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.