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

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228 17 Issues for General Practitioners A young pregnant woman who could not speak English was seen just before a Bank Holiday with bronchopneumonia and treated with antibiotics. Her GP thought he had “safety netted” by telling her husband to take her to the ED over the weekend if her condition worsened. The husband did not contact the OOH service and she was not seen again until four days later when she was seriously ill and admitted to hospital. She died shortly afterwards of fulminating pulmonary TB. In this case the GP care was substandard; her usual GP, who saw her before a Bank Holiday failed to recognise how ill she was. He should have admitted her to hospital directly if early reassessment was impossible or communicated his worries about the patient directly to the OOH services. It is inappropriate to expect sick patients or their relatives to do this. Box 17.11 GP learning points: out of hours (OOH) care OOH services and usual GPs need to be able to communicate with each other rapidly and effectively, preferably electronically or by fax. OOH services and usual GPs need to maintain records of all contacts with patients both within and between each service. Conclusions It is ironic that this Chapter, the fi rst to be written specifi cally for GPs, comes at a time when GPs are no longer the main providers of antenatal care for women with low risk pregnancies. Nevertheless the contributions that they can make are still very signifi cant: GPs are “experts” in managing uncertainty, the early presentation of illness and in managing and minimising risk. There is a risk that changes in midwifery care will lead to GPs becoming de-skilled, although they will still be the fi rst to be involved if the family or midwife suspect something may be wrong. This role needs to be recognised and encouraged. They need to maintain their skills and professional development to be able to provide excellent care for all pregnant or recently delivered women, including those at higher risk or in emergency situations. Even if they are no longer the lead carer, GPs still have a duty of care for pregnant women and should be interested in their health and well-being as they will be caring for these women, and their families, for many years to come. GPs should therefore not only make sure that the midwives or specialists caring for their pregnant women are as fully informed as possible of any past or current medical, psychological or social problems, but should also give them access to her complete case notes on request. It is hoped that the learning points and recommendations in this Chapter will help to maintain and improve the care that GPs can provide.
References 1 RCOG. Thromboprophylaxis during pregnancy, labour and after vaginal delivery. Guideline No 37. London: RCOG; 2004. www.rcog.org.uk/resources/Public/pdf/Thromboprophylaxis_no037.pdf 2 APEC. Pre-eclampsia community guideline (PRECOG guideline); London: APEC; 2004. www.apec.org.uk/pdf/guidelinepublishedvers04.pdf 3 Lewis G (ed). Why Mothers Die. The Sixth Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom, 2000-02. The Confi dential Enquires into Maternal and Child Health. London: RCOG press; 2004. 4 Lewis G (ed). Why Mothers Die. The Fifth Report of the Confi dential Enquires into Maternal Deaths in the United Kingdom, 1997-99. The National Institute of Clinical Excellence. London: RCOG Press; 2001. 5 Steer PJ, Gatzoulis MA, Baker P (eds). Heart Disease and Pregnancy. London: RCOG Press; 2006. 6 NICE. Antenatal and postnatal mental health. Clinical management and service guidance. National Institute for Clinical Excellence. Clinical Guideline 45. London: NICE; 2007. http://guidance.nice.org.uk/CG45/niceguidance/pdf/English 7 Department of Health, Welsh Offi ce, Scottish Home and Health Department, Department of Health and Social Services, Northern Ireland. Report on the Confi dential Enquires into Maternal Deaths in the United Kingdom, 1991-93. London: HMSO; 1996. 8 Tan J, de Swiet M. Prevalence of heart disease diagnosed de novo in pregnancy in a West London population. Br J Obstet Gynaecol. 1998; 105: 1185-8. 9 Car J, and Sheikh A. Information in practice: Telephone consultations. BMJ, 2003, 326: 966-969. 10 McKinstry B and Sheihk A. Unresolved questions in telephone consultations. J R Soc Med 2006: 99; 2-3. 11 BMA. Consulting in the modern world. London: BMA; 2001. www.bma.org.uk 12 Car et al. Improving quality and safety of telephone based delivery of care: teaching telephone consultation skills. Qual Saf Health Care 2004; 13: 2-3. 13 Department of Health. Standard 11. National Service Framework for Children, Young People and Maternity Services: London: Department of Health; 2004. 14 Shribman S. Making it better for mother and baby. The clinical case for change. London: Department of Health; 2007. 15 National Institute for Clinical Excellence. Antenatal care: Routine care for the healthy pregnant woman. London: National Institute for Clinical Excellence; 2003. www.nice.org.uk 229
Page 1 and 2:
Confidential Enquiry into Maternal
Page 3 and 4:
Saving Mothers’ Lives: Reviewing
Page 5 and 6:
Contents Maternal deaths Indirectly
Page 7 and 8:
Foreword Having a baby is a joyous
Page 9 and 10:
The ‘top ten’ key recommendatio
Page 11 and 12:
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
Page 19 and 20:
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
Page 27 and 28:
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
Page 33 and 34:
Figure 1.1: Overall maternal mortal
Page 35 and 36:
Coincidental deaths The deaths of 5
Page 37 and 38:
Leading causes of maternal deaths:
Page 39 and 40:
Table 1.5 Maternal deaths by gestat
Page 41 and 42:
Table 1.7 Number of maternal deaths
Page 43 and 44:
of note is that every women who die
Page 45 and 46:
Table 1.11 Numbers and percentage o
Page 47 and 48:
These messages are repeated in many
Page 49 and 50:
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
Page 59 and 60:
Table 1.19 Direct and Indirect mate
Page 61 and 62:
double the number of cases in the l
Page 63 and 64:
was ill and he should take her to a
Page 65 and 66:
Table 1.22 Characteristics of the a
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Most staff reported learning clinic
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exception. The health service has a
Page 75 and 76:
17 Shah A, Sands J, Kenny L. Matern
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Country of birth and migration A fa
Page 79 and 80:
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
Page 91 and 92:
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
Page 131 and 132:
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
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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
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Aspergillosis usually occurs in imm
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Liver disease There were four mater
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Diseases of the circulatory system
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11 Cancer and other tumours Gwyneth
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her delivery, but her case should h
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Severe abdominal and back pain, sci
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References 1 Drife, J O. The contri
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Psychiatric deaths: Specifi c recom
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cut off point for maternal deaths,
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Report, 26 deaths from suicide were
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Current psychiatric treatment In th
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12 Deaths from psychiatric causes S
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caring for the woman. Nonetheless,
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Commentary on deaths related to dru
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It is known that women presenting w
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antibiotics nor returned to her gen
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It is still evident that there is a
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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 and 226: References 1 Royal College of Patho
Page 227 and 228: 16 Issues for midwives Grace Edward
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: signifi cance in the pregnancy. It
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
Page 283 and 284: The Director of the Maternal Death
Page 285 and 286: Verifi cation of Ascertainment Asce
Page 287 and 288: Scotland A single panel of assessor
Page 289 and 290: CEMACH Regional Managers East of En
Page 291 and 292: Regional Assessors in Pathology Eas
Page 293 and 294: NORTHERN IRELAND Department of Heal
Page 295 and 296: 267
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Saving Mothers' Lives: - Public Health Agency for Northern Ireland

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