A 3-year survey of subaponeurotic haemorrhage (January 1991 to December 1993) in a tertiary referral centre in Hong Kong revealed that the incidence of this life-threatening condition was 6.4 per 1000 ventouse-associated deliveries, which is 60-fold more common than with other modes of childbirth. We highlight a lesser known phenomenon of marked male predominance (male to female ration 8:1). Three of 18 (17%) infants with subaponeurotic haemorrhage died. Severe subaponeurotic haemorrhage with a decrease in venous haematocrit >25% of the baseline value at birth and requiring urgent blood transfusion in the first 12 h, in association with significant birth asphyxia with arterial cord blood pH <7.20 and 1-min Apgar score < or = 3 were the most important risk factors for death. A worrying feature was the silent presentation of occult subaponeurotic haemorrhage in two of the fatal cases. Frequent monitoring of haematocrit, early and rapid restoration of blood volume and prompt commencement of cardiac inotropes are the keys to the management of this condition, which should be suspected in all ill newborn infants subjected to the ventouse applicator.