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

Recommendations

Info

Normanrecommendations made in successive Reports that seniorstaff should be involved in these deliveries.Amongst the deaths, the lack of early senior multidisciplinaryinvolvement, the lack of close postoperative monitoringand the failure to act on signs and symptoms that awoman is seriously unwell, including readings fromMEOWS charts, remain important contributors to maternaldeath from haemorrhage. All clinicians involved in the careof pregnant women could further reduce the risk of haemorrhage-relatedmaternal death by improvements in theseelementary aspects of clinical care.Disclosure of interestsNone.FundingThis work was undertaken by the Centre for Maternal andChild Enquiries (CMACE) as part of the CEMACH programme.The work was funded by the National PatientSafety Agency; the Department of Health, Social Servicesand Public Safety of Northern Ireland; NHS QualityImprovement Scotland (NHS QIS); and the ChannelIslands and Isle of Man.AcknowledgementsThe chapter has been seen by and commented on byDr Brian Magowan, Consultant Obstetrician of BordersGeneral Hospital and Dr Rhona Hughes, ConsultantObstetrician for Royal Infirmary of Edinburgh.References1 Brace V. Learning from adverse outcomes—major haemorrhage inScotland in 2003–05. BJOG 2007;114:1388–96.2 Knight M, Callaghan WM, Berg C, Alexander S, Bouvier-Colle M-H,Ford JB, et al. Trends in postpartum hemorrhage in high resourcecountries: a review and recommendations from the InternationalPostpartum Hemorrhage Collaborative Group. BMC Pregnancy Childbirth2009;9:55.3 Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHOanalysis of causes of maternal death: a systematic review. Lancet2006;367:1066–74.4 Knight M, Kurinczuk JJ, Spark P, Brocklehurst P. Cesarean deliveryand peripartum hysterectomy. Obstet Gynecol 2008;111:97–105.5 Knight M. Peripartum hysterectomy in the UK: managementand outcomes of the associated haemorrhage. BJOG 2007;114:1380–7.6 Scottish Confidential Audit of Severe Maternal Morbidity. AnnualReport 2008. NHS Quality Improvement Scotland, 2010.[www.nhshealthquality.org/maternityservices]. Accessed 6 September2010.7 Lewis G (editor). The Confidential Enquiry into Maternal and ChildHealth (CEMACH). Saving Mothers Lives; reviewing maternal deathsto make motherhood safer 2003–05. The Seventh Report of the UnitedKingdom Confidential Enquiries into Maternal Deaths in the UnitedKingdom. London: CEMACH, 2007. [www.cmace.org.uk].Accessed 6 September 2010.8 National Patient Safety Agency and Royal College of Obstetriciansand Gynaecologists. Placenta praevia after caesarean section carebundle: background information for health professionals. London:NPSA, 2010.9 Royal College of Obstetricians and Gynaecologists. Placenta praeviaand placenta praevia accreta: diagnosis and management. ClinicalGuideline no 27. London: RCOG Press, 2005.10 Wing DA, Paul RH, Millar LK. Management of the symptomatic placentapraevia: a randomised, controlled trial of inpatient versus outpatientexpectant management. Am J Obstet Gynecol 1996;175:806–11.11 National Collaborating Centre for Women’s and Children’s Healthcommissioned by the National Institute for Clinical Excellence. Inductionof labour. Clinical Guideline. 2008. London: RCOG Press, 2008.12 Triulzi DJ. Transfusion-related acute lung injury: current concepts forthe clinician. Anesth Analg 2009;108:770–6.13 Royal College of Obstetricians and Gynaecologists. Prevention ofpostpartum haemorrhage. Clinical Guideline no 52. London: RCOGPress, 2009.14 Van Wolfswinkel ME, Zwart J, Schutte J, Duvekot J, Pel M, VanRoosmalen J. Maternal mortality and serious maternal morbidity inJehovah’s witnesses in The Netherlands. BJOG 2009;116:1103–8;discussion 1108–10.15 Royal College of Obstetricians and Gynaecologists. Blood transfusionin obstetrics. Clinical guideline No. 47. London: RCOG Press, 2008.16 Ng T et al. Recombinant erythropoietin in clinical practice. PostgraduateMedical Journal 2003;79:367–70.76 ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203
Chapter 5: Amniotic fluid embolismChapter 5: Amniotic fluid embolismAJ Dawson (on behalf of the Centre for Maternal and Child Enquiries)Consultant Obstetrician, Nevill Hall Hospital, Abergavenny, UKCorrespondence: Amendment after online publication (11 March 2011): the correct address for this author is Nevill Hall Hospital, AbergavennyNP7 7EG, UK. Email: andrewdawson.work@btinternet.comKeywords amniotic fluid embolism, Confidential Enquiry, maternal,mortality.Amniotic fluid embolism: specific recommendations• All maternal death autopsies should be performed as soon after death as possible, and not delayed by several days,because the diagnosis of AFE then becomes difficult if not impossible.At autopsy:• confirm the diagnosis using immunochemistry• in clinically classical cases where no squames can be found, search for mucins.Amniotic fluid embolism: learningpointsAmniotic fluid embolism (AFE) should no longer beregarded as a condition with near universal maternalmortality. High-quality supportive care can result ingood outcomes for both mother and baby dependingon the place of collapse.There were several examples of excellent practice thistriennium, including prompt peri-mortem caesareansection.AFE may be confused with other presentations, includingeclampsia, septic or anaphylactic shock and pulmonaryembolism, but ultimately the immediate actiontaken should be resuscitative and the initial treatment isunlikely to differ.Summary of key findings for 2006–08In this triennium, the deaths of 13 mothers who died ofAFE were reported to the Enquiry, giving a mortality rateof 0.57 per 100 000 maternities (95% CI 0.33–0.98).Although AFE continues to rank as a major cause of Directmaternal deaths, it has fallen from being the second to thefourth leading cause of Direct deaths this triennium.As shown in Table 5.1, the numbers and mortality rate forthis triennium are less than the 17 deaths and mortality rateof 0.80 per 100 000 maternities (95% CI 0.50–1.29) attributedto AFE for the period 2003–05. This decline is not statisticallysignificant. Neither does it appear that there is anupwards trend, which is consistent with the findings of thelatest morbidity study from the United Kingdom ObstetricSurveillance System (UKOSS) (A detailed description of UKObstetric Surveillance System (UKOSS) can be found in theIntroduction Chapter of this Report.) discussed below.Maternal morbidity: the incidence of amnioticfluid embolismProspective national surveillance of AFE has been undertakenthrough UKOSS since 2005. A recent analysis of casesreported over 4 years between February 2005 and February2009 documented an incidence of 2.0 cases per 100 000Table 5.1. Direct deaths attributed to amniotic fluid embolism andrates per 100 000 maternities; UK: 1985–2008Triennium n Rate 95% CI1985–87 9 0.40 0.21–0.751987–90 11 0.47 0.26–0.831991–93 10 0.43 0.23–0.801994–96 17 0.77 0.48–1.241997–99 8 0.38 0.19–0.742000–02 5 0.25 0.11–0.592003–05 17 0.80 0.50–1.292006–08 13 0.57 0.33–0.98ª 2011 Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1), 1–203 77
Page 1:
Volume 118, Supplement 1, March 201
Page 4 and 5:
AcknowledgementsSaving Mothers’ L
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
Page 60 and 61: DrifeTable 2.1. Direct deaths from
Page 62 and 63: Drifewomen who died in 2006-08 had
Page 64 and 65: 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
Page 76 and 77: Normanwhich there was catastrophic
Page 80 and 81: DawsonBox 5.1. The UK amniotic flui
Page 82 and 83: 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
Page 88 and 89: HarperGroup A b-haemolytic streptoc
Page 90 and 91: Harperthe 6-week postnatal period,
Page 92 and 93: Harpera major intrapartum haemorrha
Page 94 and 95: HarperBox 7.1. Signs and symptoms o
Page 96 and 97: Harperwoman was given several litre
Page 98 and 99: Harper2 Lamagni TL, Efstratiou A, D
Page 100 and 101: LucasTable A7.1 Proposed new catego
Page 102 and 103: Lucasthe same infection scenario as
Page 104 and 105: McClure, CooperChapter 8: Anaesthes
Page 106 and 107: McClure, Cooperaddress, but protoco
Page 108 and 109: McClure, CooperPostpartum haemorrha
Page 110 and 111: 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
Page 120 and 121: 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
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?