Elective Caesarean Section for Fetal Congenital Anomalies
Elective caesarean section is not routinely recommended for most fetal congenital anomalies, with the notable exception of large cystic hygromas that may obstruct the airway at delivery. 1
Specific Congenital Anomalies and Delivery Recommendations
Cystic Hygroma (Clear Indication for CS)
- Caesarean section is indicated for large anterior lymphangiomas (cystic hygromas) that can obstruct the fetal airway, providing optimal conditions for immediate airway management at birth 1
- This represents the clearest fetal structural anomaly indication for elective CS to prevent mortality from airway obstruction
Neural Tube Defects (Conditional Indication)
- Caesarean section benefits fetuses with neural tube defects presenting by breech position 1
- For vertex presentations, there is no clear evidence that CS improves outcomes 1
- When the meningomyelocele sac exceeds 6 cm in diameter, caesarean section may be justified to decrease the risk of sac disruption during delivery 1
- Vaginal delivery is preferable in all other cases to reduce maternal morbidity 1
Sacrococcygeal Teratoma (Size-Based Decision)
- The current approach is based on tumor size: vaginal delivery may be attempted when the tumor measures less than 5 cm 1
- Caesarean section is recommended for tumors ≥5 cm to prevent tumor rupture and hemorrhage 1
Ventral Wall Defects
Omphalocele
- There is no conclusive evidence that caesarean section is beneficial for fetuses with omphalocele 1
- Vaginal delivery is acceptable unless obstetric indications for CS exist 1
Gastroschisis
- There is no evidence of significant differences in outcome between vaginal versus caesarean delivery for gastroschisis 1
- Trauma to abdominal viscera can occur during either route of delivery 1
- Careful delivery technique is mandated regardless of route 1
Important Clinical Caveats
Maternal Considerations Override Fetal Anomalies
The decision for CS should prioritize maternal indications when they exist, including:
- Severe cardiac conditions (pulmonary hypertension, significant aortopathy, acute heart failure) 2, 3
- Maternal anticoagulation therapy to minimize time off anticoagulation 2, 3
- Anticipated difficult airway to avoid emergency general anesthesia 2, 3
Common Pitfalls to Avoid
- Do not perform routine caesarean section for fetal anomalies without specific airway or size-related concerns, as this increases maternal morbidity without improving fetal outcomes 1
- Avoid assuming all structural anomalies require CS—the evidence supports vaginal delivery for most congenital defects 1
- Ensure immediate neonatal resuscitation capacity and appropriate specialists (pediatric surgery, ENT) are available regardless of delivery route when fetal anomalies are known 2
Breech Presentation Context
While not a congenital anomaly per se, breech presentation often coexists with fetal anomalies. The evidence shows planned vaginal delivery for breech increases neonatal morbidity and mortality compared to elective CS 4, 5, which may influence decision-making when anomalies are also present.