The incidence of preterm birth in developed countries has steadily increased over the past two decades and now approaches 12.5% of all live births in the U.S. This is due, in part, to our incomplete understanding of the pathways that maintain uterine quiescence throughout pregnancy, as well as those that promote increased uterine contractility and cervical ripening leading to labour. It is clear that uterine quiescence throughout most of pregnancy is maintained by progesterone acting through its nuclear receptor (PR). Furthermore, there is increasing evidence that both preterm and term labour are associated with activation of inflammatory response pathways in the pregnant uterus and cervix. In this article, we will consider the factors that induce the inflammatory response leading to term and preterm labour. We also will review findings to support the novel concept that the maintenance of uterine quiescence vs. induction of uterine contractility is exquisitely controlled by the cross-repressive effect of progesterone/PR and inflammatory transcription factors, such as nuclear factor κB (NF-κB).

Acardiac anomaly, twin reversed arterial perfusion (TRAP) sequence or chorioangopagus parasiticus are synonymous terms referring to a rare complication unique to monochorionic multiple pregnancies in which there is apparent lack of a well-formed cardiac structure in one fetus (the acardiac twin), which is abnormally perfused by a structurally normal co-twin (the pump twin) through a single superficial artery-to-artery placental anastomosis. The condition therefore results in arterial blood flowing in a retrograde fashion from the pump twin towards the affected fetus, and this underlying pathophysiology indicates the preferred use of the clinical term TRAP-sequence. Pathophysiologically, the acardiac fetus acts as a parasite that can only survive in-utero as it is haemodynamically dependent upon the pump twin. The principal perinatal problems being associated with the TRAP sequence are pump-twin congestive heart failure, polyhydramnios and severe preterm delivery, although intrauterine death of the pump twin has been reported even in the absence of such features.

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.

This article examines the question as to what is the right age to reproduce from the biological point of view of its purpose; that of achieving a healthy mother and baby. We start with an assumption that issues surrounding sex, fertility, pregnancy, miscarriage, abortion and childbearing are private and emotionally laden. We are not looking at, nor judging, individual reproductive choices; what might be “right” for one person, or couple, in one context will be unsuitable for another. It is traditional obstetric and gynaecological teaching that human reproductive outcomes are worse at the extremes of maternal age. Yet the advice given in a recent BMJ editorial entitled “Which career first? The securest age for childbearing remains 20–35” appeared to be controversial. The ensuing scientific and media interest raised such headlines as “Horns of the dilemma”, “A sinister article”, “Late mums face baby misery” and “Are we having children too late? IVF not the answer, say docs”. Products have recently appeared on the market offering kits to women to indicate the time left on their ‘biological clock’ so they can choose whether to continue pursuing their career or try for a baby. Why is there so much interest in the right time to reproduce? Are women (and men) doing something differently compared to the past? If there has been a demographic shift in the age women reproduce (hitherto unexplained), there are important and specific risks older women may face as compared to younger women.

Prenatal diagnosis is now an established part of modern obstetrical practice around the world. While the current definitive methods for prenatal diagnosis rely mainly on invasive procedures such as chorionic villus sampling and amniocentesis, such procedures carry a low but definite risk of fetal loss. As a consequence of the procedure-associated risk of miscarriage, prenatal diagnosis is currently limited to pregnant women with an increased likelihood of bearing an abnormal fetus. To extend the application of prenatal diagnosis to all pregnant women, it has been a long-sought goal of researchers worldwide to introduce safer methods for prenatal diagnosis, towards noninvasive prenatal diagnosis.

Baron Clemens von Pirquet, an Austrian paediatrician, proposed in 1903 the terms allergy and allergen after observing that some of his patients had “altered responses” to certain substances. Allergic symptoms are not necessarily accompanied by sensitization or vice versa. Recently, nomenclature for allergy has been revised.

Evidence-based reviews and practice guidelines have identified a number of risk factors associated with vacuum assisted delivery (VAD) that may result in adverse effects on the newborn infant, injuries to the mother's genital tract, and difficulty or failure of the procedure. In addition, clinical circumstances that predispose to increased risk, such as the use of the vacuum extractor for rotational and mid-cavity procedures, have been highlighted as possible avoidable factors. Although there is general agreement that success of vacuum delivery depends on the knowledge, experience and skill of the operator, system analyses of adverse outcomes often reveal inadequate training as a major contributing factor. It is beyond the scope of this review to present the detailed knowledge and technical skills required for correct use of the vacuum extractor. A variety of teaching resources is available for this purpose and practitioners who wish to obtain more information are referred to them.

A large number of studies show that low birth weight is associated with cardiovascular disease and its risk factors including raised blood pressure, glucose intolerance and the metabolic syndrome. These findings have formed the basis for the ‘fetal origins hypothesis’. This suggests that the operation of adverse influences during intrauterine life leads to permanent alterations in fetal structure and physiology which predispose to adult disease. The process is known as developmental plasticity or programming and is strongly supported by studies in experimental animals. Ongoing research is providing important insights in to the underlying mechanisms. It is likely that adverse environmental factors during pregnancy are important, and that these include suboptimal nutrition of the mother. The long-term programming effects may be transduced by alterations in the set-point of key hormonal axes, especially the hypothalamic-pituitary-adrenal axis, and recent evidence suggests that epigenetic modification of gene expression may be a key factor. Importantly, this has the potential to produce transgenerational effects.

The hypothesis has not remained unchallenged and a wide variety of criticisms have been put forward. These include accusations that the associations are weak and overestimated due to publication bias, that there are many inconsistencies between studies, that the associations are confounded by lifestyle factors, and that there has been inappropriate adjustment for adult size. Finally many studies report that the findings in singletons do not seem to be replicated in twins. While many of these issues have been resolved, some continue to form the basis of a lively dialogue and ongoing research. Nevertheless the research findings have important implications for clinical obstetric practice and maternal-fetal medicine.

Adolescent pregnancy rates in the United Kingdom remain the highest in Western Europe. Interestingly, throughout most of Western Europe teenage birth rates fell during the 1970s, 80s and 90s, but in the United Kingdom rates have remained high. An increasing incidence has also been noted, with 49.9 births per 1,000 women under 18 in 2001 and 52.8 live births per 1,000 women in 2002.

Preterm birth is a significant contributor to perinatal morbidity and mortality. Any intervention to effectively decrease the complications of a preterm birth must not only delay or prevent preterm delivery, but also improve neonatal outcomes. Until recently, interventions to prevent preterm birth have been largely unsuccessful. While some interventions are demonstrated to delay delivery for a short interval, the increased latency period does not result in improved neonatal outcomes. Recently, two randomized clinical trials demonstrated that progestational agents may decrease the incidence of preterm birth. As obstetricians, it is critical that we question the biological plausibility of a treatment prior to using it as standard of care. This review will address the physiologic role of progesterone in preterm and term labour, the molecular mechanisms by which progestational agents might exert a biological effect and the possible mechanisms by which these agents may prevent preterm birth.

Obstetric caregivers must deal with a wide range of emergencies, some of which are quite uncommon, and many believe they have achieved a high level of expertise based on study rather than experience. Yet a growing body of work demonstrates that simulation training can sharpen the skills of all caregivers and promote the development of efficient teams capable of reducing the morbidity of these rare events. This paper outlines current recommendations for emergency and teamwork training in obstetrics and reviews different training methods and their effectiveness.

Nausea and vomiting of pregnancy (NVP) is a term used to describe a wide spectrum of symptoms. At one end of the spectrum is the common, mild to moderate nausea and vomiting that is usually limited to the first trimester. At the other end of the spectrum are the intractable, severe symptoms of hyperemesis gravidarum (HG) that is associated with weight loss, dehydration, electrolyte imbalance and hospitalisation.

Until recently two possibilities were available to the expectant parents of a fetus diagnosed with a congenital diaphragmatic hernia: termination of pregnancy or continuation of the pregnancy until term with a potential change in the place of delivery. Open fetal surgery has been used to treat a growing number of congenital malformations with life-threatening or highly morbid consequences including congenital diaphragmatic hernia. However, its effectiveness is limited by the occurrence of preterm labour, chorioamniotic membrane separation, preterm prelabour rupture of the membranes and altered fetal homeostasis. These problems were the impetus for the development of minimal access fetal surgery. Developments in endoscopic surgical technology over the past three decades have provided the opportunity to develop techniques adapted for prenatal fetal intervention.

Regional anaesthesia is preferred by most anaesthetists for the majority of caesarean sections. The major advantage of regional anaesthesia is the avoidance of maternal morbidity and mortality associated with general anaesthesia. The importance of this can be seen in the most recent Report of Confidential Enquires into Maternal Deaths in which it was reported that of the direct maternal deaths attributed to anaesthesia, all six were associated with difficulties during general anaesthesia. Although a number of regional anaesthesia techniques are available, spinal anaesthesia is particularly popular because it is fast, easy to perform and provides excellent intraoperative analgesia.

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.

Many authors assert that there is essentially nothing that can be done to better manage shoulder dystocia. They will point to injuries that have been proven to occur spontaneously and to a stable or even rising injury rate over the last decade and claim:

1. that the risk of injury cannot be reduced

2. that no manoeuvre has been proven superior to another or guaranteed to work in all circumstances

3. that the choice and sequence of specific shoulder dystocia manoeuvres beyond McRoberts' should be left to the discretion of the birth attendant

4. that the predominant concern during shoulder dystocia is its expedient resolution, by whatever means necessary, to avoid central nervous system damage or even death.