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

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AcknowledgementsSaving Mothers’ Lives: Reviewing maternal deaths to make motherhoodsafer—2006–08The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United KingdomDirector and EditorGwyneth Lewis OBE MSc MRCGP FFPH FRCOG FACOG DScCentral Assessors and AuthorsRoch Cantwell FRCPsychThomas Clutton-Brock FRCP FRCAGriselda Cooper OBE FRCA FRCOGAndrew Dawson MD FRCOGJames Drife MD FRCOG FRCP (Ed) FRCS (Ed) FCOG (SA) FFSRHDebbie Garrod RM, DPSM, BA, MA, PGCEAnn Harper OBE MD FRCOG FRCPI FFSRHDiana Hulbert FRCS FCEMSebastian Lucas FRCP FRCPathJohn McClure FRCAHarry Millward-Sadler FRCPath, MHSMJames Neilson MD FRCOGCatherine Nelson-Piercy FRCP FRCOGJane Norman MD FRCOGColm O’Herlihy MD FRCPI FRCOG FRANZCOGMargaret Oates OBE FRCPsych FRCOGJudy Shakespeare MRCP FRCGPMichael de Swiet MD FRCP FRCOGCatherine Williamson MD FRCPOther authors and contributorsValerie Beale RN RM Dip Man MScMarian Knight MPH DPhil FFPHChristopher Lennox FRCOGAlison Miller RN RM RDMDharmishta Parmar BA HonsJane Rogers BA PhD DPSM SRN RMAnna Springett BSc MSc2 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
ContentsContentsAcknowledgementsForewordTop ten recommendationsBack to Basics Margaret Oates, Ann Harper, Judy Shakespeare and Catherine Nelson-PiercyAims, objectives and definitions used in this report Gwyneth LewisKey Findings for 2006–20081. The women who died 2006–2008 Gwyneth LewisMaternal deaths Directly related to pregnancy2. Thrombosis and thromboembolism James Drife3. Pre-eclampsia and eclampsia James Neilson4. Haemorrhage Jane Norman5. Amniotic fluid embolism Andrew Dawson6. Deaths in early pregnancy Colm O’Herlihy7. Sepsis Ann HarperAnnex 7.1: A possible future approach to case definitions Sebastian Lucas8. Anaesthesia John McClure and Griselda CooperMaternal deaths Indirectly related to pregnancy9. Cardiac disease Catherine Nelson-PiercyAnnex 9.1. Pathological overview of cardiac deaths including sudden adult/arrhythmic death syndrome (SADS) SebastianLucas10. Other Indirect deaths Michael de Swiet, Catherine Williamson and Gwyneth Lewis11. Deaths from psychiatric cause Margaret Oates and Roch CantwellDeaths apparently unrelated to pregnancy12. Deaths apparently unrelated to pregnancy from Coincidental and Late causes including domestic abuse GwynethLewisAnnex 12.1: Domestic abuseKey Issues and lessons for specific health service practice, organisation and/or health professionals13. Midwifery Debbie Garrod, Valerie Beale and Jane Rogers14. General Practice Judy Shakespeare15. Emergency medicine Diane Hulbert16. Critical Care Tom Clutton-Brock17. Pathology overview Sebastian Lucas and Harry Millward Sadler17.1 The main clinico-pathologies encountered at autopsy in maternal death and specific pathological scenarios(Adapted from Royal College of Pathologists: Guidelines on Autopsy Practice. Scenario 5: Maternal Death. May2010.)AppendicesAppendix 1: The method of EnquiryAppendix 2A: Summary of United Kingdom Obstetric Surveillance System (UKOSS) Report on near miss studiesAppendix 2B: Summary of Scottish Confidential Audit of Severe Maternal Morbidity Report 2008Appendix 3: Contributors to the Maternal Death Enquiry for triennium 2006 08 and CMACE personnelAppendix 4: CMACE Governanceª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 3
Page 1: Volume 118, Supplement 1, March 201
Page 6 and 7: AcknowledgementsAcknowledgementsCMA
Page 8 and 9: Forewordbeen written jointly by a m
Page 10 and 11: ‘Top ten’ recommendationsServic
Page 12 and 13: ‘Top ten’ recommendationscommun
Page 14 and 15: ‘Top ten’ recommendationsof suc
Page 16 and 17: ‘Top ten’ recommendationsMarch
Page 18 and 19: Oates et al.Back to basicsM Oates 1
Page 20 and 21: Oates et al.BreathlessnessBreathles
Page 22 and 23: Oates et al.appropriate pathway of
Page 24 and 25: LewisIntroduction: Aims, objectives
Page 26 and 27: LewisAn important limitation of ran
Page 28 and 29: Lewismaternal and public health-pol
Page 30 and 31: Lewisresult in a live birth at any
Page 32 and 33: LewisChapter 1: The women who died
Page 34 and 35: Lewiswho would not have been identi
Page 36 and 37: Lewis1098Rate per 100 000 materniti
Page 38 and 39: LewisTable 1.4. Numbers and rates o
Page 40 and 41: Lewis2.50Rate per 100 000 materniti
Page 42 and 43: LewisTable 1.9. Number of maternal
Page 44 and 45: LewisTable 1.12. Numbers and percen
Page 46 and 47: LewisThere were cases where a major
Page 48 and 49: LewisBox 1.5. Classifications of Bo
Page 50 and 51: LewisTable 1.20. Number and estimat
Page 52 and 53: LewisNew countries of the European
Page 54 and 55:
LewisTable 1.23. Direct and Indirec
Page 56 and 57:
LewisTable 1.26. Characteristics* o
Page 58 and 59:
Lewis4 Lewis G (ed). The Confidenti
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DrifeTable 2.1. Direct deaths from
Page 62 and 63:
Drifewomen who died in 2006-08 had
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Drifedelivery she became breathless
Page 66 and 67:
DrifePathological overviewFourteen
Page 68 and 69:
NeilsonChapter 3: Pre-eclampsia and
Page 70 and 71:
Neilsontrue, and what might be the
Page 72 and 73:
NeilsonConclusionThe number of deat
Page 74 and 75:
NormanBackgroundIn the UK, major ob
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Normanwhich there was catastrophic
Page 78 and 79:
Normanrecommendations made in succe
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DawsonBox 5.1. The UK amniotic flui
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Dawsontry despite an extensive sear
Page 84 and 85:
O’HerlihyTable 6.1. Numbers of Di
Page 86 and 87:
O’Herlihytoxic shock syndrome aft
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HarperGroup A b-haemolytic streptoc
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Harperthe 6-week postnatal period,
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Harpera major intrapartum haemorrha
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HarperBox 7.1. Signs and symptoms o
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Harperwoman was given several litre
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Harper2 Lamagni TL, Efstratiou A, D
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LucasTable A7.1 Proposed new catego
Page 102 and 103:
Lucasthe same infection scenario as
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McClure, CooperChapter 8: Anaesthes
Page 106 and 107:
McClure, Cooperaddress, but protoco
Page 108 and 109:
McClure, CooperPostpartum haemorrha
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McClure, CooperWorkloadA number of
Page 112 and 113:
Nelson-PiercyTable 9.1. Indirect ma
Page 114 and 115:
Nelson-Piercynary arteries. In view
Page 116 and 117:
Nelson-Piercynormal left ventricle
Page 118 and 119:
LucasAnnex 9.1. Pathological overvi
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Lucasdiac death that is non-ischaem
Page 122 and 123:
de Swiet et al.causes but are aggra
Page 124 and 125:
de Swiet et al.died of SUDEP before
Page 126 and 127:
de Swiet et al.for 6 weeks after de
Page 128 and 129:
de Swiet et al.mised. The obstetric
Page 130 and 131:
de Swiet et al.CancerPregnancy does
Page 132 and 133:
de Swiet et al.a thorough autopsy w
Page 134 and 135:
Oates, CantwellChapter 11: Deaths f
Page 136 and 137:
Oates, CantwellTable 11.1. Timing o
Page 138 and 139:
Oates, CantwellTable 11.5. Maternal
Page 140 and 141:
Oates, CantwellChild protection iss
Page 142 and 143:
Oates, CantwellAll women who are su
Page 144 and 145:
Oates, Cantwell4 Kendel RE, Chalmer
Page 146 and 147:
Lewismaternal mortality rates or ra
Page 148 and 149:
Annex 12.1. Domestic abuseAnnex 12.
Page 150 and 151:
Annex 12.1. Domestic abuseshe could
Page 152 and 153:
Garrod et al.supportive but challen
Page 154 and 155:
Garrod et al.• Culture and system
Page 156 and 157:
Garrod et al.the second stage and s
Page 158 and 159:
Garrod et al.through the still heal
Page 160 and 161:
ShakespeareChapter 14: General prac
Page 162 and 163:
Shakespeareemergency caesarean sect
Page 164 and 165:
ShakespeareCardiac diseaseDeaths fr
Page 166 and 167:
Shakespearereduce the risks to the
Page 168 and 169:
ShakespeareManaging a maternal deat
Page 170 and 171:
Hulbertin the ED was of a high qual
Page 172 and 173:
HulbertPre-eclampsia/eclampsia: lea
Page 174 and 175:
HulbertTransfersWhen the obstetric
Page 176 and 177:
Clutton-Brocksimply the case that s
Page 178 and 179:
Clutton-BrockDiagnosis of sepsisTak
Page 180 and 181:
Clutton-Brockpulseless electrical a
Page 182 and 183:
Clutton-BrockImprovement Scotland (
Page 184 and 185:
Lucas, Millward-Sadler95 mmHg. This
Page 186 and 187:
Lucas, Millward-Sadleran agreed mai
Page 188 and 189:
Annex 17.1. The main clinico-tholog
Page 190 and 191:
MillerAppendix 1: The method of Enq
Page 192 and 193:
MillerDatanotificationNotificationR
Page 194 and 195:
Knight• investigating different m
Page 196 and 197:
Knightbaseline incidence against wh
Page 198 and 199:
LennoxAppendix 2B: Summary of Scott
Page 200 and 201:
LennoxEvidence of effective managem
Page 202 and 203:
Appendix 3: Contributors to the Mat
Page 204 and 205:
Appendix 3: Contributors to the Mat
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6.-March-2011-Saving-Mothers-Lives-reviewing-maternal-deaths-to-make-motherhood-safer-2006-2008

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