6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

‘Top ten’ recommendationsThe understanding, identification, initial managementand referral for serious commoner medical and mentalhealth conditions which, although unrelated to pregnancy,may affect pregnant women or recently deliveredmothers. These may include the conditions in recommendation1, although the list is not exclusiveThe early recognition and management of severely illpregnant women and impending maternal collapseThe improvement of basic, immediate and advanced lifesupport skills. A number of courses provide additionaltraining for staff caring for pregnant women and newbornbabies.RationaleA lack of clinical knowledge and skills among some doctors,midwives and other health professionals, senior orjunior, was one of the leading causes of potentially avoidablemortality this triennium. One of the commonestfindings in this Report was the initial failure by manyclinical staff, including GPs, Emergency Department staff,midwives and hospital doctors, to immediately recogniseand act on the signs and symptoms of potentially lifethreateningconditions. To help with this, the assessorshave developed a short new section, Back to basics, whichis included in this Report for the first time. Although notexhaustive, nor designed to replace more in-depth clinicaltraining, it does contain useful checklists to act as anaide memoire. Its contents may appear simplistic or selfevidentto many readers, but it nevertheless reflects thefact that these basic signs and symptoms were too oftenoverlooked and may have contributed to some maternaldeaths this triennium.As with the previous Report, even sick women who wereadmitted to specialist care were still failed by a lack of recognitionof the severity of their illness or a failure to referfor another opinion (see also Recommendation 6).There is also a need for staff to recognise theirlimitations and to know when, how and whom to call forassistance.Baseline and auditable standardsThe provision of courses and a system for ensuring all staffattend and complete the training as identified in the ClinicalNegligence Scheme for Trusts (CNST) Training NeedsAnalysis. This is a level 1 requirement for CNST maternityservices in England. The record of attendees should be regularlyaudited to reinforce, familiarise and update all staffwith local procedures, equipment and drugs.• Number and percentage of members of all cardiac arrestteams who know where the maternity unit is and whoknow the door codes for gaining immediate access to it.Target 100%.Recommendation 6: Specialist clinicalcare: identifying and managing verysick women6.1. There remains an urgent need for the routine useof a national modified early obstetric warning score(MEOWS) chart in all pregnant or postpartum womenwho become unwell and require either obstetric orgynaecology services. This will help in the more timelyrecognition, treatment and referral of women who have,or are developing, a critical illness during or after pregnancy.It is equally important that these charts are alsoused for pregnant or postpartum women who areunwell and are being cared for outside obstetric andgynaecology services e.g. Emergency Departments.Abnormal scores should not just be recorded but shouldalso trigger an appropriate response.6.2. The management of pregnant or postpartum womenwho present with an acute severe illness, e.g. sepsis withcirculatory failure, pre-eclampsia/eclampsia with severearterial hypertension and major haemorrhage, requires ateam approach. Trainees in obstetrics and/or gynaecologymust request help early from senior medical staff,including advice and help from anaesthetic and criticalcare services. In very acute situations telephoning anexperienced colleague can be very helpful. The recentRCOG guideline of the duties and responsibilities ofconsultant on call should be followed.6.3 Pregnant or recently delivered women with unexplainedpain severe enough to require opiate analgesiarequire urgent senior assessment/review.RationaleAs mentioned in the Back to basics recommendation, alack of clinical knowledge and skills among some doctors,midwives and other health professionals, senior or junior,was one of the leading causes of potentially avoidablemortality. This was not only the case when distinguishingthe signs and symptoms of potentially serious diseasefrom the commonplace symptoms of pregnancy in primarycare or the Emergency Department but also once awoman was admitted to hospital. There were a numberof healthcare professionals who either failed to identifythat a woman was becoming seriously ill or who failed tomanage emergency situations outside their immediate areaof expertise, and did not call for advice and help.In many cases in this Report, and relevant to the issuesidentified in the preceding paragraph, the early warningsigns of impending maternal collapse went unrecognised.The early detection of severe illness in mothers remains achallenge to all involved in their care. The relative rarityª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 11