In the Obstetrical Journal of Great Britain and Ireland (August 1878), Dr Hamilton from Falkirk, Scotland wrote an article entitled “mortality in childbed statistics”. Quoting a Dr Murphy, he stated that “in 75,911 cases of midwifery occurring in British practice, there were 138 forceps cases, and in thirty five of these, or one in every four, the child was stillborn”. Then, as now, obstetricians were discussing intervention during labour and were divided in their views, with one side claiming that intervention caused fetal loss, while the other side being convinced that only by intervention would lives of mothers and babies be saved.

Despite many advances in the management of lung disorders of premature infants, respiratory distress syndrome (RDS) remains the major cause of morbidity and mortality in the preterm infant. Approximately 30% of infants born at less than 34 weeks gestation will develop RDS, secondary to deficiency in surfactant production by alveolar type II pneumocytes. Without surfactant, work of breathing is increased and gas exchange impaired by diffuse atelectasis, reduced pulmonary compliance and ventilation perfusion mismatch.

As a haematologist I would like to present an alternative view to the belief that routine iron supplements during pregnancy are neither necessary or beneficial in developed countries and that advantages, if any, are far outweighed by widely publicized real and theoretical side effects.

For most clinicians it is difficult to accept that in well nourished populations the extra requirements of pregnancy are not met by a normal mixed diet. The haemodilution which occurs in healthy pregnancy because of the dramatic expanse in plasma volume has encouraged the acceptance of abnormally low haemoglobin levels as being physiological. Traditionally, obstetricians have believed that the only manifestation of iron deficiency during pregnancy is maternal anaemia which results in very few clinical manifestations and there are no other adverse sequelae for the mother and none at all for the fetus and infant. These concepts are supported by the fact that controlled trials do not demonstrate any obvious benefit of iron supplementation, particularly if the neonate is not subjected to long-term follow-up. More indirect associations such as general maternal wellbeing, reduced fetal placental ratio, preterm deliveries, post-partum haemorrhage and recovery from blood loss at delivery have not been looked at in an objective manner.

Holoprosencephaly (HPE) is an uncommon and clinically severe abnormality of forebrain development, resulting from failure of septation, or cleavage, of the midline forebrain structures. It encompasses a range of brain pathology classified as lobar, semilobar or alobar HPE reflecting increasing degrees of failed septation. The closely related development of the mid-face area is frequently disturbed, with coexisting facial phenotypes ranging from cyclopia to normal.

The first attempt to visualise the fetus with a panendoscope was performed in 1954. Embryoscopy and fetoscopy were developed in the 1970's. They were introduced as a diagnostic tool to visualise external malformations of the fetus in the first, second and third trimesters of pregnancy as well as to obtain fetal tissue for diagnostic purposes and perform fetal intravascular transfusion.

Diagnostic fetoscopy during the second and third trimester was abandoned in the late 80's due to the invasive nature of the technique and the development of high resolution ultrasound imaging. Percutaneous access to fetal blood and tissue sampling under continuous ultrasound guidance also became possible in the late eighties. Recently there has been renewed interest in embryo-fetoscopy due to the increasing use of ultrasound in the first trimester together with the development of new equipment, especially miniature fiberscopes. These have improved image resolution while being less invasive. Anomalies suspected in the first trimester often call for a rapid and complete fetal evaluation and microendoscopy allows for a sono-endoscopic assessment of fetal anatomy. This may help a couple to decide whether to carry on with the pregnancy or to opt for early termination of pregnancy (TOP). More recently, embryoscopy and fetoscopy have been used to operate on the placenta and membranes and also on the fetus itself.

The diagnosis of twin pregnancy whilst causing delight for many of the parents and families involved is a source of concern and worry for their obstetric caregivers. This review will not deal with the myriad complications of twin pregnancies but will concentrate on two for which Doppler ultrasound has been often discussed; placental insufficiency and the problems of shared placental circulations in monochorionic twins.

Caesarean section rates in the United Kingdom continue to be a topic of importance in both the medical and lay press. In previous years most of the discussion has been about what the correct caesarean section rate should be. More recently the debate has focused on whether a woman has the right to choose to have her baby delivered by caesarean section in the absence of a medical indication. This has medical implications, in terms of short and long term complications for the woman, but also carries a financial burden that the National Health Service can ill afford.

Definitions of domestic violence vary according to the frequency, severity and nature of the violence as well as the context in which it occurred and the relationship between the victim and the perpetrator. Though there is a lack of uniformity, a generally accepted definition of domestic violence is the physical, sexual or emotional abuse of an adult woman by a man with whom she has or has had an intimate relationship, regardless of whether the couple are living together. Although violence can be carried out by other family members or occur in same-sex relationships, it is argued that men use violence in order to maintain dominance and control over their female partners. Physical violence is just one of the many tactics that an abuser may use to exert control over his partner. Other behaviours include isolation, intimidation, threats of violence, threats to take the children away or hurt them and emotional or economic abuse. Whilst some studies have identified demographic patterns associated with domestic violence, it can affect any woman regardless of age, race, ethnicity, social class, employment status, religion, marital status or disability.

Delivery of an infant via an abdominal and uterine incision has a very long history. It is impossible to discover when the first such operation was performed, but it is known to have been practised in ancient Roman, Hindu and Egyptian civilisations. Usually it was performed on a recently dead mother in the hope of saving the infant, but there is also some evidence that in ancient times it may occasionally have been attempted on living mothers. In more recent centuries, there are several reports of caesarean sections being performed on living patients in Europe from 1500 onwards. The date of the first successful operation is uncertain, but there is no doubt that mortality of both mothers and infants was very high. In the British Isles, out of 131 caesarean sections performed between 1737 and 1878, only 23 mothers survived. The high maternal mortality was not surprising considering that there was no anaesthesia nor effective control of infection, and the uterine incision was not closed.

Human chorionic gonadotropin (hCG) has an essential role in early pregnancy. It is a member of the glycoprotein hormone family also comprising the pituitary derived follicle stimulating hormone (FSH), luteinizing hormone (LH) and thyroid stimulating hormone (TSH). Each hormone consists of a non-covalently bound α and β subunit. Within a species the α subunit is identical and hormone specificity is determined by the unique β subunit.

Oxygen radicals and reactive oxygen species are normal attributes of aerobic life. In most molecules, the electrons are paired and, with the exception of hydrogen, the four outer most pairs of each atom form chemical bonds. Electrons are in a relatively stable energy state when paired. A free radical is a molecule with an unpaired electron. Free radicals of oxygen are of particular importance to living organisms in which they are involved in the genesis of a wide array of diseases and physiological processes (e.g. life span and ageing).

Placenta praevia describes a placenta which partially or completely lies within the lower segment of the uterus. It is a major cause of antepartum haemorrhage and when it obstructs the internal os prevents safe vaginal delivery of the fetus.

Women with severe pre-eclampsia (PE) commonly require delivery by Caesarean section (CS). Whilst the choice of anaesthetic technique in this group of women has been controversial for a number of years, clinical experience has demonstrated the relative safety and value of well-managed incremental epidural anaesthesia. Several studies attest to the benefits of epidural analgesia in labour and epidural anaesthesia for CS. It is now widely recognised that epidurals provide relatively smooth control of blood pressure, maintain or improve utero-placental perfusion, optimising fetal outcome, and eliminate the airway and haemodynamic problems associated with general anaesthesia. Thus, epidural anaesthesia is the current technique of choice amongst most obstetric anaesthetists for CS in severe PE. Good inter-disciplinary communication between anaesthetic and obstetric staff should allow the need for CS to be anticipated early, and the epidural catheter inserted and topped-up in good time. However, in the case of urgent CS where it is not considered appropriate to wait the time required to produce effective epidural blockade, the choice of technique lies between spinal and general anaesthesia.

Because half its genes are inherited from the father, the embryo during pregnancy has been frequently compared to an allograft transplanted into the maternal uterus. The question why the embryo is, therefore, not rejected by the mother's immune response in the same way as other allografts has still not been satisfactorily answered. Recent investigations indicate that this analogy may not be as close as it initially appears. One major difference is the expression of an unusual combination of HLA class I molecules by the placental trophoblast cells which invade into uterine decidua during implantation. Furthermore, the lymphoid population in the uterus potentially capable of interacting with these trophoblast HLA class I antigens also appears to be unique. These observations have led to the suggestion that implantation might utilise a novel immune system which is different to that seen in clinical transplantation immunology. Much research effort is now directed towards the elucidation of the mechanisms involved and the outcome of this interaction because this is likely to be how implantation is controlled.

Fetal asphyxia as a cause of brain damage has been a concern since the 19th century when the association of asphyxia during labour and asphyxia before the onset of labour to deficits in children was proposed. The significance of fetal asphyxia as a cause of brain damage remained obscure until the middle of the 20th century when the systematic examination of the effect of asphyxia and ischaemia on the fetus began in the research laboratory.

The results of these laboratory studies have provided the foundation of our current understanding of the role of fetal asphyxia as a cause of brain damage. Clinical studies have provided an opportunity to determine if these concepts are equally relevent to the human fetus.

An assessment of amniotic fluid volume has become an important component of antenatal testing for the at-risk pregnancy. The presence of normal amniotic fluid volume, either in association with a reactive nonstress test or as a component of the biophysical profile is considered to reflect current fetal well being and probable absence of chronic stress. The chronically stressed fetus is likely to have low amniotic fluid volume because of the shunting of blood preferentially to the brain, heart and adrenal glands at the expense of other body systems during the period of chronic stress. Decreased renal blood flow leads to decreased urinary output. Because the primary component of amniotic fluid in the third trimester of pregnancy is fetal urine, ongoing chronic stress can be recognised as oligohydramnios.

Precise amniotic fluid volume (AFV) measurement is accomplished either by use of a dye-dilution technique or by direct measurement of the fluid volume at the time of caesarean delivery. The need for laboratory support and the inherent invasiveness of dye-dilution procedures limits their application to study protocols. Direct measurement of AFV at caesarean delivery is reflective only of fluid volume at the time of delivery and cannot be used to serially evaluate fluid volume as a component of antenatal testing.