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

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18 Emergency Medicine
Pregnant women referred directly to the gynaecology or obstetrics team will generally be seen in a
gynaecology admissions unit, an Early Pregnancy Unit, the triage area on the labour ward or on a
general ward. This will depend on the round-the-clock availability of such facilities as well as the woman’s
gestation, presenting problem and apparent severity of the illness. Some women may be seen by the
specialist teams within the confi nes of the ED but not by emergency medicine clinicians themselves. This
was the case for a small number of the women whose cases were reviewed for this Report.
Summary of key fi ndings for 2003-05
Of the women whose cases were assessed in relation to ED practice, the main diagnoses were:
• pulmonary embolism
• ectopic pregnancy
• intracerebral bleed
• sepsis
• road traffi c accidents.
Fifty-two women who died from Direct, Indirect or Coincidental causes died in the ED. The majority of
these women had either collapsed in the community and were already undergoing cardio-pulmonary
resuscitation (CPR) on arrival or collapsed shortly afterwards.
Emergency care before arrival at the ED
The emergency services’ response to a 999 call about a sick pregnant woman will usually consist
of an ambulance staffed by a paramedic and an ambulance technician. Untrained personnel are not
permitted to work in ambulances; the minimum training for an ambulance technician is equivalent to that
of a nursing auxiliary. Additionally, in some areas, there may be a rapid response vehicle which allows
early interventions to be carried out if this vehicle arrives fi rst. These are staffed by paramedics usually
in a car. In addition there are emergency care practitioners (usually with an ED nursing background)
whose role is to manage the patient at home according to protocols. Regardless of type of vehicle, most
paramedic crews act within very specifi c guidelines in terms of their resuscitation algorithms. Nevertheless,
unanticipated problems can still occur:
A woman being transported to the hospital with severe abdominal pain was given nalbuphine en
route for pain relief. This is an opioid which has become less commonly used with the advent
of morphine into paramedic protocols. She had a profound anaphylactic reaction resulting in
cardiorespiratory arrest and eventual death.
In some areas a doctor will attend the patient in the community at the request of the paramedics. These
doctors have undergone pre-hospital training (i.e. they are trained to manage sick patients outside a
hospital environment) and most are GPs, ED doctors or anaesthetists. They provide a different set of skills
for the patient out of hospital and a proportion of these patients are pregnant or peripartum women.
Women in extremis on admission
Fifty-two (18%) of women who died from Direct or Indirect maternal causes this triennium died in the ED,
most of whom were brought in already undergoing cardio-pulmonary resuscitation (CPR). Several others
were initially resuscitated and then moved to critical care. Overall, the level of care and the resuscitation