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

Introduction
For the fi rst time in the more than 50-year history of these Reports a summary chapter has been written
specifi cally for Emergency Department (ED) practitioners. It is also the fi rst time that a consultant in
emergency medicine has reviewed the relevant maternal deaths to distil lessons and recommendations of
particular relevance to staff working in emergency medicine services. Issues concerning the care provided
for pregnant women in the ED have been highlighted in earlier Reports and this chapter endorses and
strengthens these previous recommendations.
The aim of this new chapter is to draw attention to key messages in the Report of relevance to the
emergency services and to highlight issues relating to pregnant or recently delivered women that
particularly affect ED clinicians and other staff working in emergency medicine. It cannot provide an
exhaustive overview of all the Report’s fi ndings but ED staff should be aware of the key recommendations
and overarching risk factors highlighted in Chapter 1 as well as acting on the fi ndings in this chapter.
Emergency services
Emergency services in the UK are provided in the community by general practice and the ambulance
services, in minor injuries units and in Emergency Departments (EDs). Minor injuries units are usually
staffed by nurse practitioners working autonomously but some are also managed by local GPs or
secondary care doctors. Some of these units are overseen by consultants in emergency medicine, but
usually in a managerial rather than a clinical role. There are clear criteria and guidelines for the referral
from minor injuries units to the local ED for any patient whose condition causes concern. Some have
specifi c guidelines for pregnant women, but this is not universal.
In the ED various methods and levels of assessment are available for all patients depending on the
severity of their presenting complaint. A patient can be seen entirely within the ED and discharged home,
admitted to a short stay ward (also called a clinical decision unit or observation ward) for a period of
observation and to await the outcome of specifi c tests or referred to an inpatient specialty team, usually for
admission. In most EDs, pregnant women who need admission will be referred to a gynaecology ward up
to a specifi ed number of weeks of gestation and to the labour ward thereafter.
Occasionally a woman may be referred directly by her GP or midwife to an on-call team, usually the
obstetric team but sometimes, as happened in one of the cases in this Report, to the on-call medical team.
Most women who have been directly referred will not be seen in the ED but will be taken straight to the
designated medical admissions centre to be seen by the on-call physicians. This centre may be called the
Acute Medical Unit, the Emergency Medical Unit, the Acute Admissions Unit or the Medical Admissions
Unit. For example:
A new, older, mother was admitted to an acute admissions unit by her GP with breathlessness,
pyrexia and hypotension two or three weeks after a normal delivery. A differential diagnosis
of pneumonia or pulmonary embolism was made but a very few hours after admission she
was transferred to a gynaecology ward where she later arrested and died. Autopsy showed a
pulmonary embolism.
This mother was clearly very unwell and should have been managed in a high dependency area. It is
possible that being pregnant or postpartum can cloud the issues for clinicians but it is important that a
patient is treated in an environment appropriate to their medical status.
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