To the Editor: Wilkinson et al1 shared their findings from the national database where they found that predelivery diagnosis of Chiari Malformation Type I (CM-1) may influence obstetric decisions despite there is no evidence of substantially increased delivery risk in this group. In pregnant women, abnormal anatomy and physiology associated with CM-1 and associated syndromes present a unique management challenge during the gestational period and delivery.2,3 In the literature, there are many articles providing information on the delivery route and the anesthetic technique to be used in these cases.4-6 Neuraxial analgesia in CM-1 patients can be considered a relative contraindication. The pharmacological management of general anesthesia (succinylcholine and ketamine) of patients with CM-1 is also a relevant issue to consider, especially in patients who may require this type of anesthetic management.7 Based on the literature and our experience, we propose: First, in asymptomatic or incidentally diagnosed patients with CM-1, vaginal delivery may be offered unless there is an obstetric absolute contraindication; secondly, to symptomatic patients with or without neurological comorbidities birth to cesarean section should be given; thirdly, to symptomatic patients with CM-1 who have been considered surgical management by neurosurgery and have not accepted surgery should be offered by cesarean delivery; and fourthly, to patients with CM-1 treated by neurosurgery indifferently whether they have favorable or non-favorable postoperative evolution cesarean section is recommended. When cesarean section is offered, an exemplary analgesic technique should be performed during labor. Minimizing the loss of cerebrospinal fluid (less than 2 ml?) is foundamental. Also, it is necessary to avoid Valsalva maneuvers by the instrumentation of the expulsive labor period. The use of oxytocin intraoperatively should not be contraindicated, rather it would be helpful in the vaginal delivery assistance, as reported in few cases.3 Due to the high risk of spinal catheter manipulation, it is suggested to handle these patients with extreme and strict caution during postpartum anesthesia and neurological surveillance. We congratulate authors for their unique observations and suggest that the findings from the present study can be further expanded to better understand the risk factors for poorer outcomes associated with CM-1 in pregnant women and, ultimately, to improve the maternal and fetal outcomes. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.