Pregnant women have traditionally been discouraged from participating in physically demanding sports because they have been considered to be in poor condition and it was thought that strenuous exercise could harm the mother and the fetus. More recently, however, many physically active women have wished to continue sport in pregnancy and research over the past 20 years has shown that in general it is safe to do so.

Kielland's forceps have been in obstetric practice for over 80 years but their use causes a wide spectrum of reactions in obstetricians. Those that have been well tutored in their use argue that they are a very effective instrument to achieve vaginal delivery in the malpositioned fetus, avoiding the problems of full cervical dilation caesarean section, with low complications in their hands. These exponents of the instrument argue that the “art” of obstetrics is demonstrated in the use of Kielland's forceps. However, others claim that Kielland's forceps are dangerous with high complication rates and that they should be confined to the obstetric museum. This paper reviews the history of the instrument and its inventor, to consider evidence for its effectiveness and its safety, to briefly consider other methods for delivery of the malpositioned fetus at full cervical dilation and finally to complete the journey by considering the future with particular emphasis on training the new generation of obstetricians.

The ductus venosus is a blood vessel functioning exclusively in the fetal circulation. According to many reports it was described for the first time by Giulio Cesare Arantius (Bologna 1530–1589) in his book De humano foetu libellus (1563) and it is often referred to as the ductus Arantii. Thorough research, however, has made it clear that Andreas Vesalius described this vessel in 1561 in his book Examen observationium Falloppii, which was published three years later. Moreover, it has been pointed out that the first and second editions of Arantius’s book did not contain a description of the ductus venosus but that this appeared in the 1571 edition.

There have been significant strides made over the last two decades in the understanding of the natural history and pathophysiology of fetal thoracic lesions. Largely as a result of advances in prenatal ultrasound we are not only able to offer a tentative diagnosis of these lesions and advise parents about the prognosis but in selected centres offer the possibility of intervention for the most severely affected fetuses. Large gaps do remain in the current state of knowledge, in particular in the inability to predict pulmonary hypoplasia. Fetal surgery for lesions such as congenital cystic adenomatous malformation (CCAM) and pulmonary sequestration sequence (PSS) is still restricted to a very few centres and is reserved for those fetuses with hydrops where there is an extremely poor prognosis. Selection criteria for intervention have been refined over the last decade. Postnatal imaging studies, particularly computed tomography (CT) are essential in the evaluation of these lesions prior to surgical resection.

The techniques currently used by most specialist centres for magnetic resonance (MR) imaging of the fetus were developed in the 1990s, when fast imaging sequences capable of good soft tissue contrast were introduced. Earlier pioneering work on fetal MR imaging in the early 1980s revealed some promise for this application, but at the time it was not generally considered of diagnostic quality or clinical practicality because of the long acquisition times and inevitable image degradation resulting from fetal movement, problems which were overcome only by means of maternal sedation or neuromuscular blockade of the fetus. As with the early development of MR imaging in general, it is the ability to image central nervous system (CNS) tissues with a clarity and contrast far exceeding X-ray computed tomography and ultrasound that has shown the most benefit to date. Subsequent development of techniques for specific problem solving in other areas of the body will undoubtedly follow.

Subspecialization in fetal medicine has expanded the scope for obstetricians to investigate the fetus and its surrounding environment in greater detail. Of the advances in technology that have made this possible, ultrasonography is the most important. A high degree of skill is required if it is to be applied to the performance of invasive diagnostic techniques. These should be performed only in specialized centres with appropriate facilities and an adequate referral base. However, it is important for obstetricians to know what is possible in the field of prenatal diagnosis and therapy in order to give patients the best advice.

Advances in both imaging techniques and in treatments for immune thrombocytopenias affecting the fetus have allowed for more accurate antenatal predictions of severe disease and effective antenatal treatments for those fetuses who are at risk of sequelae. This article will review current knowledge of the diagnosis and treatment of affected fetuses in alloimmune thrombocytopenia and in immune thrombocytopenic purpura.

Obesity is a growing problem in obstetric practice. A recent study from Glasgow (UK) showed that 50% of women of childbearing age are either overweight (Body Mass Index [BMI] = 24.9–29.9kg/m2) or obese with 18% starting pregnancy as obese. Obesity prevalence has doubled over a decade from the early 1990’s. In the US it is estimated that 30% of reproductive-age women have a BMI greater than 30 kg/m while 7% have a BMI > 40 kg/m2. A recent report from the UK found that 5% of women had a BMI >35 kg/m2, 2% > 40 kg/m2 and 0.2% >50 kg/m2 with an association not only with social deprivation, but also with a higher prevalence of pre-existing medical disorders such as diabetes and hypertension and medical complications of pregnancy such as preeclampsia. Obesity was also associated with increased rates of macrosomia, operative delivery and postpartum haemorrhage. These data highlight the fact that obesity is an increasing health concern particularly in young women of childbearing age. Obesity will expose them to significant pregnancy complications ranging from miscarriage and fetal abnormality through to operative delivery and thromboembolism. There are also challenges for the delivery of maternity care to meet the needs of these women. As obesity is associated with significant pregnancy complications it is important that women enter pregnancy with an optimum body weight. Many complications, such as fetal abnormality occur in the first trimester and so pre-pregnancy weight reduction is preferred. Further, there is insufficient evidence to recommend specific dietary and/or physical activity interventions to reduce weight or moderate weight gain during pregnancy.

Congenital cytomegalovirus (CMV) infection is now the commonest infective cause of neurological handicap. Arguably, there is no other single contributor to developmental disability where a greater opportunity, and imperative, exists to improve outcomes than CMV. CMV is the most common intrauterine infection and congenital CMV is the leading non-inherited cause of sensorineural deafness. The public health impact of CMV is significant: the overall birth prevalence of congenital CMV is estimated at 0.64%, with 11% of live born infants displaying symptoms.

The childhood effects of antenatal exposure to cocaine are largely unknown. While several authors have evaluated the consequences of antenatal cocaine exposure during the neonatal period and early childhood, there are no large, blinded and systematic studies of the effects beyond early childhood and no data at early school age.

The historical background of post partum haemorrhage (PPH) dates back to the 17th century. William Smelley published his famous treatise of the theory and practice of midwifery in 1752. His observations sent a clear message to practitioners of the time that haemorrhage in midwifery can be a messenger of death.

Hypoxia in pregnancy is rare, however the anatomical and physiological changes associated with pregnancy may exacerbate hypoxia and hypoxaemia arising from pathological processes.

In this review we seek to briefly outline the well recognised changes to the maternal airway and respiratory anatomy and physiology. We will discuss a hierarchical approach to the tests used in differential diagnoses, summarise the physical principles behind commonly used tests and identify pitfalls and considerations in their use in the obstetric population. Some of the more commonly seen pathological states that may cause hypoxia in pregnancy will be discussed.

Cardiac and respiratory systems undergo significant changes in pregnancy and the puerperium, and the course of disease of these two systems in pregnancy can be difficult to predict and manage. Good assessment and planning is essential for the general management of patients with cardiorespiratory disease and will directly impact on the anaesthetic services they require and receive.

The last century has seen dramatic developments in medical care as technological advances have been applied to both diagnosis and treatment. Some areas of obstetrics have been slow to benefit from these advances – and none more so than the care of the fetus in labour.

Current hypotheses regarding the origins of preeclampsia have focused on the “Two stage model”. This model suggests that the primary steps in the pathophysiologic sequence of preeclampsia are initiated by abnormal placentation including the classic finding of abnormal trophoblast invasion of maternal decidual spiral arteries. The second stage of the sequence includes the elaboration of a single or multiple substances from these disordered placentas which contribute to the generalized maternal systemic illness, eventually manifesting as endothelial injury, hypertension and proteinuria. Recent studies have focused on the role of pro and anti-angiogenic peptides as potential placentally derived aetiologic agents in this pathophysiologic sequence, although other placental products have been highlighted in recent research. Despite the fact that this modeling of preeclampsia has widespread support significant limitations to this hypothesis can be identified.

Some half a million women die annually across the world from causes related to pregnancy and childbirth. Approximately one-quarter of these deaths are caused by complications of the third stage of labour, mainly postpartum haemorrhage (PPH). In the developing world, the risk of maternal death from PPH is approximately one in 1000 deliveries. In the United Kingdom the risk of maternal death from obstetric haemorrhage is about 0.39 in 100000 deliveries.

Polycystic ovary syndrome (PCOS) is a common hormonal disorder affecting around 5–8% of women of reproductive age. It has a variable clinical spectrum including hyperandrogenism, menstrual abnormalities, polycystic ovaries and metabolic features like diabetes mellitus, obesity and dyslipidaemia. The manifestation of PCOS and its impact especially on reproductive function and pregnancy are profoundly affected by associated features of obesity/raised body mass index and metabolic syndrome.

Asthma is the most common significant chronic medical condition affecting young adults and it is therefore often encountered in pregnancy. Approximately 3% of women of child-bearing age suffer some degree of asthma and this prevalence is increasing. Some of the apparent increase is due to heightened awareness of the condition, although air pollution and increased childhood exposure to house dust mite may also be contributing.

There is an intimate relationship between the kidney and pregnancy. Renal plasma flow increases by 50–70% during a normal pregnancy and the glomerular filtration rate by about 50%.1 These changes commence in the first trimester and fall in the last trimester reaching normal levels within about four weeks postpartum. These physiological changes are accompanied by striking anatomical changes which consist of dilatation of the ureter, pelvis and calyces, together with an increase in renal parenchymal size. The dilatation i s more marked on the right and may appear in the first trimester. At term, 90% of pregnant women show this change.2

The uterine cervix is a remarkable structure, which plays an essential role in pregnancy. During the development of the conceptus within the uterus, the cervix usually remains firmly closed to ensure that the developing fetus attains an appropriate degree of maturity to permit extra-uterine survival. On the other hand, it prepares for labour and birth, by undergoing a process of effacement, whereby the substance of the cervix shortens and thins out. During labour, it must be stretched and dilated to a sufficient diameter, usually about 10cm at term, to allow the successful passage of the fetus through the birth canal.