The true measure of success or failure of perinatal care is not merely neonatal survival, but survival with good health and well-being into childhood and beyond. Quantifying this measure is important for all babies, particularly for those born prematurely. The risks are highest for those with a birthweight less than 1 kg (extremely low birthweight) and/or at less than 26 weeks gestation. There is continuing concern about the burden of illness and disability amongst survivors in this vulnerable group. However, we must not forget that all preterm infants are at increased risk of disability later in childhood and that the same is true for babies born at term who are sick enough to require neonatal intensive care.

In the absence of any prenatal screening, some two percent of babies will be born with a structural anomaly; a further 1 in 700–800 will be born with Down's syndrome, with similar numbers having other chromosomal and serious genetic disorders. The prevalence of abnormalities in early pregnancy is higher because abnormal fetuses are more likely to miscarry than normal ones. A small number of women enter pregnancy at increased risk of conceiving a baby with an abnormality. They may have a maternal condition such as diabetes, need medication for conditions such as epilepsy, or have a family history of a genetic disorder (www3.ncbi.nlm.nih.gov/Omim/searchomim.html). Most abnormalities, however, occur in healthy, low-risk women.

Prevention programmes against Rh alloimmunization are now so widespread as to be universal in the developed world. Accordingly, there has been a dramatic decline in the incidence of fetal anaemia secondary to this cause, along with relative growth in the importance of alloimmunization due to other antibodies, particularly Kell. Antibodies to the Kell group of antigens, in particular K1, can cause profound fetal anaemia leading to hydrops and fetal demise unless appropriate and timely intervention is undertaken.

Iron deficiency and iron supplementation are well known but unresolved issues of perinatal care. Approximately one thousand articles listed in Medline® over the last ten years focus on iron and pregnancy. Clearly, there are many unresolved questions regarding perinatal iron deficiency and iron supplementation.

With the ascendancy of biophysical assessment with Doppler velocimetry, and the establishment of routine scan dating in early pregnancy, there needs to be a radical re-think of the role of ultrasound biometry in the definition and assessment of fetal growth restriction (FGR).

Doppler flow velocimetry of the umbilical artery has proven its value in defining the FGR fetus. It is more useful than cardiotocography (CTG) or biophysical profile scoring. However, the sensitivity of any test depends on the prevalence of the condition being looked for. While Doppler is of value in fetuses which are small-for-gestational age (SGA), it is less useful in predicting growth restriction or adverse outcome in the general population. The question is therefore, how to detect those pregnancies for which further fetal assessment is indicated.

Hypoplastic Left Heart Syndrome (HLHS) was first described fifty years ago. It is characterised by underdevelopment of the left ventricle with associated aortic and mitral valve hypoplasia or atresia, and varying degrees of hypoplasia of the aortic arch (Figure 1). In utero a physiological right to left shunt of oxygenated blood through the ductus arteriosus bypasses the obstruction and allows normal fetal growth. Closure of the ductus arteriosus in the post-natal period interrupts systemic blood flow, resulting in rapid deterioration and death. Untreated it is a universally fatal condition, leading to neonatal death within the first few days or weeks of life. Although HLHS affects only one baby in 10,000 and accounts for less than 10% of all congenital heart disease, HLHS is responsible for 25% of all deaths due to congenital cardiac disease occurring within the first week of life.

Within the human placenta the villous trophoblast represents the epithelial covering of the chorionic villi. This layer of trophoblast actively participates in transport processes between mother and fetus and is the surface of the barrier separating maternal and fetal blood. It represents the main site of metabolic and endocrine activities of the placenta. It is comprised of an outer continuous layer without cell borders, the syncytiotrophoblast, beneath which resides a population of proliferating cytotrophoblast cells. Daughter cytotrophoblast cells fuse into the syncytium, while aged nuclei inside syncytial fragments are shed into the maternal circulation (Figure 1). Any process disturbing the balance between proliferation, syncytial fusion or shedding will alter the integrity and function of the layer as a whole, which in turn may impair gas and/or nutrient transfer to the fetus as well as endocrine activities. Trophoblast turnover is thus tightly regulated to ensure normal fetal development.

Despite substantial advances in pre- and postnatal care, the problem of preterm labour continues to be a significant medical, economic and social burden. Globally, it is estimated that 13 million babies are born preterm each year, but the incidence varies substantially between different countries and population groups. In the United States alone, approximately 11% of pregnancies, i.e. 380,000 cases annually are delivered after preterm labour and in Europe the overall incidence is believed to be approximately 6%, representing an annual population of 375,000. The main complication of very early preterm birth to the newborn is immaturity of different organs, in particular incomplete maturation of the lungs. However, a recent multi-centre surveillance study demonstrated that also modest degrees of prematurity are associated with developmental delays, implying that adequate intrauterine maturation of the fetus is vital to postnatal development.

Improved diagnosis and corrective cardiac surgery has led to an increasing number of women with congenital heart diseases reaching reproductive age. Pregnancy places considerable strain on the heart and circulation, requiring marked cardiorespiratory adaptation. Today, with the exception of the Eisenmenger syndrome, there is no increased mortality associated with pregnancy in congenital heart disease. In contrast, there is still considerable morbidity, due to congestive heart failure, thromboembolic complications and disturbances of rhythm.

Placenta praevia is an uncommon but dangerous and occasionally fatal condition. It increases maternal, fetal and neonatal morbidity and mortality. Placenta praevia is one of the leading causes of third-trimester bleeding and the incidence of both placenta praevia and placenta accreta is steadily increasing due to the rising caesarean section rate. At delivery, women with placenta praevia have an increased risk of abruptio placenta, caesarean delivery, fetal malpresentation, postpartum haemorrhage and disseminated intravascular coagulation. Massive obstetric haemorrhage is still a leading cause of pregnancy-related deaths, and placenta praevia/accreta remains one of the major predisposing factors.

Cigarette smoking continues to be the main preventable cause of premature death in industrialised countries. It is estimated globally to kill 3 million people annually and this figure is expected to rise to 10 million per year within the next 30–40 years. In the UK alone, smoking is responsible for 120,000 premature deaths per year and in the US the death toll from smoking is running at approximately 420,000. Most of the harm from cigarette smoking results from decades of exposure. Thus deaths generally do not occur in substantial numbers until the smoker has reached 40 years of age. However, there are some circumstances in which smoking has acute effects which can lead to serious illness or death. One of these is prior to surgery, where smoking is strongly associated with adverse post-operative outcomes. The other is during pregnancy. This review examines the health consequences of smoking as it relates to pregnancy, the effects of stopping smoking at this time, the prevalence of smoking and smoking cessation in pregnancy and factors associated with these and finally the effectiveness of interventions aimed at tackling this problem.

Routine electronic fetal heart rate monitoring has been associated with a significant reduction in fetal mortality and early onset neonatal seizures. However, the positive predictive value of changes in the fetal heart rate pattern is very low, and thus there has been a disproportionate increase in the rates of operative intervention in labour, compared with very modest reductions in neonatal encephalopathy. Recent studies have demonstrated that postasphyxial encephalopathy in term babies now derives almost entirely from low and medium risk pregnancies. This suggests that the current model of obstetric care is very effective in high-risk populations. However, further improvements in the care of what are now generally low risk patients will require simple, widely applicable strategies for detecting the infant at risk of asphyxial complications.

With the advent of nuchal translucency as a screening test for trisomy 21, increasing numbers of women are having an ultrasound scan between 11 and 14 weeks. The RCOG Working Party (July 2000) recommendations for ultrasound in pregnancy do not mention a first trimester scan for nuchal translucency or fetal anatomy. However, this scan is not just an opportunity to perform nuchal translucency; many structural abnormalities can also be seen at this stage.

Since the first report by Simpson (1957) of the association between premature birth and maternal smoking, the research on the consequences of maternal smoking during pregnancy on perinatal outcome has been intense. Even if some of the findings have been contradictory, it is now evident that maternal smoking is associated with pre-term birth and low birth weight, low birth weight for gestational age, small head circumference, low Apgar score at 5 min, stillbirth and neonatal death.

Premature birth is associated with substantial excess childhood mortality and morbidity and therefore represents an important public health problem worldwide. In the United Kingdom and other industrialised countries it is now the commonest cause of infant mortality. This review will outline the most recently available data for the incidence of premature birth at local, regional, national and international level, and compare them to previously published figures. Any variation in these incidences will be considered along with factors likely to account for these differences. Problems with data collection and analysis will also be discussed.

Musculoskeletal complaints are a common source of antenatal and peripartum morbidity, yet are frequently dismissed by healthcare professionals. Although increasing pelvic laxity is thought to be physiological as pregnancy advances, a number of women develop pain and disability out of proportion to the degree of joint distension. The term ‘symphysis pubis dysfunction’ is one of the many used to describe the constellation of typical symptoms and signs. (Table 1) The first formal documentation of the condition is accredited to Snelling in 1870. “The affection appears to consist of a relaxation of the pelvic articulations, becoming apparent suddenly after parturition, or gradually during pregnancy; and permitting of a degree of mobility of the pelvic bones which effectively hinders locomotion, and gives rise to the most peculiar, distressing and alarming sensations.” Although dated his description still provides a succinct description of the condition.