Due to the responsibility for the mother and the unborn child, fetal surgery represents a challenging task for the anesthesiologist. Maternal changes during pregnancy have to be considered as well as the fetal physiology and the surgeon's needs. Main principles of the anesthesiological management of fetal surgery include the stabilization of the mean arterial pressure in order to preserve a sufficient placental blood flow, sustainment of an adequate oxygenation and ventilation as well as thorough temperature surveillance. Since the mothers are at risk for perioperative pulmonary edema, extended hemodynamic monitoring might be necessary. This article presents the principles of fetal surgery, informs about pregnancy-related changes in circulatory and respiratory physiology and contains anesthesiological considerations to this topic. Georg Thieme Verlag KG Stuttgart · New York.