proportion of failed trials was highest where the fetus was large but clinicians were poor at estimating fetal weight. Decision theory is used to examine the maternal utility of trial of vaginal breech delivery versus elective cesarean section when the intrapartum cesarean rate rises to these levels. It is shown that, from the point of view of maternal mortality and morbidity in the current pregnancy, trial of vaginal delivery maybe the more dangerous maternal option. Thus a low threshold for cesarean section in labor leads to greater fetal safety at the mother's expense. It is nevertheless concluded that maternal attitude and the long-term effects of a uterine scar should be considered in the final decision.     

An analysis of the indications for cesarean section in a teaching hospital in China

Objectives

Cesarean delivery rates have increased remarkably worldwide. The indications for this increase are not fully understood and there may be regional, ethnic or health system differences in quoted indications which may explain, at least in part, the observed changes. In 2008 China was cited as having one of the highest rates of cesarean delivery in the world, but there was no accurate information about the indications for the high rate. This study sought to provide some information about the high cesarean section rate in China.

Study design

Data on all births in a university teaching hospital in northern China serving a general obstetric population, excluding premature births, were collected from the hospital database from January 2009 to September 2012. All indications on the mode of delivery were analyzed for live births.

Results

There were 5267 births and the cesarean delivery rate was 41.4% in the study period. There was no significant trend in the cesarean delivery rate from 2009 to 2012. Fetal indications contributed most to the rate. More than 50% of all cesarean deliveries were due to nuchal cord, previous cesarean delivery, fetal distress and malpresentation. The rate of cesarean delivery on maternal request was 9.07%. Smaller contributions to the indications for cesarean delivery came from cephalopelvic disproportion, preeclampsia, prolonged labor, uterine rupture and other obstetric conditions.

Conclusion

The data show increased fetal or maternal risk assessments are the main indications for cesarean delivery rather than cesarean delivery on maternal request in China.     

Cesarean delivery surveillance system at a maternity hospital in Kabul, Afghanistan

OBJECTIVE: To use an active facility-based maternal and newborn surveillance system to describe cesarean delivery practices and outcomes in a resource-poor setting. METHODS: Using data from operating room logbooks, 392 cesarean deliveries were evaluated between April 1 and June 30 2006 at a large public maternity hospital in Kabul, Afghanistan. RESULTS: The perinatal mortality rate was 89 per 1000 births: 57% antepartum and 37% intrapartum stillbirths. Fetuses with normal birth weight comprised 85% of intrapartum stillbirths. Obstructed labor, uterine rupture, and malpresentation accounted for more than 50% of perinatal deaths. The cesarean delivery rate was 10.2% and there were 2 maternal deaths. CONCLUSION: The high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. The use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives.     

Intrapartum elective cesarean delivery: a previously unrecognized clinical entity

OBJECTIVE: The purpose of the study was to investigate the incidence of intrapartum patient choice cesarean delivery-patients' requesting cesarean delivery and physicians' offering it during labor-and factors possibly influencing these requests and offers. METHODS: For a 6-month period from May 1, 2002, to October 31, 2002, obstetricians were asked to complete a questionnaire after all intrapartum cesarean deliveries regarding whether cesarean delivery was offered by the obstetrician or requested by the patient before being medically indicated. Patient medical records and physician demographic information were reviewed. RESULTS: There were 422 cases that met inclusion criteria. Questionnaires were completed in 100% of cases. Cesarean delivery was offered in 13% before a clear medical indication and requested in 8.8%. Older obstetricians, maternal-fetal medicine specialists, and full-time faculty were significantly more likely to offer cesarean delivery (P =.009, P <.001, and P =.015, respectively). Patients who were unmarried or undergoing labor induction were less likely to request cesarean delivery (P =.029 and P =.035, respectively). Maternal age, parity, stage or length of labor, epidural use, gestational age, insurance status, day of week, and time of delivery did not affect whether patients requested or were offered cesarean delivery. CONCLUSION: This study documents a heretofore unrecognized clinical entity: intrapartum elective cesarean delivery. Physician characteristics, as opposed to patient characteristics or intrapartum factors, are a major determinant of whether laboring patients are being offered cesarean delivery. LEVEL OF EVIDENCE: III     

Increased risk of cesarean delivery with advancing maternal age: indications and associated factors in nulliparous women

OBJECTIVE: To investigate factors that contribute to the increased risk of cesarean delivery with advancing maternal age. STUDY DESIGN: We reviewed demographic and ante- and intrapartum variables from a data set of term, nulliparous women who delivered at Brigham and Women's Hospital in 1998 (n = 3715). RESULTS: Cesarean delivery rates increased with advancing maternal age (< 25 years, 11.6%; > or = 40 years, 43.1%). Older women were more likely to have cesarean delivery without labor (< 25 years, 3.6%; > or = 40 years, 21.1%). Malpresentation and prior myomectomy were the indications for cesarean delivery without labor that were more prevalent in our older population as compared to our younger population. Even among women with spontaneous or induced labor, cesarean delivery rates increased with maternal age (< 25 years, 8.3%; > or = 40 years, 30.6%). Cesarean delivery rates were higher with induced labor, and rates of induction rose directly and continuously with maternal age, especially the rate of elective induction. Cesarean delivery for failure to progress or fetal distress was more common among older parturients, regardless of whether labor was spontaneous or induced. Among women who underwent cesarean delivery because of failure to progress, use of oxytocin and length of labor did not vary with age. CONCLUSIONS: Older women are at higher risk for cesarean delivery in part because they are more likely to have cesarean delivery without labor. However, even among those women who labor, older women are more likely to undergo cesarean delivery, regardless of whether labor is spontaneous or induced. Part of the higher rate among older women who labor is explained by a higher rate of induction, particularly elective induction. Among women in both spontaneous and induced labor, cesarean delivery for the diagnoses of failure to progress and fetal distress was more frequent in older patients, although management of labor dystocia for these patients was similar to that for younger patients.     

Maternal and neonatal copeptin levels at cesarean section and vaginal delivery

Objective

The objective of the study was to measure the copeptin levels in maternal serum and umbilical cord serum at cesarean section and vaginal delivery in normotensive pregnancy and pre-eclamptic women.

Study design

This was a prospective study at Mansoura University Hospital, Egypt. Ninety cases were included. They were divided into six groups: (1) normal pregnancy near term, as a control group, (2) primiparas who had vaginal delivery, (3) primiparas who had vaginal delivery and mild preeclampsia, (4) elective repeat cesarean section, (5) intrapartum cesarean section for indications other than fetal distress, and (6) intrapartum cesarean section for fetal distress. Serum copeptin concentrations were quantified with an enzyme-linked immunosorbent assay (ELISA). Mean, standard deviation, and paired t-test were used to test for significant change in quantitative data.

Results

The vaginal delivery groups had higher levels of maternal serum copeptin than the elective cesarean section group (P < 0.01). Higher maternal serum copeptin levels were found in cases with pre-eclampsia as compared with the normotensive cases. The maternal copeptin levels during intrapartum cesarean section were higher than that during elective repeat cesarean section. There was a significant correlation between maternal copeptin levels and the duration of the first stage. In the presence of fetal distress, umbilical cord serum copeptin levels were significantly higher than other groups.

Conclusion

Vaginal delivery can be very painful and stressful, and is accompanied by a marked increase of maternal serum copeptin. Increased maternal levels of serum copeptin were found in cases with pre-eclampsia as compared with the normotensive cases, and it may be helpful in assessing the disease. Intrauterine fetal distress is a strong stimulus to the release of copeptin into the fetal circulation.     

Maternity Care and Outcomes in a High-Risk Service: The North Central Bronx Hospital Experience

ABSTRACT: The maternity service of the North Central Bronx Hospital, a New York City municipal hospital for the medically indigent, has demonstrated that good maternal and infant outcomes can be obtained in an unselected population of disadvantaged women by using obstetric interventions only when medically indicated. Approximately 70 percent of the mothers cared for in the service are considered at risk or high risk. Of the 3287 deliveries in 1988, 86.1 percent were performed by the midwives on staff. Midwives were the primary providers of prenatal, intrapartum, and postpartum care for all low-risk mothers, and comanaged with the attending obstetricians the care of all high-risk mothers. The cesarean section rate was 11.8 percent, and the rate of instrumental delivery was 0.3 percent, with minimal use of oxytocin augmentation (6.4%). Among the 3323 infants delivered in 1988, the last full year before an obstetric residency program was established, the rate of those requiring special or intensive care was 11.1 percent, and neonatal mortality was 9.2 per 1000 live births for all birth weights and 3.7 per 1000 for infants over 1000 g. The experience gained from 10 years and over 25,000 births suggests that the maternity care of both high- and low-risk mothers could be improved by minimizing obstetric intervention whenever possible.     

Characteristics of antepartum and intrapartum eclampsia in the National Maternal and Child Health Center in Cambodia

AIM: To measure maternal and perinatal outcome and analyze risk factors for antepartum and intrapartum eclampsia, which is one of main causes of high maternal mortality at the top referral hospital in the Kingdom of Cambodia. METHODS: A hospital-based retrospective study of 164 antepartum and intrapartum eclampsia cases out of 20,449 deliveries. RESULTS: Overall case-fatality rate was 12%. Rate of stillbirth and low birth weight were 20% and 44%, respectively. Eighty percent of the cases presented signs of severe pre-eclampsia and 27% of the patients who gave birth received cesarean section. Living outside the capital city, teenage pregnancy and twin pregnancy are more frequently associated with eclampsia. CONCLUSION: Antepartum and intrapartum eclampsia is associated with severe pre-eclampsia and with poor maternal and perinatal outcome. Recommendations to reduce the burden of eclampsia are promoting and improving quality of antenatal care and health education especially in the third trimester; increasing access to high-quality essential obstetric care; improving the service delivery in rural areas; and monitoring the progress by hospital data.     

Usefulness of ultrasound in the delivery room

The use of diagnostic ultrasound and the diffusion of the technique improved the obstetric treatment and the usefulness of ultrasound increases in the delivery room for maternal and fetal care and as method of diagnosis of some obstetric complications. The knowledge of intrapartum ultrasound imaging can be considered useful for the obstetric team, since there is evidence that ultrasound can improve the obstetric management. The mean indications are described: fetal biometry and estimated fetal weight, amniotic fluid volume, fetal situation and presentation, placental localization and anatomy, assessment of size and location of uterine leiomyomas, fetal cardiac activity, evaluation of umbilical cord and fetal cardinal movements intrapartum. Besides, the use of ultrasound is reported in obstetric and postpartum complications. Actually ultrasonography, as a non-invasive, safety and low-cost technique, offers a diagnostic method in particular conditions during labour, delivery and postpartum.     

Obstetric anesthesia: Not just for cesareans and labor

The scope of obstetric anesthesia practice ranges far beyond the delivery of care to women for vaginal and cesarean deliveries. Increasingly, obstetric anesthesiologists are involved in the management of anesthetics for new procedures and for new indications. Anesthesia is frequently needed for maternal procedures, as well as fetal procedures, and at varying times in the intrapartum period. Maternal-specific procedures include cerclage, external cephalic version (ECV), postpartum bilateral tubal ligation (BTL), and dilation and evacuation (D and E). Fetus-specific procedures include fetoscopic laser photocoagulation and ex-utero intrapartum treatment (EXIT). This review will not include discussion of the anesthetic management of non-obstetric surgery during pregnancy, such as appendectomy or cholecystectomy.     

Perinatal hospice. Comprehensive care for the family of the fetus with a lethal condition

OBJECTIVE: To describe our experience in providing a program of structured interdisciplinary care for the families of fetuses prenatally diagnosed with a lethal congenital anomaly. STUDY DESIGN: We developed a comprehensive "perinatal hospice" program for the supportive care of families with fetuses known to have a lethal condition. Upon prenatal diagnosis of a lethal fetal condition, parents were presented with the option of elective pregnancy termination versus a multi-disciplinary program of ongoing supportive care until the time of spontaneous labor or until delivery was required for obstetric indications. We evaluated patient use of this new service and the natural history of pregnancies managed in this fashion. RESULTS: The population consisted of 33 patients carrying a fetus with a clearly delineated lethal anomaly. Twenty-eight (85%) chose to participate in the perinatal hospice program. Of these, 11/28 (39%) had an intrauterine fetal death and 17/28 (61%) delivered a live-born infant. Among the live-born infants were 12 vaginal deliveries, 4 preterm and 8 at term. Obstetric indications or maternal request resulted in cesarean delivery for 5/28 (18%), 4 preterm and 1 at term, all live born. All live-born infants died within 20 minutes to 2 months. There were no maternal complications. CONCLUSION: The availability of a structured program providing ongoing, comprehensive, multidisciplinary, supportive perinatal care offers a tangible and safe alternative to early elective pregnancy termination for patients carrying a fetus with a lethal congenital condition.     

Estimating the Rate of Cesarean Section by Maternal Request: Anonymous Survey of Obstetricians in Australia

Background: The rate of cesarean section in Australia now exceeds 30 percent, and evidence from population studies indicates that maternal requests for elective cesarean delivery might make an important contribution. The objective of this study was to explore the rate of such deliveries in Australia, in the absence of a formal investigation. Methods: An anonymous survey was sent to all 1,239 specialist obstetricians and 317 obstetric specialty trainees in Australia. Specialists were asked the number of elective cesarean deliveries they performed in 2006 that satisfied the National Institutes of Health definition of maternal request cesarean delivery. Trainees were asked whether they intended to agree to maternal requests for cesarean section in their future specialist practice. Results: The response rate from specialists was 98.6 percent, and from trainees was 81 percent. To account for possibility of multiple submissions, we performed two analyses: one using all responses, the other after removing 297 surveys in the second mail‐out that were identical to surveys received from the first mail‐out (n = 735). Proportions were similar in both groups. We estimated that between 8,553 and 12,434 maternal request cesarean sections were performed in Australia in 2006, representing at least 17 percent of all elective cesarean sections, and slightly more than 3 percent of all births. Conclusion: Maternal request is an important contributor to cesarean section rates in Australia.     

Adverse perinatal events and subsequent cesarean rate.

OBJECTIVE: To determine whether severe intrapartum complications resulting in poor neonatal outcome increased obstetricians' cesarean delivery rates. METHODS: From July 1996 through June 1998 we prospectively studied 3008 deliveries by 12 obstetricians. We chose adverse neonatal outcomes that would be viewed by obstetricians as anxiety-provoking experiences that are rare in obstetric practice. Index events included head entrapment of breech infants, Apgar score less than 3 at 10 minutes, shoulder dystocia resulting in persistent brachial plexus injury, and intrapartum fetal death. After an index event was identified, the obstetrician's cesarean delivery rate for the 50 deliveries before the index event was compared with the 50 deliveries after the index event. Obstetricians who had no intrapartum complication during the observational period were matched as controls. RESULTS: Six index events were identified, three cases of shoulder dystocia and three intrapartum fetal deaths. In three of these six cases, the Apgar score at 10 minutes was less than 3. Obstetricians who attended a delivery with severe intrapartum complications had an average increase in their cesarean delivery rate of 37% in the 50 deliveries after the index event (21.0% to 28.7%, P < .05). This rate was greater (P < .05) than that of matched control obstetricians observed during the same observation period (19.0% to 18.7%). CONCLUSION: Intrapartum complications such as persistent neonatal brachial plexus injury or fetal death increased the cesarean delivery rate of the obstetrician experiencing these events. Obstetricians should be aware of the effect of these adverse events on their practice of obstetrics.     

Fatal fetal abnormalities. Route of delivery and effect of the development of antepartum diagnostics in the last 13 years.

The appropriateness of cesarean section as the route of delivery in pregnancies complicated by fatal fetal abnormalities was evaluated in an obstetric population of 47,924 deliveries during the years 1978-90. The incidence of fatal fetal abnormalities was 0.50% and did not change during the study period. The cesarean section rate was twice that in the whole obstetric population, and the procedure was performed mainly for inappropriate fetal indications. One-third of the sections were caused by antepartum or intrapartum fetal distress. After the advent of sophisticated real-time ultrasound equipment, the obstetric management of those cases seemed to increase, but later the incidence of cesarean sections for fetal indications decreased, from increased experience with assessing the prognosis of malformed fetuses and increased opportunities to examine the fetal karyotype. Some conservatism seems justified when choosing obstetric management of a malformed fetus before large, controlled, clinical studies become available.