This article examines the question as to what is the right age to reproduce from the biological point of view of its purpose; that of achieving a healthy mother and baby. We start with an assumption that issues surrounding sex, fertility, pregnancy, miscarriage, abortion and childbearing are private and emotionally laden. We are not looking at, nor judging, individual reproductive choices; what might be “right” for one person, or couple, in one context will be unsuitable for another. It is traditional obstetric and gynaecological teaching that human reproductive outcomes are worse at the extremes of maternal age. Yet the advice given in a recent BMJ editorial entitled “Which career first? The securest age for childbearing remains 20–35” appeared to be controversial. The ensuing scientific and media interest raised such headlines as “Horns of the dilemma”, “A sinister article”, “Late mums face baby misery” and “Are we having children too late? IVF not the answer, say docs”. Products have recently appeared on the market offering kits to women to indicate the time left on their ‘biological clock’ so they can choose whether to continue pursuing their career or try for a baby. Why is there so much interest in the right time to reproduce? Are women (and men) doing something differently compared to the past? If there has been a demographic shift in the age women reproduce (hitherto unexplained), there are important and specific risks older women may face as compared to younger women.

A large number of studies show that low birth weight is associated with cardiovascular disease and its risk factors including raised blood pressure, glucose intolerance and the metabolic syndrome. These findings have formed the basis for the ‘fetal origins hypothesis’. This suggests that the operation of adverse influences during intrauterine life leads to permanent alterations in fetal structure and physiology which predispose to adult disease. The process is known as developmental plasticity or programming and is strongly supported by studies in experimental animals. Ongoing research is providing important insights in to the underlying mechanisms. It is likely that adverse environmental factors during pregnancy are important, and that these include suboptimal nutrition of the mother. The long-term programming effects may be transduced by alterations in the set-point of key hormonal axes, especially the hypothalamic-pituitary-adrenal axis, and recent evidence suggests that epigenetic modification of gene expression may be a key factor. Importantly, this has the potential to produce transgenerational effects.

The hypothesis has not remained unchallenged and a wide variety of criticisms have been put forward. These include accusations that the associations are weak and overestimated due to publication bias, that there are many inconsistencies between studies, that the associations are confounded by lifestyle factors, and that there has been inappropriate adjustment for adult size. Finally many studies report that the findings in singletons do not seem to be replicated in twins. While many of these issues have been resolved, some continue to form the basis of a lively dialogue and ongoing research. Nevertheless the research findings have important implications for clinical obstetric practice and maternal-fetal medicine.

Obstetric caregivers must deal with a wide range of emergencies, some of which are quite uncommon, and many believe they have achieved a high level of expertise based on study rather than experience. Yet a growing body of work demonstrates that simulation training can sharpen the skills of all caregivers and promote the development of efficient teams capable of reducing the morbidity of these rare events. This paper outlines current recommendations for emergency and teamwork training in obstetrics and reviews different training methods and their effectiveness.

Many authors assert that there is essentially nothing that can be done to better manage shoulder dystocia. They will point to injuries that have been proven to occur spontaneously and to a stable or even rising injury rate over the last decade and claim:

1. that the risk of injury cannot be reduced

2. that no manoeuvre has been proven superior to another or guaranteed to work in all circumstances

3. that the choice and sequence of specific shoulder dystocia manoeuvres beyond McRoberts' should be left to the discretion of the birth attendant

4. that the predominant concern during shoulder dystocia is its expedient resolution, by whatever means necessary, to avoid central nervous system damage or even death.