Indications for cesarean delivery among patients with life-limiting fetal diagnoses

Mode of delivery is uniquely complex when a neonate is not expected to survive after birth. Cesarean delivery (CD) generally confers increased maternal morbidity but may be pursued to mitigate intrapartum fetal risk. Prior studies have reported elevated CD rates among patients with a life-limiting fetal diagnosis (LLFD) but have not characterized the indications that drive this increase. We sought to characterize the proportion and indications for CD among patients with selected LLFDs.

This retrospective cohort includes patients with an antenatal LLFD who delivered at a tertiary care center between January 1, 2018 and May 1, 2025 at or above 24 weeks' gestation. LLFD cases were chosen for inclusion after manual review by Maternal-Fetal Medicine and Neonatology subspecialists, and the cohort was further restricted to six LLFDs: anencephaly, trisomy 13, trisomy 18, anhydramnios due to genitourinary etiologies, limb-body wall complex, and severe skeletal dysplasia. The primary outcome was CD; the secondary outcome was indication for CD.

Of 32,523 eligible deliveries, 241 were identified as having an antenatal LLFD; after restriction to six prespecified diagnoses, the final LLFD cohort included 106 patients. CD occurred in 42.5% of LLFD pregnancies. Proportion of deliveries by CD varied by diagnosis: 0% in anencephaly, 36.4% in skeletal dysplasia, 40.0% in trisomy 13, 45.8% in trisomy 18, 40.0% in limb/body wall complex, and 54.5% in anhydramnios due to a genitourinary cause. A total of 53.3% of CDs were performed for a fetal indication, most commonly malpresentation and non-reassuring fetal status.

Driven by fetal indications for delivery, patients with a known LLFD underwent CD in 42.5% of pregnancies, with substantial variation across diagnoses. It is unclear whether the increased proportion of CD is driven by traditional obstetric indications or patient-centered choices regarding the delivery experience.