Universal lessons for care
Sara Kenyon
MBRRACE-UK Collaborator
Background
• Maternal deaths have decreased, but
there are still lessons we can learn
• Two thirds of women die from medical and
mental health problems and one third from
direct complications of pregnancy
• Three quarters of the women who died
had medical or mental health problems
before they become pregnant
Universal lessons
This highlights the importance of
• history taking at booking and
• recognition and referral when necessary
Access to antenatal care
Almost 11% of women did not receive any antenatal care,
however, five of the 35 women died in early pregnancy (≤10
weeks)
Only 29% of women who had antenatal care received the
recommended level of care according to NICE antenatal care
guidelines (booking at 10 weeks or less and no routine antenatal
visits missed)
Almost two thirds received a minimum level of antenatal care
(booking at less than 13 weeks and three or fewer antenatal visits
missed); 25% did not receive even this minimum level of care
We must continue our efforts to engage women
High risk groups
• Maternal mortality rates were higher amongst
older women, women living in the most deprived
areas and women from some ethnic minority
groups (Asia and Africa)
• Women born outside the UK were significantly
more likely to die than those born in the UK
We must continue our efforts to engage
these high risk women
Co-existing medical complications
• Nearly three quarters of women who died had a coexisting medical complication
• There has been no significant change in the rate of
indirect maternal death of the last ten years, when the
rate of deaths from direct causes has halved
• The rate of indirect maternal deaths (6.87 per 100,000
maternities) is now twice that of direct deaths (3.25 per
100,000 maternities)
Actions are urgently needed to address deaths from
indirect causes
Universal lessons
Women with medical disorders in pregnancy should have
access to a coordinated multidisciplinary obstetric and
medical clinic, thereby avoiding the need to attend multiple
appointments and poor communication between senior
specialists responsible for their care, including in the preconceptual period
Pregnant women with medical conditions require an
individualised care plan made together by members of the
multidisciplinary team including a midwife, obstetrician,
obstetric anaesthetist, obstetric or specialty physician,
surgeon and psychiatrist or members of the allied health
professions as appropriate
Universal lessons
• There is a need to ensure physicians are
appropriately trained
• If your obstetric service currently does not
offer joint care for women with identified
needs with specialist physicians then you
need to carefully consider either
– Referring women to an existing service
– Starting a service of your own
Importance of observations
• Do not presume normality; confirm it with a
full set of clinical observations
– Temperature, pulse, respirations and blood
pressure
• Record on a MEWS (or similar) chart
• If abnormal refer to a more senior
colleague
Think Sepsis
Signs and symptoms to watch out for
• High temperature (over 38.30C)
• Chills and shivering
• Tachycardia
• Breathlessness
• Headache
• Severe abdominal pain
• Extreme sleepiness
Vignette: sepsis
Two hours after delivery a woman became unwell on the
postnatal ward feeling faint. Her oxygen saturation was
65%. She was reviewed by junior staff and found to be
shocked, with moderate PV bleeding. Her temperature
was never measured. A diagnosis of haemorrhage was
made and she was treated with fluids. She failed to
improve and was taken to theatre where she had a cardiac
arrest. A laparotomy and hysterectomy were carried out but
resuscitation failed. The postmortem found an extensive
blistering skin rash, swollen labia and disseminated
intravascular coagulation all as a result of overwhelming
Group A Streptococcal sepsis.
Vignette; sepsis
A woman who was seven days post spontaneous vaginal
delivery became unwell at home with a fever. She was advised
to attend the maternity unit immediately. On admission she
was noted to be tachycardic, breathless and febrile. She
was prioritised for urgent medical review. A diagnosis of
acute sepsis from retained products was made and fluid
resuscitation started immediately. Intravenous antibiotics were
started within one hour of the diagnosis and she was transferred
to the high dependency unit. The retained products of
conception were removed promptly and she made a full
recovery. Blood culture subsequently grew Klebsiella. Early
recognition, clear advice and prompt treatment led to a good
outcome without any further complications.
Vignette; haemorrhage
A woman had labour induced on the antenatal ward where she
received uterotonic agents. She did not have observations done on
arrival and subsequent observations were extremely limited,
inadequate and infrequent (at best at 9 hourly intervals). This
failure to record observations continued even when the woman’s
condition was deteriorating and the woman was becoming increasingly
distressed. A further uterotonic was administered without any recorded
observations or examination.
Staff handover was mentioned as a reason for the delay in attending to
the woman who was becoming increasingly unwell. Her condition
continued to deteriorate until she collapsed and had a cardiac arrest.
She had a perimortem caesarean section on the antenatal ward where
a large haemoperitoneum was discovered secondary to a uterine
rupture. She had not had a previous caesarean section.
Referral is important
Physiological observations including the
respiratory rate recorded within a trigger
system such as the MEOWS chart should
be used to monitor all antenatal and
postnatal admissions. However, it is the
response to the abnormal score that will
affect outcome, not simply its
documentation
Vignette: referral
A woman had an elective caesarean section
with cumulative blood loss of 2000mls. She
had a rising respiratory rate, a tachycardia
and a falling blood pressure. There was no
escalation of care despite very worrying
and deteriorating observations. She was
eventually found to have had a serious
concealed haemorrhage and died
Influenza
• 1 in 11 of all women died from flu and more than
half of these could have been prevented with a
flu jab
• Vaccination rates are generally around 25% if
the only indication is pregnancy (Public Health
England)
• In the majority of women (94%) who presented
with respiratory illness, influenza was not
considered, even in the height in the H1N1
pandemic
Vignette: influenza
A pregnant woman presented to A&E and was admitted
overnight with a cough, fever and breathlessness. All
members of her family had an influenza-like illness. She
was discharged home the next day with no relevant
investigations performed and no antibiotic or antiviral
treatment initiated.
Her condition deteriorated and when reviewed by her GP
the next day, emergency readmission was arranged.
Testing for H1N1 was conducted which was positive and
antiviral treatment commenced, however the woman
rapidly deteriorated and died 3 days later.
Universal lessons
• The benefits of influenza vaccination to
pregnant women should be promoted and
pregnant women at any stage of pregnancy
should be offered vaccination against
seasonal and pandemic influenza with
inactivated vaccine
• Consider influenza as a possible diagnosis
for women presenting with respiratory illness
Epilepsy
Common features of all deaths included:
• Women of child bearing age were not given
preconception counselling
• Epilepsy nurses and other specialists were not
available or used during pregnancy to help care
for women with epilepsy
Epilepsy
• There was a delay in referring pregnant women
with epilepsy or seizures to specialist services,
or barriers to them accessing those services
• Pregnant women with epilepsy were still not
routinely identified as a high risk group (both in
outpatient and inpatient settings), and
appropriate precautions such as never placing
them in single rooms were not always taken
Universal lessons
• Epilepsy remains a high risk condition in
pregnancy and should continue to be
managed as such in antenatal and
postnatal care
• Multi-agency evidence based operational
guidance is urgently required to
standardise and improve the care of
pregnant women with epilepsy
The care setting
• There should be adequate provision of
appropriate critical care support for the
management of a pregnant woman who
becomes unwell
• All consultant led delivery suites must have
access to level 2 high dependency unit facilities
that are appropriately equipped and staffed by
teams of senior obstetricians, anaesthetists and
midwives, skilled in looking after seriously ill
women especially those with sepsis
Learning lessons to improve
care
We owe it to those left behind to
learn from the death of their
mother, partner, daughter or friend
and to make changes for the future
to prevent other women from dying
Universal lessons
• The deaths of all women should undergo
multidisciplinary review at a local level
• All staff should participate in the review of
care for the Confidential Enquiry
• Individual clinician’s perspectives on the
care they have provided to women who
die or have severe morbidity is invaluable
to identify fully the lessons to be learned
Multidisciplinary review
Sepsis Deaths
Maternal
sepsis deaths
n=83
Women with
septic shock
n=34
Internal review NOT undertaken
39 (47%)
22 (65%)
Internal review undertaken
44( 53%)
12 (35%)
• Obstetrician
28 (64%)
12 (100%)
• Midwife
28 (64%)
5 (42%)
• Anaesthetist
19 (43%)
2 (17%)
• Other
23 (52%)
3 (25%)
2 (5%)
0 (0%)
17 (39%)
4 (33%)
Staff involved in internal review:
• External
Root Cause analysis undertaken
Universal lessons
To increase the rigour of review
• Consideration should be given to the
develop a standardised toolkit for
multidisciplinary review of maternal death
in a Maternity Unit
• Independent review should be part of the
process
Summary
• Observations:
– Confirm normality, do not presume it
– Record and refer to more senior staff if
required
• Women with existing medical
conditions should be seen by a multidisciplinary team
• All maternal deaths should be
reviewed
Summary
The focus of this 2009-12 report is on
improving care; recommending changes or
actions, small and large, that can be made
to make care better for pregnant women
across the UK.
By learning from each and every maternal
death, changes can be made to prevent
pregnant women dying in the future.
Thank you