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Garrod et al.the second stage and suspected fetal compromise. She collapsedand died of a haemorrhage some hours later. Theonly mention of an interpreter was when the woman wasin extremis and the staff wished to explain events to herhusband.Basic observations and assessmentThere were many examples of failure to make or actupon basic observations. For instance, a woman with severalrisk factors for pre-eclampsia arrived at hospital witha fully dilated cervix and promptly gave birth. She wasgiven Syntometrine and, over the next few hours, wasobserved to have at least four abnormal features symptomaticof pre-eclampsia. These were not acted uponuntil she suffered a cerebral haemorrhage as a result anddied.Appropriate risk assessment must be performed for allwomen and risk status reviewed as necessary. For example:A morbidly obese woman with additional risk factors forhypertension had neither obstetric nor anaesthetic review ineither pregnancy or labour and so had no plan for deliverycare. She was induced at term, having had prelabourrupture of membranes; the syntocinon rate was increased,on the instruction of the senior midwife, when the cardiotocographwas already pathological. An emergency caesareansection was carried out for suspected fetal compromise, andthis was followed by a fatal postpartum haemorrhage.Another woman had a retained placenta following a normaldelivery. There seemed to be no appreciation of thechange in her risk status, which led to failure to performappropriate observations and monitoring. It was severalhours before she was transferred to theatre. She suffered amassive haemorrhage and underwent a hysterectomy butdied.In these, and other cases, there seemed to be norecognition that a further risk assessment needed to bemade in the light of an unforeseen complication andthat delay in responding might exacerbate the woman’scondition.Recognition of risk factors/signs of serious illnessand team workingWomen with risk factors need clear multidisciplinary careplans for labour and birth. On occasion, midwives’ failureto call for senior medical help illustrated that this is associatedwith a lack of recognition of the seriousness of thecondition or with an inadequate response, including pooror no planning. For example:A woman with severe pre-eclampsia was admitted to thelabour ward by an Senior House Officer but was not seenby a registrar for some hours. Treatment eventually commencedbut was inadequate, and by the time a consultantwas involved (several hours after admission), the womanhad sustained an intracerebral haemorrhage. She died thefollowing day.The midwife should have escalated this woman’s referralto the consultant obstetrician.Staffing and SupervisionFor some women, documentation in case notes indicatedthat the unit was very busy. However, it was apparent inalmost every case that escalation policies were not activatedappropriately, including involvement of the Supervisor ofMidwives. 4 There were, however, some examples of exemplarypractice:A woman expecting her first baby was an inpatient at term;she collapsed and required resuscitation, during which anemergency caesarean was undertaken. Despite excellent care,she did not survive.The clinicians involved in this event responded in aprompt, efficient and energetic manner, and excellentteamwork was evident. The standard of the statement writingis such that a clear audit trail can be seen. In particular,there was thorough support from the Supervisor of Midwives,who was present for the emergency and alsoarranged extensive support for the midwives during thedays and weeks following.Postnatal careMidwives should be aware that the postnatal period ispotentially a time of higher risk than pregnancy or labour.As shown in Chapter 1, 63% of the 261 women who diedfrom Direct and Indirect causes did so following the birthof their babies. There is a concern that the growing reductionin the frequency of direct postnatal visits and the driveto replace direct contact with telephone communicationmay be leading to less than optimal care. This is a researchrecommendation in this Report.Getting the basics rightAssessment of the woman’s health and wellbeing willreduce the risk of the midwife focusing on emotional/mentalhealth issues that may be masking signs of physical illness.Having made an overall assessment of wellbeing, themidwife should ensure that basic observations are performedand recorded, acting on abnormal findings. Therewere examples in the report of midwives failing in thesebasic responsibilities, following both normal and operativedeliveries.154 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203