Operative vaginal births (OVB) have an important role to play in modern obstetric care. OVB should be offered only when the benefits outweigh the potential risks, taking account of both maternal and neonatal perspectives. A systematic clinical assessment, effective communication and expertise in the intended procedure are prerequisites for OVB. OVBs are classified primarily by the station and position of the fetal head. OVB are performed when birth needs to be expedited and may be indicated for conditions of the fetus or the mother or both. Suspected fetal compromise, as revealed by a suspicious or pathological fetal heart rate pattern on cardiotocography (CTG), is also a common indication for OVB. Careful patient assessment, observing the rules of safe obstetric practice and working within the appropriate clinical indications for OVBs should ensure that the benefits of recommending OVB outweigh the risks.

The main aim of fetal monitoring is to timely identify and hence to salvage fetuses that are at risk of intrapartum hypoxic injury, whilst avoiding unnecessary operative intervention to fetuses that are normoxic or those who are mounting a good compensatory response. Cardiotocography (CTG) interpretation based on pattern recognition leads to unnecessary interventions as well as lack of action as all the CTG patterns of fetal neurological injury are not currently known and the specific CTG patterns do not correlate with poor neonatal outcomes. Intrapartum hypoxia should be suspected when there are changes in the baseline heart rate (i.e. below 110 beats per minute (bpm) or above 160 bpm) and/or presence of decelerations (on auscultation for 1 min after a uterine contraction) on intermittent auscultation. The decelerations are classified as early, late and variable in relation to the uterine contractions.

The birth of an infant who has a possible hypoxic ischaemic encephalopathy (HIE) is a source of great concern to the parents, obstetricians and paediatricians. Hypoxic cerebral brain injury that occurs in the perinatal period is recognised as a cause of severe long-term neurological deficit in children; it is often referred to as cerebral palsy. The absence of information and specific guidelines on HIE means that advice provided to women has to be collated from evidence-based effective antenatal and perinatal care that maximises the opportunity to deliver a healthy baby. Approaches to the prevention of HIE include the antenatal administration of corticosteroids to women in preterm labour, as this has been shown to reduce perinatal mortality, respiratory distress and intraventricular haemorrhage by over 50%. All units should have a regular continuing programme of in-service training including cardiotocography (CTG) interpretation, drills on emergency ('crash') caesarean section and neonatal resuscitation.