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

measures were of a good or excellent standard with adherence to protocols. Even when the outcome is
poor there can be a sense of satisfaction that these well researched guidelines are followed effectively.
Perimortem caesarean section
Thirteen of the women who died in the ED were delivered by perimortem caesarean section. A number of
other women had a perimortem section in the ED but survived long enough to be transferred to Critical
Care. Two of the women who had the operation performed in the ED, and who died there were only 20-22
weeks pregnant and only six women were more than 34 weeks of gestation. The median gestational age
was 30 weeks. The only baby who survived was born to a mother at term who suffered a cardiac arrest
after admission and for whom the operation could be performed within the recommended fi ve minutes of
collapse1 . None of the babies of the women who were admitted already undergoing active CPR survived.
The total number of perimortem caesarean sections performed for all mothers this triennium, 52, has
almost doubled since the last Report, where only 27 cases were assessed. In this Report twenty babies
survived, including one set of twins, but their chances of survival were greatly improved with advanced
gestational age. These fi ndings indicate that with improved resuscitation techniques more babies are
surviving perimortem caesarean sections particularly where the women collapsed in an already well-staffed
and equipped delivery room or operating theatre. However they also highlight the very poor outcome for
babies delivered in Emergency Departments, especially on women who arrive after having undergone CPR
for a considerable length of time.
These fi ndings underscore the guidelines from the Managing Obstetric Emergencies and Trauma course
(MOET) 1 which make it clear that perimortem caesarean section should only be carried out when the
mothers cardiac arrest has been witnessed within the previous fi ve minutes. The outcome of any other
circumstance is universally poor. In addition the baby must be delivered within fi ve minutes to facilitate
resuscitation.
The care the mothers received
A large number of women who died in 2003–2005 came into contact with emergency services including
paramedics and on-call physicians in addition to those working in the ED. In the cases in which ED
treatment has been implicated in the death, there are three clear themes for lessons to be learned:
• clinical practice
• education and training, and
• service provision.
Clinical practice
Recognition of the sick woman
One of the core skills of being a clinician is the recognition of a patient who is unwell. This is not the
same as making a diagnosis. In fact the two skills are often independent of each other. Recognition of the
seriously ill woman relies on taking a complete history (listening to the cues given by her or her relatives),
measurement and understanding of vital signs such as heart rate, respiratory rate and pulse oximetry.
It is not dependent on complex and time-consuming tests. Recognition of illness needs to be taught to
clinicians of all grades on a regular basis. It is also important to make this teaching multi-disciplinary.
233