The decision regarding the timing and mode of delivery is made on the basis of the hemodynamic status of the patient (Table 4). Early delivery is not required in all patients with cardiomyopathies or heart failure. The decision is made on the basis of the failure of the patient to respond to medical therapy and the overall hemodynamic status of the patient. The issue of the timing of delivery for critically ill pregnant women with heart failure requires a coordinated decision between the cardiologist, obstetrician, and anesthesiologist that balances the risks of continuing a pregnancy to the mother and fetus versus the risk of delivery and how that delivery should take place. If the heart failure of the patient is refractory to medical therapy, delivery needs to be strongly considered. Because no official recommendations exist, an individualized approach is sought. Virtually all pregnant women with cardiac disease should expect an attempt at vaginal delivery, unless obstetric contraindications exist. For women with pre-existing cardiac disease, a vaginal delivery poses less cardiac risk, because cesarean delivery is accompanied by approximately twice as much blood loss. Patients who are considered stable from a cardiac perspective can be allowed to spontaneously progress through the various stages of labor. However, if there are concerns about the functional adequacy of the heart and circulation, labor can be induced under controlled conditions. The timing of induction can be individualized, taking into account the cardiac status of the patient, inducibility of the cervix, and fetal lung maturity. From a practical point of view, it is useful to plan the induction so that delivery occurs during a time when all services are available. In general, a long induction in a woman with an unfavorable cervix should be avoided. Induction of labor in a patient with a favorable cervix usually requires only oxytocin administration and artificial rupture of membranes. An unfavorable cervix, however, should be treated with a prostaglandin E analogue. Even this should be done cautiously in women with underlying cardiomyopathies, because prostaglandin analogues might be absorbed systemically, causing unwanted hemodynamic consequences, including a decreased systemic vascular resistance and reflex tachycardia (49). In a recent study of patients with dilated cardiomyopathy, most deliveries were vaginal (81%), and the most frequently used form of anesthesia was epidural anesthesia (86%) (4). Indications for cesarean delivery were unrelated to pre-existing cardiac disease in any 1 of these patients. As would be expected, fetal/neonatal event rates were higher in women with at least 1 obstetric risk factor, including a history of premature delivery or rupture of membranes, an incompetent cervix, or the need for cesarean delivery. Smoking, anticoagulation use, multiple gestation, and maternal age <20 or >35 years were nonobstetric risk factors that were also associated with increased fetal/neonatal events.