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Discussing the management of coarctation of the aorta in pregnancy, Dr Venning and her colleagues (May 2003 JRSM1) emphasize the importance of close monitoring, control of hypertension and a multidisciplinary approach. We agree absolutely; but we disagree with their recommendation that 'elective caesarean section be performed in such cases to avoid the second stage and to reduce the need for Valsalva manoeuvres...'. We have cared jointly for many parturients with cardiac disease, including coarctation and Marfan's syndrome, and unless the mother or fetus is in imminent danger we recommend vaginal delivery with low-dose epidural analgesia, and elective instrumental delivery without maternal pushing in the second stage, to avoid Valsalva manoeuvres. This avoids the risks associated with caesarean section—namely, bleeding, deep vein thrombosis, infection, the need for intravenous Syntocinon (oxytocin) with its potential for adverse cardiovascular effects, and an increased requirement for caesarean section in subsequent pregnancies. Furthermore, both regional anaesthesia (which we prefer) and general anaesthesia for caesarean section are more likely to induce cardiovascular instability than low-dose epidural analgesia in labour. If caesarean section is required, the epidural can be readily extended in most cases. In the past, elective caesarean section (usually under general anaesthesia) was the mode of delivery for many women with cardiac disease, but there is increasing evidence that vaginal delivery with regional analgesia can produce a good outcome.2 Elective caesarean section may be desirable in the occasional patient with coarctation and uncontrollable systemic hypertension, marked aortic root dilatation and/or severe residual or native coarctation,3 although supportive data for this approach are clearly required.