Maternal perception of decreased fetal movements (DFM) is associated with increased incidence of stillbirth and intrauterine growth restriction. We hypothesised that clinical assessment of women perceiving DFM may identify patients at highest risk of poor perinatal outcome. This was a retrospective study of 203 patients presenting to the obstetric triage service with DFM. Information on obstetric and past medical history, the current presentation with DFM and the outcome of pregnancy was collected. Using multivariate analysis, odds ratios (OR) and 95% confidence intervals (CI) were calculated for poor pregnancy outcome defined as stillbirth, small for gestational age or pre-term delivery. The rate of stillbirth was increased in women with DFM (OR 2.9). Some 26.6% of women perceiving DFM had a poor perinatal outcome. Women with relevant past obstetric history (OR 2.11), two or more presentations of DFM (OR 1.92), or who measured small-for-dates (OR 19.53) were at increased risk of poor pregnancy outcome. These preliminary data suggest that some features of clinical assessment can identify patients at increased risk of poor perinatal outcome after presentation with DFM. Such patients may be prioritised for detailed assessment of fetal growth and wellbeing.

Some cases of stillbirth are associated with placental abnormality; recent classification systems have included some features of placental pathology. This study aimed to determine whether placental investigations assist in determining the cause of stillbirth. A total of 71 consecutive cases of stillbirth were reviewed. Placental investigations were undertaken in 54% of cases. Women who had placental assessment were significantly less likely to have an unexplained stillbirth (OR = 0.17; 95% CI 0.04-0.70). In 47% of cases, the findings of placental investigation were included in the classification of stillbirth. In 16% of cases the classification was determined primarily by placental examination. Some placental abnormalities found were associated with clinical causes of stillbirth, such as placental infarction and IUGR or leukocyte infiltration and chorioamnionitis (p < 0.05). We conclude that assessment of the placenta can aid classification of stillbirth and recommend that histological analysis of placental tissue be offered in all cases of stillbirth, even when full infant post-mortem is declined.

The incidence of surrogacy is rising. Literature on associated obstetric risks is scarce and caution must be exercised when labelling surrogate pregnancies as low risk. Although obstetricians’ responsibilities lie with the surrogate mother, they must ensure her wishes do not conflict with the best interests of the baby. Prepregnancy counselling is the key to a successful surrogacy arrangement. Learning objectives: To gain an awareness of the different types of surrogacy. To understand the law surrounding surrogacy. To learn about antenatal, intrapartum and postpartum care in surrogacy. Ethical issues: When the surrogate mother's wishes and the interests of the child conflict, do obstetricians have the right to discuss this with the commissioning parents without her consent? When should obstetricians seek ethical and legal support? Please cite this article as: Bhatia K, Martindale EA, Rustamov O, Nysenbaum AM. Surrogate pregnancy: an essential guide for clinicians. The Obstetrician & Gynaecologist 2009;11:49–54.

References 1 Lockwood CJ, Senyei AE, Dische MR et al. Fetal fibronectin in cervical and vaginal secretions as a predictor of preterm delivery. N Engl J Med 1991; 325: 669414. 2 Momson JC, Allbert JR, McLaughlin BN et al. Oncofetal fibronectin inpatients with false labor as a predictor of preterm delivery. Am J Obstet Gynecoll993; 168: 538-542. 3 Nageotte MP, Casal D, Senyei AE. Fetal fibronectin inpatients at increased risk for premature birth. Am J Obstet Gynecol 1994; 170: 4 Anderson HF, Nugent CE, Wanly SD et al. Prediction of risk of preterm delivery by ultrasonographic measurement of cervical length. Am JObstet Gynecoll990; 163: 859-867. 20-25. An analysis of recent trends in vacuum extraction and forceps delivery in the United Kingdom Sir,We commend Dr Meniru for his illuminating analysis of the current trend of increasing use of the vacuum extractor over the traditional forceps for assisted vaginal delivery (Vol 103, February 1996)'. Whilst we approve of this trend, the finding that 67% of his respondents would apply the ventouse cup before full dilatation of the cervix is worrying. We note the 40% response rate of the survey, probably from vacuum extraction enthusiasts, hence nearly 7 in 10 of them would use the ventouse in an incompletely dilated cervix. This may not necessarily be representative of practice in the United Kingdom. It is also not clear if they simply acknowledged this procedure existed or routinely practised this technique.

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