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

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CEMACH Mission statement Our aim is to improve the health of mothers, babies and children by carrying out confi dential enquiries on a nationwide basis and by widely disseminating our fi ndings and recommendations. Please cite this work as: Lewis, G (ed) 2007. The Confi dential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report on Confi dential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. This work was undertaken by CEMACH. The work was funded by the National Patient Safety Agency Centre, the Scottish Programme for Clinical Effectiveness in Reproductive Heath and by the Department of Health, Social Services and Public Safety of Northern Ireland. The views expressed in this publication are those of the Enquiry and not necessarily those of its funding bodies. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of CEMACH, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk] Enquiries concerning reproduction outside the terms stated here should be sent to CEMACH at the address printed on this page. Making duplicate copies of this Report for legitimate clinical or other non-commercial purposes within the UK National Health Service is permitted provided that CEMACH is identifi ed as the originator of the information. Making alterations to any of the information contained within, or using the information in any other work or publication without prior permission, will be a direct breach of copyright and may result in civil action. The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant laws and regulation and therefore free for general use. Product liability: CEMACH can give no guarantee for information about drug dosage and application thereof contained in this guideline. In every individual case the respective use must check its accuracy by consulting other pharmaceutical literature. Published December 2007 CEMACH, Chiltern Court, 188 Baker Street, London, NW1 5SD Tel: 0207 486 1191 Fax: 0207 486 6543 Email: info@cemach.org.uk Website: www.cemach.org.uk Designed and produced by Interface. Bristol Tel 0117 923 2235. ISBN: 978-0-9533536-8-2
Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer – 2003-2005 The Seventh Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom Director and Editor Gwyneth Lewis MSc MRCGP FFPH FRCOG Central Assessors and Authors Thomas Clutton-Brock MRCP FRCA Griselda Cooper OBE FRCA FRCOG James Drife MD FRCOG FRCPEd FRCSEd FCOG(SA) Grace Edwards RN RM ADM Cert Ed Med PhD Ann Harper OBE MD FRCPI FRCOG Diana Hulbert FRCS FFAEM William Liston FRCOG Alison Macfarlane BA Dip Stat C Stat FFPH James Neilson MD FRCOG Catherine Nelson-Piercy FRCP FRCOG John McClure FRCA Margaret Oates DPM FRCPsych Gillian Penney MD FRCOG MFFP Judy Shakespeare MRCP FRCGP Michael de Swiet MD FRCP FRCOG Harry Millward- Sadler FRCPath MHSH Robin Vlies FRCSEd FRCOG Other authors and contributors Naufi l Alam BSc (Hons) MSc Valerie Beale RN RM Dip Man MSc David Bogod FRCA LLM Victoria Brace MRCOG Nirupa Dattani BSc MPhil Dawn Kernaghan MRCOG Alison Miller RN RM RDM Jo Modder MRCOG Judy Myles BAO FRCPsych Jane Rogers BA PhD DPSM SRN RM Kate Sallah MBE RN RM ADM MPH iii
Page 1: Confidential Enquiry into Maternal
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
Page 73 and 74:
exception. The health service has a
Page 75 and 76:
17 Shah A, Sands J, Kenny L. Matern
Page 77 and 78:
Country of birth and migration A fa
Page 79 and 80:
Table A1.4 Direct and Indirect deat
Page 81 and 82:
Body mass index varies with age, be
Page 83 and 84:
2 Thrombosis and thromboembolism Ja
Page 85 and 86:
Pulmonary embolism Of the 33 women
Page 87 and 88:
Family history In two deaths there
Page 89 and 90:
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
Page 115 and 116:
Table 5.1 Direct deaths attributed
Page 117 and 118:
of over ten litres. Despite a hyste
Page 119 and 120:
References 1 Clark SL, Pavlova Z, G
Page 121 and 122:
The women who died The ages of the
Page 123 and 124:
A woman who had not been long in th
Page 125 and 126:
7 Genital tract sepsis Ann Harper G
Page 127 and 128:
Sepsis in early pregnancy Six women
Page 129 and 130:
Box 7.3 Learning points: Sepsis in
Page 131 and 132:
Risk factors for, and the identifi
Page 133 and 134:
Box 7.7 Features of septicaemic sho
Page 135 and 136:
8 Anaesthesia Griselda Cooper and J
Page 137 and 138:
The third case also highlights the
Page 139 and 140:
A woman suffered a concealed haemor
Page 141 and 142:
Sepsis Poor anaesthetic or resuscit
Page 143 and 144:
What did you learn from this case a
Page 145 and 146:
9 Cardiac disease Catherine Nelson-
Page 147 and 148:
Table 9.2 Causes of maternal death
Page 149 and 150:
an estimated incidence of 1.1 per 1
Page 151 and 152:
Quality of care Care was considered
Page 153 and 154:
y a doctor, with a systolic blood p
Page 155 and 156:
Box 9.3 Learning points: peripartum
Page 157 and 158:
Infectious endocarditis Two women d
Page 159 and 160:
10 Other Indirect deaths Michael de
Page 161 and 162:
Table 10.1 Causes of Other Indirect
Page 163 and 164:
Fifty-eight of the eighty-seven wom
Page 165 and 166:
Previous Reports have emphasised th
Page 167 and 168:
Aspergillosis usually occurs in imm
Page 169 and 170:
Liver disease There were four mater
Page 171 and 172:
Diseases of the circulatory system
Page 173 and 174:
11 Cancer and other tumours Gwyneth
Page 175 and 176:
her delivery, but her case should h
Page 177 and 178:
Severe abdominal and back pain, sci
Page 179 and 180:
References 1 Drife, J O. The contri
Page 181 and 182:
Psychiatric deaths: Specifi c recom
Page 183 and 184:
cut off point for maternal deaths,
Page 185 and 186:
Report, 26 deaths from suicide were
Page 187 and 188:
Current psychiatric treatment In th
Page 189 and 190:
12 Deaths from psychiatric causes S
Page 191 and 192:
caring for the woman. Nonetheless,
Page 193 and 194:
Commentary on deaths related to dru
Page 195 and 196:
It is known that women presenting w
Page 197 and 198:
antibiotics nor returned to her gen
Page 199 and 200:
It is still evident that there is a
Page 201 and 202:
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 and 256:
signifi cance in the pregnancy. It
Page 257 and 258:
References 1 RCOG. Thromboprophylax
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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