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

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198 17 Halliday DJ, Hutchinson S, Lonie L, et al, 2002, Twelve novel FBN1 mutations in Marfan syndrome and Marfan related phenotypes test the feasibility of FBN1 mutation testing in clinical practice. Journal Medical Genetics, 39, 589-93. 18 Jonasson B & Saldeen T. 2002, Citalopram in fatal poisoning cases. Forensic Science International, 2002, 126, 1-6. 19 Geocadin RG, Razumovsky AY, Wityk RJ, et al. 2002, Intracerebral haemorrhage and postpartum vasculopathy. J. Neurol Sci. 205, 29-34. 20 Witlin AG, Mattar F, Sibai BM. 2000, Postpartum stroke: a twenty year experience. Am J Obst Gyn, 183, 83-88. 21 Edmondson H A, Peters R L, Reynolds T B, Kuzma O T, 1963, Sclerosing hyaline necrosis of the liver. A recognizable clinical syndrome. Annals of Internal Medicine, 59, 646-73 .
16 Issues for midwives Grace Edwards a a This Chapter was written in collaboration with Val Beale Local Supervising Authority Midwifery Offi cer NHS South West, Grace Edwards Consultant Midwife Liverpool Women’s NHS Foundation Trust, Alison Miller, Programme Director and Midwifery Lead, CEMACH and Jane Rogers, Consultant Midwife, Southampton University Hospital Trust. Midwifery practice: Specifi c recommendations Professional competence and accountability National The Nursing and Midwifery Council (NMC) should audit the content of undergraduate and ongoing postgraduate midwifery programmes to ensure all staff have up-to-date knowledge and recognition of the warning signs of immediate collapse as well as the signs and symptoms of serious medical conditions and to know when to refer women for medical opinion. Providers of post registration education and training must ensure that all midwives have up-to-date knowledge and are able to recognise the warning signs of immediate collapse. In addition, that all staff can recognise the signs and symptoms of medical conditions and are able to provide basic management and refer women appropriately for medical opinion. Individual All midwives should read, and adopt, the Action checklist for midwifery practice which can be found at the end of this Chapter. In particular: • They must ensure they are competent to practice, identify, and address gaps in their knowledge base and skills, including recognising deviations from normal and act appropriately. • Every midwife has a responsibility to ensure that s/he is familiar with all emergency procedures and attend regular updates appropriate to their needs and local recommendations. • If a midwife is unhappy with a medical opinion s/he has a duty to take further action, seeking support from a Supervisor of Midwives or midwifery manager if necessary. Raising standards through audit and review Strategic The Strategic Health Authority (SHA) or equivalent has a responsibility to share good practice. Since it also has a responsibility for the performance management of all trusts, it should evaluate every trust’s response to the recommendations of the ‘Why Mothers Die’/’Saving Mothers’ Lives’ Report. This could be linked to the response to serious untoward incidences (SUIs) and include the Local Supervising Authority Midwifery Offi cer and supervisor of midwives. This should include all Primary and Acute NHS Trusts or equivalents. Local It should be mandatory for all Trusts to disseminate and audit the uptake of recommendations arising from all external or internal reviews, or root cause analysis of a maternal death, SUIs or ‘near misses’, for educational purposes for all staff. 199
Page 1 and 2:
Confidential Enquiry into Maternal
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Saving Mothers’ Lives: Reviewing
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Contents Maternal deaths Indirectly
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Foreword Having a baby is a joyous
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The ‘top ten’ key recommendatio
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Migrant women 4. All pregnant mothe
Page 13 and 14:
Clinical skills 7. Maternity servic
Page 15 and 16:
Early warning scoring system 9. The
Page 17 and 18:
References 1 Redshaw M, Rowe R, Hoc
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Working together to save mothers’
Page 21 and 22:
Severe maternal morbidity, “near
Page 23 and 24:
At a national level In every countr
Page 25 and 26:
Table 1 Defi nitions of maternal de
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For the past nine years, ONS have b
Page 29 and 30:
Chapter 1 Which mothers died, and w
Page 31 and 32:
Key fi ndings for 2003-05 Maternal
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Figure 1.1: Overall maternal mortal
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Coincidental deaths The deaths of 5
Page 37 and 38:
Leading causes of maternal deaths:
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Table 1.5 Maternal deaths by gestat
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Table 1.7 Number of maternal deaths
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of note is that every women who die
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Table 1.11 Numbers and percentage o
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These messages are repeated in many
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Doctors may need specifi c training
Page 51 and 52:
Table 1.13 Total number of Direct a
Page 53 and 54:
Ovarian hyperstimulation syndrome (
Page 55 and 56:
The obese women who died From the n
Page 57 and 58:
Pre-pregnancy counselling and weigh
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Table 1.19 Direct and Indirect mate
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double the number of cases in the l
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was ill and he should take her to a
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Table 1.22 Characteristics of the a
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Page 69 and 70:
Page 71 and 72:
Most staff reported learning clinic
Page 73 and 74:
exception. The health service has a
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17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
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Table A1.4 Direct and Indirect deat
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Body mass index varies with age, be
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2 Thrombosis and thromboembolism Ja
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Pulmonary embolism Of the 33 women
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Family history In two deaths there
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vigilance and take symptoms serious
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Deaths after caesarean section Seve
Page 93 and 94:
of pregnancy, seven had identifi ab
Page 95 and 96:
Annex 2.1 Summary of the key recomm
Page 97 and 98:
The grades of recommendations (B or
Page 99 and 100:
High risk patients Patients assesse
Page 101 and 102:
Table 3.2 Numbers of deaths from pr
Page 103 and 104:
publication from the United States
Page 105 and 106:
References 1 Knight M, Kurinczuk JJ
Page 107 and 108:
obstetricians and anaesthetists rou
Page 109 and 110:
Detailed guidelines for the managem
Page 111 and 112:
acute bleeding situation although i
Page 113 and 114:
References 1 Brace V, Penney G, Hal
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Table 5.1 Direct deaths attributed
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of over ten litres. Despite a hyste
Page 119 and 120:
References 1 Clark SL, Pavlova Z, G
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The women who died The ages of the
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A woman who had not been long in th
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7 Genital tract sepsis Ann Harper G
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Sepsis in early pregnancy Six women
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Box 7.3 Learning points: Sepsis in
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Risk factors for, and the identifi
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Box 7.7 Features of septicaemic sho
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8 Anaesthesia Griselda Cooper and J
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The third case also highlights the
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A woman suffered a concealed haemor
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Sepsis Poor anaesthetic or resuscit
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What did you learn from this case a
Page 145 and 146:
9 Cardiac disease Catherine Nelson-
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Table 9.2 Causes of maternal death
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an estimated incidence of 1.1 per 1
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Quality of care Care was considered
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y a doctor, with a systolic blood p
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Box 9.3 Learning points: peripartum
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Infectious endocarditis Two women d
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10 Other Indirect deaths Michael de
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Table 10.1 Causes of Other Indirect
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Fifty-eight of the eighty-seven wom
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Previous Reports have emphasised th
Page 167 and 168:
Aspergillosis usually occurs in imm
Page 169 and 170:
Liver disease There were four mater
Page 171 and 172:
Diseases of the circulatory system
Page 173 and 174:
11 Cancer and other tumours Gwyneth
Page 175 and 176: her delivery, but her case should h
Page 177 and 178: Severe abdominal and back pain, sci
Page 179 and 180: References 1 Drife, J O. The contri
Page 181 and 182: Psychiatric deaths: Specifi c recom
Page 183 and 184: cut off point for maternal deaths,
Page 185 and 186: Report, 26 deaths from suicide were
Page 187 and 188: Current psychiatric treatment In th
Page 189 and 190: 12 Deaths from psychiatric causes S
Page 191 and 192: caring for the woman. Nonetheless,
Page 193 and 194: Commentary on deaths related to dru
Page 195 and 196: It is known that women presenting w
Page 197 and 198: antibiotics nor returned to her gen
Page 199 and 200: It is still evident that there is a
Page 201 and 202: 13 Domestic abuse Gwyneth Lewis Dom
Page 203 and 204: The mothers affected: 2003-05 Durin
Page 205 and 206: Of the women who were murdered: •
Page 207 and 208: Annex 13.1 The recommendations of t
Page 209 and 210: Road traffi c accidents during and
Page 211 and 212: Table 14.2 Late deaths known, or no
Page 213 and 214: Table 15.2 Quality of autopsy repor
Page 215 and 216: Haemorrhage Thirteen of the sevente
Page 217 and 218: association with obesity as eight o
Page 219 and 220: Obesity was present in 55% of these
Page 221 and 222: Toxicology showed non-lethal citalo
Page 223 and 224: Box 15.6 Pathology learning points:
Page 225: References 1 Royal College of Patho
Page 229 and 230: effective service for women who may
Page 231 and 232: Professional accountability and com
Page 233 and 234: Box 16.1 Key physical signs that ma
Page 235 and 236: Midwives’ responsibility for vuln
Page 237 and 238: Table 16.1 Poor or non attenders fo
Page 239 and 240: Action checklist for midwifery prac
Page 241 and 242: 17 Issues for General Practitioners
Page 243 and 244: Box 17.1 Summary of the key issues
Page 245 and 246: Box 17.3 Risk factors for venous th
Page 247 and 248: headaches. The indications for emer
Page 249 and 250: Box 17.8 GP learning points: Heartb
Page 251 and 252: medication after delivery and been
Page 253 and 254: Women with mitral stenosis may seem
Page 255 and 256: signifi cance in the pregnancy. It
Page 257 and 258: References 1 RCOG. Thromboprophylax
Page 259 and 260: Introduction For the fi rst time in
Page 261 and 262: measures were of a good or excellen
Page 263 and 264: A woman collapsed at home following
Page 265 and 266: never preclude requesting opinion f
Page 267 and 268: admissions represented 0.9% of all
Page 269 and 270: Modifi ed early warning scoring sys
Page 271 and 272: Box 19.3 Critical care learning poi
Page 273 and 274: her initial collapse she was transf
Page 275 and 276: Chapter 19 Annex A This Annex is av
Page 277 and 278:
Table 20.1 Inclusion criteria used
Page 279 and 280:
Table 20.3 Numbers and rates of sev
Page 281 and 282:
References 1 Baskett TF,.O’Connel
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The Director of the Maternal Death
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Verifi cation of Ascertainment Asce
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Scotland A single panel of assessor
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CEMACH Regional Managers East of En
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Regional Assessors in Pathology Eas
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NORTHERN IRELAND Department of Heal
Page 295 and 296:
267
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