Saving Mothers' Lives: - Public Health Agency for Northern Ireland

78
4 Haemorrhage
William Liston
Obstetric haemorrhage: Specifi c recommendations
All staff require regular training on identifi cation and management of maternal collapse, including
the identifi cation of hidden bleeding and the management of haemorrhage, which is also a key
recommendation of this Report.
An early warning scoring system of the type described in the Chapter on Critical Care, another key
recommendation of this Report, may help in the more timely recognition of cases of hidden bleeding.
When severe haemorrhage occurs it is good practice to call straight away for the aid of colleagues with
greater gynaecological surgical experience.
The management of women with placenta percreta requires careful multidisciplinary planning in the
antenatal period and the involvement of a consultant-led multidisciplinary team at delivery.
Guidelines for the management of women who refuse blood products must be made available to, and
discussed with, all maternity staff as part of their routine training, postgraduate education, continuing
professional development and practice.
Women should be advised that caesarean section is not an entirely risk-free procedure and can hold
problems for current and future pregnancies.
All women who have had a previous caesarean section must have their placental site determined.
This, too, is a key recommendation of this Report. If there is any doubt, magnetic resonance imaging
(MRI) can be used along with ultrasound scanning in determining if the placenta is accreta or percreta.
Summary of key fi ndings for 2003-2005
The last Report drew attention to the impressive decline in deaths from obstetric haemorrhage in the
United Kingdom over the last 50 years and outlined some of the possible reasons for this. In this triennium,
2003-05, 14 women died from haemorrhage; a rate of 0.66 per 100,000 maternities, similar to the rate
for the previous triennium. Three other cases of haemorrhage associated with uterine rupture or genital
tract trauma are included here, which, in previous Reports were counted and discussed in a now defunct
Chapter relating to other causes of Direct maternal deaths. This old Chapter is no longer required as the
number of maternal deaths from these causes is now too small for them to require a specifi c Chapter of
their own.
Overall in the United Kingdom (UK), the risk of a pregnant women dying from haemorrhage is very small.
However, there are several points which are not immediately apparent from these few UK deaths:
• Ten of the 17 women, almost three-fi fths, of those who died received less than optimal care. In
particular, there were questions concerning the most appropriate management of women with
placenta percreta, a problem likely to become more prevalent due to its emerging relationship with
previous caesarean section scars. There were also apparent failures in recognising the signs and
symptoms of intra-abdominal bleeding especially after caesarean section. Lastly, ergometrine often
seems to have been forgotten as a useful oxytocic drug.
• At least two major surveys in developed countries 1, 2 , have shown around two thirds of all cases of
severe maternal morbidity, so called “near misses”, are related to severe haemorrhage. Midwives,