Objective To investigate the cause of a recent increase in hysterectomies for postpartum haemorrhage in Canada.Design Retrospective cohort study.Setting Canada between 1991 and 2004.Population All hospital deliveries in Canada as documented in the database of the Canadian Institute for Health Information (excluding incomplete data from Quebec, Manitoba and Nova Scotia).Methods Deliveries with postpartum haemorrhage by subtype were identified using International Classification of Diseases codes, while hysterectomies were identified using procedure codes. Changes in determinants of postpartum haemorrhage (all postpartum haemorrhage and that requiring hysterectomy) were examined, and crude and adjusted period changes were assessed using logistic models. Conclusions There has been a recent, unexplained increase in the frequency, and possibly the severity, of atonic postpartum haemorrhage in Canada.

II.

The second twin is at greater risk of adverse perinatal outcome than the first twin, independent of presentation, chorionicity, or infant sex. Planned vaginal delivery, birth weight discordance, and prolonged interdelivery interval increase this infant risk. Elective cesarean delivery at term may improve perinatal outcome for the second twin. However, the number of cesarean births required to prevent one case of composite adverse outcome, assuming causality, was 33.

aTo estimate maternal and perinatal morbidity associated with caesarean delivery at full cervical dilatation, a population-based cohort study from 1997 to 2002 was used, which included 1623 nullipara with singleton pregnancies at 37-42 weeks of gestation requiring caesarean delivery in labour. Compared to caesarean delivery at less than full dilatation, women undergoing caesarean delivery at full dilatation were more likely to have complications of intraoperative trauma (RR 2.6, P < 0.001) and infants with perinatal asphyxia (RR 1.5, P < 0.05). There was no difference in maternal or perinatal morbidity when duration of the second stage of labour or when failed assisted vaginal delivery was considered.

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Objective To determine the level of near-miss maternal mortality and morbidity due to severe Design Retrospective review. Setting A free-standing maternity hospital delivering 5500 infants per year. Methods The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted. Results Over 14 years there were 76,119 women delivered with two maternal deaths (2-6/100,000).Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (1 5%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3-92). Conclusion A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.obstetrical complications or maternal disease in a tertiary maternity hospital.

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The increased maternal morbidity in elective cesarean delivery compared with spontaneous onset of labor is limited to puerperal febrile morbidity. Maternal morbidity is increased after assisted vaginal delivery and cesarean delivery in labor compared with cesarean delivery without labor.