Objective To describe the annual incidence over time of postpartum haemorrhage (PPH) in the Netherlands as documented in routine birth statistics, stratified by induction of labour, augmentation of labour and mode of birth for nulliparous women. Design Population-based cohort study. Setting Nationwide. Population All nulliparous women who gave birth after 22 weeks’ gestation in the Netherlands between January 1, 2000, and December 31, 2020 (n=1,568,279). Methods This study used the Dutch Perinatal Registry (Perined) from 2000 to 2020. PPH trends were analyzed for nulliparous women based on mode of birth, induction and/or augmentation of labour. Main outcome measures PPH, defined as blood loss of >1000 ml. Results Documented PPH increased from 4.4% to 7.0 % of all births between 2000 and 2009, after which the rate stabilized until 2020. In the entire period, PPH rates were higher after vaginal birth compared to caesarean section. Induction of labour was consistently correlated with higher PPH rates, which increased further in the presence of augmentation. The sharp increase in all groups in the first decade occurred after guide line adjustments and introduction of the mandatory training for health professionals active in obstetric acute care: the Managing Obstetric Emergencies and Trauma (MOET) course, particularly after caesarean section, and indicates that better objectifiable measurements of blood loss might have played a role. Conclusion After an initial increase, the documented rate of PPH stabilized in the Netherlands. Induction and augmentation of labour are associated with a higher risk of PPH.

Objective: To investigate trends in low 5-minute Apgar scores in (near) term singletons. Design: Nationwide cohort study. Setting: The Netherlands. Population: A cohort of 1,583,188 singletons liveborn between 35 +0 and 42 +6 weeks of gestation in the period 2010-2019 from the Dutch Perinatal Registry. Methods: We studied trends using Cochrane-Armitage trend tests. Risk factors were studied by logistic regression analysis and Population Attributable Risk (PAR) calculation. Main outcome measures: Low 5-minute Apgar score (<7 and <4) as primary outcome. Results: The proportion of infants with low 5-minute Apgar score <7 and <4 increased significantly between 2010 and 2019 (1.04-1.42% (p<0.001), 0.17-0.19% (p=0.009), respectively). While neonatal mortality remained unchanged, NICU admissions and low umbilical artery pH’s increased significantly. Many perinatal characteristics showed a significant association with low Apgar scores. The highest risks were found for nulliparity, epidural analgesia, emergency caesarean section, instrumental vaginal delivery, prolonged second stage of labour, male sex and delivery in secondary care. The obstetric interventions induction of labour, epidural analgesia and planned caesarean section showed an increasing trend. Instrumental vaginal delivery and emergency caesarean section were performed less frequently over time, however within these obstetric intervention subgroups the highest increase in low Apgar scores was observed. Conclusions In the Netherlands, the risk of a low 5-minute Apgar score increased significantly over the last decade, with the highest increase being observed in the obstetric intervention subgroups of instrumental vaginal delivery and emergency caesarean section. Neonatal mortality remained stable over the study period.