Chronic fetal growth restriction is associated with both increased perinatal mortality and impaired neurodevelopment. Although it is a much more important cause of fetal neurological damage than intrapartum birth asphyxia, it is more difficult to treat, since the main intervention, timed delivery, carries its own risks. Since it is associated with a range of circulatory changes, which may also cause fetal damage, understanding these may improve management. In this article we review these fetal circulatory changes and assess their significance for predicting perinatal and long term neurodevelopmental outcome. We describe the Doppler assessment techniques, their clinical role in prediction of adverse outcome and the pathogenesis of brain injury in the preterm growth restricted fetus.