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

80
4 Haemorrhage
More than half of the women were from ethnic minorities and several spoke no English. This extra barrier
made the provision of care for these women more diffi cult. However, unusually, compared with most other
causes of Direct maternal deaths, all but two of the women received regular and timely antenatal care
and were also in stable relationships with at least one partner in full time employment. At least three of the
women were professionally qualifi ed health care workers.
In previous Reports some deaths from haemorrhage followed concealed pregnancies or a lack of
engagement with the maternity services. This is also the case this triennium. For example:
A single woman whose previous children were in the care of social services concealed her pregnancy
until she attended in spontaneous labour. She discharged herself almost immediately after an
apparently uneventful delivery, leaving her baby behind. She died, alone, of a postpartum bleed
several days later, having made herself impossible to trace for community midwifery follow-up.
Although very little could have been done to help this woman, who seemed determined to avoid all contact
with any heath or other agencies, there are lessons to be learnt from the care of another woman whose
antenatal care was less than optimal:
A grand multiparous woman who spoke no English was referred to the local maternity services for
booking by her General Practitioner (GP) in a timely manner. She did not receive a date for her fi rst
antenatal appointment, however, until she was more than fi ve months pregnant. Her pregnancy
proceeded well until labour was induced despite a clear history of precipitate labours. She suffered
a massive postpartum haemorrhage and died, despite a hysterectomy, some days later.
The health system let this woman down because, despite her prompt action when she discovered she was
pregnant, she did not receive her booking appointment until well after the fi rst trimester of her pregnancy,
thus missing the benefi ts of early antenatal care and opportunities for screening. She was then further let
down both by poor clinical decision-making and an additional lack of immediate access to Critical Care.
Women who refused blood products
Two women who died from haemorrhage declined blood transfusion due to their religious beliefs. This was
their free choice. However, it is almost certain that if they had received blood products they would have
survived. One other woman who refused blood products died of an amniotic fl uid embolus and her case is
counted and discussed in Chapter 5. Despite their care being generally of a high standard, there are some
general points in the care of these women that need to be re-emphasised:
• Consultant obstetric and anaesthetic involvement is necessary during the antenatal period in order
to develop a care plan together with the woman, her husband and family, and, if necessary, religious
advisors, should any diffi culty occur.
• Informed consent for red blood cell salvage during surgery and infusion of salvaged blood should
be sought and clearly recorded in the case notes. This facility should be provided for all women who
give consent for this procedure.
• All women who are known to have stated a wish not to receive blood products should be seen by a
consultant obstetrician and anaesthetist at the onset of their labour and a fi nal care plan developed. In
the past some women who died of post-operative haemorrhage were delivered by caesarean sections
carried out by trainee obstetricians. It is therefore important that, whenever possible, each woman in
labour should be cared for by a consultant obstetrician and, should an elective caesarean section or other
operative delivery be required, this should be conducted by a consultant obstetrician and anaesthetist.