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Beta-blockers in the treatment of chronic simple glaucoma.

What the obstetrician does have is the freedom of choice to make decisions when he is confident that the quality of neonatal care will be excellent, however small the baby. This need not and must not be the sole prerogative of obstetricians in regional centres. Even if there were several perinatal centres in each region they would not be likely to cope with all or even most of the high-risk pregnancies presenting at district maternity hospitals. Uncritical expansion of antenatal referral services erodes the experience of medical and nursing staff in the management of common pregnancy complications-yet at the same time accommodation for such patients at the regional centre can never be guaranteed. There would be little justification for the transfer of premature babies who are not suffering from respiratory failure and for many examples of antenatal referral if the standards of neonatal care in district maternity hospitals were improved. The essential neonatal facilities that must be maintained in district maternity hospitals can be spelt out: constantly available skilled resuscitation and short-term ventilatory support; the ability to anticipate neonatal problems and recognise them early; reliable monitoring for and prophylaxis against apnoeic attacks; scrupulous control of oxygen treatment in babies with respiratory distress; awareness ofthe individual baby's thermal homoeostasis; and a critical approach to gavage feeding in small babies. The provision of such basic care is not costly, and it is to midwives and nurses we must turn to maintain these standards. An increase in their numbers is certainly necessary in most district maternity hospitals, but ensuring that existing staff are appropriately trained is just as important. Present training programmes, in their attempt to be comprehensive, frequently fail to teach the nuances of neonatal care. Yet in this specialty it is often nuances that dictate the difference between appropriate and poor care. We have reached a crossroads in the regional organisation of perinatal care in Britain. Our health service administrators must not be allowed to lead us towards too much centralisation in the belief that money can be saved by diverting resources from the district maternity hospitals. What then should be our policy on neonatal and antenatal referral ? Neonatal transfer for impending respiratory failure is totally justified. We need a more selective policy for antenatal transfer that would include, for example, women with fetuses severely affected by rhesus disease; those with complications of pregnancy in whom preterm elective delivery is contemplated in the face of uncertainty about pulmonary maturation or a known risk of hyaline membrane disease based on biochemical analysis of amniotic fluid; and the presence of a fetal malformation amenable to surgical treatment or with a predicted need for medical treatment. Finally, undue emphasis on neonatal and antenatal transfer should not preclude regional perinatal centres from maintaining other roles. Firstly, they should find time to improve standards of care at district maternity hospitals through the training of midwives and nurses and postgraduate medical education; secondly, they need to look at innovations in the prevention and treatment of perinatal disorders-stimulated by close working contact between geneticist, obstetrician, paediatrician, neurodevelopmental specialist, paediatric pathologist, and others; and, thirdly, they should collect and analyse regional and district statistics so that more can be learnt about the influence of different patterns of perinatal care on mortality and neurodevelopmental handicap.