Multiple pregnancy is a preventable complication of in vitro fertilisation (IVF). Multiple pregnancies are often the result of a treatment approach that means more than one embryo is placed into the womb during each IVF treatment cycle in the belief that this may increase the chance of a successful pregnancy resulting in a live birth. In reality, this approach has led to a higher rate of IVF multiple pregnancies, ranging between one in three and one in seven pregnancies across many parts of the world, including the UK. Multiple pregnancy carries higher risks for both the mother and babies, most notably the risk of premature birth leading to an increased chance of early death or long-term physical or learning disability. At present, there is no available treatment that can prevent premature birth in multiple pregnancies. The number of multiple pregnancies resulting from IVF treatment can be reduced by placing one embryo per IVF treatment cycle (single embryo transfer, SET) into the womb and freezing other embryos so that they can be used at a later date. Explaining this approach to women and their partners and families is essential in agreeing to this approach. Over the past 15 years, many of those involved in providing fertility treatment, including the independent regulator, medical professional societies, all fertility treatment clinics and patient advocates, have worked together to encourage the practice of placing a single embryo per IVF treatment cycle into the womb to reduce the chance of multiple pregnancy. Those efforts have been hugely successful in reducing multiple pregnancy rates following IVF-from one in four pregnancies in 2009 to one in 16 pregnancies in 2019-without reducing the overall chance of achieving a pregnancy per IVF treatment cycle. The multiple pregnancy rate can be lowered even further to below one in 20 pregnancies with additional improvements to the IVF treatment process. This is likely to lead to more clinics and more women, their partners and families choosing single embryo transfer, particularly if the NHS is prepared to fund three full IVF treatment cycles across the whole of the UK.

The third stage of labour happens after the baby or babies are born and when the placenta (afterbirth) is delivered. This Scientific Impact Paper reviews new evidence related to clamping of the umbilical cord, and other interventions that impact the birthing woman and newborn during this part of labour. The paper summarises recent additional information on anatomy (structure of the circulation system) and physiology (how the system functions) of the newborn baby's circulation before the umbilical cord blood vessels close, whether naturally or after a clamp is placed on the umbilical cord. The minutes after birth are now recognised as a time of remarkable change within the baby and we have learned that interfering with this natural process can cause potential harm. Up until birth, the fetus's oxygen supply comes from the mother via blood flow through the umbilical cord. The baby's first breath promotes rapid and profound changes to the circulation, allowing the baby to transition to a new oxygen supply from its own lungs. Fetal blood handles oxygen in a different manner to adult blood, which may be more important immediately after birth when the baby takes its first breaths. Since the last Scientific Impact Paper, more evidence confirms there is very little justification for immediate cord clamping at all gestations. Neonatal harm and death can be reduced when blood from the placenta is allowed to transfuse spontaneously to the baby in the minutes following birth. Those attending the birth should avoid intervening too early or too much while providing initial care (e.g., thermal care, stimulation). The benefits of waiting a few minutes before clamping are especially significant for premature babies. Early cord clamping will result in the baby having a lower blood volume as it is estimated that a baby at full term will receive around 30% of its total blood volume from placental transfer via the umbilical cord. The decision on timing to clamp the umbilical cord should be based on observations of the baby, its heart rate and breathing rather than a predefined interval after birth. Also, the palpable pulsation of the cord is unrelated to the blood flowing back and forth therefore it should not be used to guide the time when clamping occurs. Clamping at the placental end allows some blood in the cord to transfer to the newborn. There are other benefits to the baby from the placental transfer of blood such as transfer of stem cells.

Pre-eclampsia is a pregnancy complication that involves the development of high blood pressure in a pregnant woman and other features such as protein in the woman's urine, kidney or liver problems, or poorer growth for the baby. It can also have long-term health impacts for the mother after pregnancy. Pre-eclampsia typically occurs after 20 completed weeks of pregnancy (either mid-pregnancy known as 'early onset pre-eclampsia' or, more commonly, later in pregnancy, at or after 34 weeks, known as 'late onset' pre-eclampsia). Different blood pressure medications can be used to treat this condition, but not all women respond in the same way to the same medication. This is probably due to variables in the function of the maternal heart and blood vessels. Over the past 20 years, technological developments have meant it is now possible to measure important individual aspects of maternal cardiovascular function, using simple non-invasive tests. These tests can establish whether the mother's heart and circulatory system have any unusual features that may place her at higher risk of complications. They can also be used to monitor whether the mother's health and circulatory system is adapting in the right way to the pregnancy. For example, it is now possible to measure cardiac output (volume of blood pumped out by the heart) and vascular resistance (the physical resistance to the flow of blood), as well as the mother's blood pressure. It is also possible to monitor if and how changes in the above follow the patterns of change that are usually seen during pregnancy. Testing, and repeat testing as necessary, can identify individual measurements, or patterns of measurements, of concern and can identify whether the mother's heart and blood flow are adapting to the pregnancy in the typical and expected way. Studies in these areas have shown two distinct patterns of abnormal measurements of blood circulation and heart health in the pregnant woman that can occur with pre-eclampsia. Some changes and abnormalities can be detected before the symptoms of pre-eclampsia become obvious. Some features associated with pre-eclampsia can also be detected early in pregnancy or even before pregnancy. For example, we understand that some pregnant women who have a lower volume of blood being pumped out of their hearts per minute (low cardiac output), are more at risk of being affected by pre-eclampsia earlier in pregnancy, and more likely to have a baby with a low birth weight. Women that develop pre-eclampsia later in pregnancy typically have more circulating blood and babies of normal or larger size. The distinct measurable features of maternal heart health and blood flow can be used to identify those women at risk of developing pre-eclampsia at an early stage. Recognising the features of maternal heart health and the patterns of blood flow associated with pre-eclampsia provides an opportunity to individualise treatment plans for pregnant women, such as a personalised plan of monitoring and review, and using the most appropriate drugs that are tailored to address specific difficulties and likely to be most effective in restoring balance to the circulatory system of that individual. Early recognition, before the onset of symptoms, also allows timely reviews, and appropriate treatment to be started sooner. This, in turn, can lower the incidence of serious manifestations of pre-eclampsia for the mother, such as the development of seizures or a stroke. There is clear evidence that the management of pre-eclampsia can be improved by more detailed cardiovascular evaluation and tailored monitoring. The drugs that lower blood pressure work in different ways and the opportunity exists to target therapy to the underlying problem, however at the time of writing, many of the non-invasive tests and assessments able to identify women at risk of pre-eclampsia are typically only being used in a research setting. Routine clinical use of the available tests, and the establishment of clear care pathways and defined parameters for risk assessment based on those maternal heart and circulation test results, would allow targeted treatment and assist in preventing avoidable harm.

The average age of childbirth in the UK in 2022 was 30.9 years, having increased by over 3 years in the past 2 decades, and 4 years since 1980. Although a woman's fertility declines markedly in her late-30s and early-40s, more women are now starting their family at this stage of their lives. Related to this, increasing numbers of women are storing their eggs (oocytes) to give them the potential opportunity to have a baby in the future. The number of egg freezing cycles accounts for 5% of in vitro fertilisation (IVF) cycles but the number of cycles using stored eggs is much lower. The use of a technique of rapid freezing called vitrification gives success rates almost as good as using fresh eggs. The reasons behind the increase in egg freezing are complex, but the most common reason given by women storing eggs is that they do not have a partner and are concerned that by the time they do find themselves in a relationship within which they wish to start a family, they may not be able to do so. This paper addresses the growing use of egg freezing and how it may have been promoted. It is essential that women are very clearly informed about the likely success rates of egg freezing, particularly as it is primarily provided by the private sector, with the associated concerns of financial costs and inappropriate or inaccurate marketing. Its success is strongly dependent on the age of the woman at the time of freezing her eggs, with much higher success rates in those under the age of 35 years. The relevant legislation changed in 2022 and now allows women to store eggs for 55 years, although consent for this needs to be renewed every 10 years. This now supports the better success rates when women store eggs at a younger age. We conclude that elective egg freezing provides women with an opportunity to act on the age-related drop in their fertility. At present, most women who are doing this are already in their later 30s when the success rates are limited. We strongly support the need for improved and continuing education of both women and men regarding the decline in female fertility with age.