Hypoxic-ischemic injury during labour is a leading cause of perinatal mortality, severe neonatal and longer-term morbidity globally. It leads to brain damage, cerebral palsy and premature death in adult survivors. Hypoxia during labour causes fetal distress which often occurs in women without obvious risk factors. When it happens, emergency operative birth (caesarean section or instrumental vaginal birth) is frequently required. Identification of infants at risk of fetal distress or other adverse outcomes is difficult – the current approach using maternal risk factors and/or clinical assessment of fetal size is poor at detecting small or vulnerable infants. Furthermore, although the association between some risk factors and adverse outcomes is known, the actual predictive utility for a specific risk factor is often relatively poor and more accurate tests are urgently required. There is currently no treatment to prevent fetal hypoxia in labour and we have limited ability to identify vulnerable fetuses before labour commences. Timely, accurate identification of this at-risk cohort with effective intervention represents one of the great challenges in perinatal medicine.

Globally the rates of induction of labour (IOL) are on the rise. The availability of prostaglandins, which act as both cervical ripening as well as inducing agent, has improved the success rates of IOL in the presence of an unfavourable cervix. Mechanical methods such as intracervical balloon catheters appear to be equally effective as compared to pharmacological agents and have fewer adverse effects. The process of IOL is associated with significant risks such as uterine hyperstimulation, fetal compromise, increased risk of operative deliveries and rarely rupture of the uterus. Hence, there should be a clear indication for IOL based on best available evidence, with benefits to either mother or fetus, which outweigh the perceived risks. The World Health Organization, the National Institute for Health and Clinical Care Excellence and various professional organisations have produced guidelines to assist clinicians in decision-making regarding IOL in various obstetric situations. The process of IOL should be tailored to meet the expectations and preferences of women in their unique circumstances.

Umbilical cord prolapse is an obstetrical emergency with an incidence of 1 to 6 per 1000 pregnancies, which is associated with high perinatal mortality. This chapter addresses several important aspects of cord prolapse. The definition of cord prolapse varies in the literature, and the term ‘occult cord prolapse’ is misleading. To address this, cord prolapse, cord presentation and compound cord presentation should be classified based on their positional relationship. Urgent delivery by cesarean delivery is the main treatment, except in cases where vaginal delivery is imminent. The urgency of delivery depends on the fetal heart rate pattern, with bradycardia cases requiring the most immediate intervention. Cord arterial pH declines significantly during bradycardia-to-delivery intervals, indicating potential irreversible pathology. Various manoeuvres can be used to relieve cord compression before caesarean delivery and an algorithm was proposed to guide the acute management of cord prolapse.