Objective: To evaluate management recommendations from the current lit
erature for patients whose fetuses are certain to have lethal anomalie
s or absent (or virtually absent) cognitive function. These recommenda
tions include termination of pregnancy or, for cases in the third trim
ester, nonaggressive intrapartum management, avoiding cesarean deliver
y for fetal indications. Methods: We report our experience with severa
l patients who voiced opposition to nonaggressive intrapartum care and
present a rationale for selectively aggressive, intrapartum managemen
t for some of these eases. Results: Four women whose fetuses had letha
l anomalies requested aggressive intrapartum management. For three of
the four, standard aggressive management of labor resulted in vaginal
delivery of live-born infants who died shortly thereafter. The patient
s found comfort in the live births. The fourth patient accepted a reco
mmendation to avoid fetal monitoring during labor, and the fetus was s
tillborn. This patient found the intrapartum experience to be very str
essful. Conclusion: When a patient's desire to avoid an intrapartum st
illbirth is strong enough that substantial psychological harm might re
sult from one, the physician's beneficence-based obligation to her and
respect for maternal autonomy justify selectively aggressive intrapar
tum therapy, even if no beneficence-based obligation to the fetus exis
ts.