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

238
19 Critical Care
Tom Clutton-Brock
Critical Care: Specifi c recommendations
The early detection of severe illness in mothers remains a challenge to all involved in their care.
The relative rarity of such events combined with the normal changes in physiology associated with
pregnancy and childbirth compounds the problem. There is a need to introduce education, training and
other processes which will improve detection rates.
Modifi ed early warning scoring systems have been successfully introduced in other areas of clinical
practice and systems appropriately modifi ed for the obstetric patient have been described. These
should be introduced for all acute obstetric admissions including early pregnancy.
Changes in medical training and work patterns have reduced the exposure of junior medical staff to life
threatening illness. This should be addressed by the introduction of simulation training, preferably as
part of a nationally accredited scheme.
The management of obstetric emergencies such as massive haemorrhage is necessarily team based.
Maternity teams should be expected to demonstrate their competency in scenario based training and
protocols for the management of obstetric emergencies should be subjected to regular review.
In the future, all staff, including temporary staff, involved in the care of seriously sick women should
have undertaken appropriate competency-based training and have a record of success.
Introduction
A chapter on Intensive Care is now a well established feature of this Report and for this triennium
the name has been changed to Critical Care in order to bring it into line with internationally accepted
defi nitions. A common criticism levelled at this type of publication is that similar messages are
repeated from one report to another and Critical Care will be no exception. The very fact that similar
conclusions appear is in itself a salutary message; we are of course dealing with rare events and
will never achieve a rate of zero. Every death remains a tragedy and any lessons that can be learnt
deserve repetition and reinforcement.
A further criticism is that denominator data are missing for many of the causes of death investigated.
Until recently the largest Critical Care obstetric dataset from the UK was that reported by Hazelgrove
et al 1 , who collected data on admissions to 14 general Critical Care Units in the South West Thames
region. They identifi ed 1.8% of all admissions (210 out of 11,385 cases) to be related to pregnancy.
More recently, in 2005, the Intensive Care National Audit and Research Centre (ICNARC) published a
study looking at the case mix, outcome and activity for obstetric admissions to adult, general Critical
Care Units 2 .
Of 219,468 admissions in the ICNARC Case Mix Programme Database (CMPD), 1452 (0.7%)
were identifi ed as Direct obstetric admissions. A further 278 admissions were identifi ed as Indirect
or Coincidental obstetric admissions by the presence of an obstetric code in the ‘Other conditions
relevant to the admission’ or a partially completed obstetric code in any fi eld. Additionally, 175
admissions matched one or more of the terms used in the text fi eld search. Of these, 164 clearly
met the condition of ‘being pregnant or having recently been pregnant’ and the remaining 11 were
excluded. This left a total of 450 Indirect or Coincidental obstetric admissions (0.2% of all CMPD
admissions). The comparison group of all non-obstetric female admissions aged 16–50 years
consisted of 22,938 admissions (10.5% of all CMPD admissions). In total, the 1902 obstetric