CHD survivorship has reshaped modern cardio-obstetrics: more women reach reproductive age, yet pregnancy remains a physiological stress test that can unmask haemodynamic and rhythm vulnerability.^{Reference Uebing, Steer, Yentis and Gatzoulis1,Reference Wu, He and Shao2} In this issue of Cardiology in the Young, a single-centre, retrospective case–control study of 162 deliveries in women with CHD (2000–2017) versus 321 matched controls without CHD (2023) reports^{Reference Brown, Voskamp and Kube3} a higher burden of composite cardiac events (approximately 14 of 162 [8.6%] vs 11 of 321 [3.4%]; risk ratio 2.5, 95% CI 1.2–5.4) and greater use of operative or assisted delivery, alongside an approximately doubled length of stay.^{Reference Brown, Voskamp and Kube3} Intriguingly, modified World Health Organization class did not associate with discrete cardiac events but scaled with length of stay—suggesting that, in lower-risk populations, modified World Health Organization may better track care intensity and monitoring needs than short-horizon events.^{Reference Brown, Voskamp and Kube3} Within the CHD cohort, maternal age independently predicted cardiac events (about 15% higher odds per year).^{Reference Brown, Voskamp and Kube3} A lower prevalence of pre-eclampsia in CHD was also noted.^{Reference Brown, Voskamp and Kube3} These findings must be interpreted in the context of a steady rise in survivorship: more girls born with CHD now reach reproductive age, reshaping routine obstetric practice.^{Reference Uebing, Steer, Yentis and Gatzoulis1,Reference Wu, He and Shao2} Counselling therefore shifts from whether pregnancy is feasible to how and where it should be managed safely, with explicit attention to haemodynamic triggers and rhythm surveillance.

What should clinicians and services do with these findings? First, pre-conception and early antenatal triage should be the standard initial step. A first-trimester cardio-obstetric review allows lesion-specific planning (arrhythmia substrate management, anticoagulation, volume strategy) and sets expectations around timing and place of birth. Validated risk prediction tools (modified World Health Organization, CARPREG II) remain valuable but are best integrated with dynamic measures—functional class, natriuretic peptides where available, and near-term rhythm burden—to form a living risk profile that informs intrapartum thresholds for intervention.^{Reference Balci, Sollie-Szarynska and van der Bijl4–Reference Regitz-Zagrosek, Roos-Hesselink and Bauersachs6} Second, delivery planning requires clarity that vaginal birth remains appropriate for most stable patients, with caesarean reserved for obstetric indications or specific cardiac scenarios.^{Reference Regitz-Zagrosek, Roos-Hesselink and Bauersachs6} Where haemodynamic reserve is borderline or where arrhythmia burden is recent, planned induction with early neuraxial analgesia and clear thresholds for assisted delivery can reconcile maternal stability with obstetric goals.^{Reference Regitz-Zagrosek, Roos-Hesselink and Bauersachs6} Adoption of unit-level bundles—and rehearsal of escalation pathways—reduces ad hoc decision-making and unwarranted variation.^{Reference Regitz-Zagrosek, Roos-Hesselink and Bauersachs6,Reference Ruys, Roos-Hesselink and Pijuan-Domènech7} Evidence to date does not show maternal benefit of planned caesarean over vaginal delivery in women with cardiac disease.^{Reference Ruys, Roos-Hesselink and Pijuan-Domènech7} The higher use of operative delivery in the study cohort underscores the need to define team-agreed thresholds for assisted birth and to adopt standardised cardio-obstetric bundles covering induction methods, neuraxial analgesia, vasopressor strategy, telemetry triggers, and postpartum rhythm surveillance. While maternal outcomes are the focus here, neonatal considerations—preterm birth and small-for-gestational-age reported elsewhere—remain central to counselling.^{Reference Hardee, Wright, McCracken, Lawson and Oster8–Reference Thompson, Kuklina, Bateman, Callaghan, James and Grotegut10}

Interpretation of finding from this study must be tempered by design constraints. The sampling frame (deliveries with an anaesthesia consultation) may undercapture very high-risk pregnancies not carried to viability and pregnancies ending before consultation; controls were drawn from a more recent era, inviting practice-change confounding despite matching by gravidity, parity, and age; and modest sample size with composite endpoints limits granularity for individual events, particularly thromboembolism and heart failure. The lower rate of pre-eclampsia in CHD may reflect surveillance and selection, including differences in baseline body mass index and unmeasured comorbidity in controls. Even so, the central messages hold: anticipatory planning, disciplined intrapartum decision-making, and explicit attention to service capacity. A structured cardio-obstetric review at 6–12 weeks postpartum, with rhythm assessment and optimisation of heart failure therapies where relevant, should be routine.^{Reference Silversides, Grewal and Mason5,Reference Regitz-Zagrosek, Roos-Hesselink and Bauersachs6} Embedding this in discharge planning, and tracking rehospitalisation as a quality metric, aligns clinical priorities with service performance and patient-reported outcomes. The next steps are pragmatic—integrate, rather than idolise, risk tools; standardise unit-level pathways for induction, analgesia, haemodynamic management and telemetry; and measure what matters, including patient-reported outcomes, 6–12-week postpartum rehospitalisation and transparent metrics of resource use in multicentre, contemporaneous cohorts.