Saving Mothers’ Lives: the top ten recommendations.
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The ten top recommendations included:
| a. | labour wards should have 24-hour resident consultant cover | False | |
| b. | immigrant pregnant women should be considered for general medical examination | True | |
| c. | CTG training should be improved | False | |
| d. | doctors should be informed of the significance of basics: hypotension, hypertension, tachycardia and tachypnoea | True! | |
| e. | early warning systems for serious illness are needed | True |
Introduction:
“Saving Mothers’ Lives” was published in 2007 by CEMACH.
It covers the years 2003 – 2005.
It made numerous recommendations, but highlighted a top ten.
Which those involved in maternity care “should plan to introduce and audit as soon as possible”.
It further recommended that the relevant data, some of which is not now routinely recorded, be collected from April 2008.
It added that dealing with
the top ten did not mean that the numerous other recommendations could be
ignored!
CEMACH indicated that it would work with key bodies, such as the Healthcare Commission.
(The Healthcare Commission no longer exists.
The Healthcare Commission was the body that provided the second level in the complaints procedure.
And provided an annual assessment of hospital performance.
CEMACH has been replaced by CMACE.
It is typical of the NHS that none of these bodies seems to last more than a few years.
The Healthcare Commission's main functions, regulating health care systems, has been taken over by the Care Quality Commission.
Its role in providing the second level of the complaints procedure has vanished.)
The liaison is to help it to weigh up how best to implement and audit these ten recommendations.
I would hope that the Colleges of Midwifery and O&G will be included.
An MRCOG essay could be: "Critically evaluate the ten top recommendations made in the 2003 - 2005 Maternal Mortality Report".
This would mean dealing with:
the ten clinical recommendations,
why they were singled out as important,
and the
bit most people will forget - the recommendations about baseline and auditable
data.
List of the ten key recommendations.
3. Access to care: referrals after 12 weeks.
4. Women from countries with poorer general health or culture of genital mutilation.
5. Management of systolic hypertension.
6. Placental localisation in pregnancy after Caesarean section.
7. Staff must learn all the lessons from critical and other incidents.
8. Training of all clinical staff.
9. Early warning scoring system for serious clinical conditions.
10. New guidelines needed for obesity, sepsis etc.
The Report states that “counselling and support, both opportunistic and planned” should be provided to women of an age to become pregnant.
And with serious medical or mental health problems.
It added the phrase “which may be aggravated by pregnancy”.
I don’t think there are many conditions of this ilk that won’t be significant in pregnancy or aggravated by pregnancy.
So the phrase is redundant and diminishes the message.
And you should be doing opportunistic pre-pregnancy counselling routinely and not just in high risk cases.
The Report makes specific mention of:
obesity,
epilepsy,
diabetes,
cardiac disease,
auto-immune disorders
and women having fertility treatment.
It recommended that obese women should be helped to lose weight:
before pregnancy
or any
type of assisted reproductive technology (
For
audit purposes, it recommended all providers of maternity services or
collect
the number and % with medical disorders offered pre-pregnancy counselling by
April 08 and at the end of 2009,
100
% of women have their
booking,
pre-pregnancy counselling or
Return to list of recommendations.
All women should be fully booked and have hand-held records by 12 weeks.
To enable this the services must be “accessible and welcoming”.
Return to list of recommendations.
3.
Access to care: referrals after 12 weeks.
Women referred to maternity services after 12 weeks must be seen within 2 weeks.
Return to list of recommendations.
4.
Women from countries with poorer general health or culture of genital
mutilation.
Some immigrant women will come from areas with problems not routinely seen in the UK.
The Report included deaths from rheumatic heart disease etc. that have largely vanished from the native population.
Immigrants from Africa and some other areas have a higher risk of untreated HIV infection.
So it is recommended that these women have a full medical examination.
The
Report says this could
be done by the GP.
Some might see this as patronising and offensive.
But I think it is mainly an effort by the authors to get GPs re-involved in obstetric care.
The
possibility of genital mutilation should be explored and a management plan
instituted.
Audit data with a baseline in April 2008 and 100% coverage by the end of 2009 to include:
the number and % of pregnant women new to the
and the number and % who had the requisite history and examination.
Return to list of recommendations.
5.
Management of systolic hypertension.
In the previous report attention was drawn to the risks of intracranial haemorrhage with systolic blood pressures of 160 mm. Hg. or above.
This has been “firmed up” into a recommendation that all of these women be given hypotensive therapy.
It pointed out that failure to give such treatment was the most serious failing in the management of severe PET.
And that systolic hypertension had also played a part in deaths from aortic dissection.
It quoted a paper suggesting 160 as the appropriate cut-off point for action:
Martin et al., Obstet Gynecol. 2005; 105: 246-54.
Return to list of recommendations.
6.
Placental localisation in pregnancy after Caesarean section.
This should already be standard practice to identify the abnormally adherent placenta.
I’m
a bit surprised that it had to be included.
Again
it recommended collection of data for audit and timescales.
Number and % of women having Caesarean section.
The indications for the operations and their types.
The
Baseline
measurement of the number % of women after C. section having a localisation scan.
A target of 100% by December 2009.
Return to list of recommendations.
7.
Staff must learn all the lessons from critical and other incidents.
No critical incident report was generated for some of the deaths in the Report.
In other cases the reports were of a poor standard.
The
Report doubted that the potential to learn from serious clinical incidents was
realised in all Trusts.
A report should be generated for each significant clinical incident.
There should be a plan at the end of the report detailing how it is to be disseminated to all the staff who should learn from it -
i.e. pretty well everybody in the department and other parties such as GPs and community midwives.
Risk
managers and relevant administrators should also be informed.
There should be audit of the % of staff involved in a clinical incident review and the feedback they got about the actions taken.
This does not seem to me to cover the issue.
Would it not be better to find out if all incidents are having appropriate reports created and if all of the staff are being informed of the lessons?
Return to list of recommendations.
8.
Training of all clinical staff.
Recognition,
immediate management and referral (if appropriate) of:
serious
mental and medical conditions,
severely ill woman or impending collapse.
General
life-support skills and those relevant to pregnancy and the neonate.
The background was the contribution to maternal deaths made by deficient knowledge and skills among doctors, midwives and others.
This constituted “one of the leading causes of potentially avoidable mortality”.
Some
of this was depressingly basic: tachycardia > 100; blood pressure < 90
mm.Hg. or > 160 and tachypnoea.
Audit should cover the courses provided and who attended.
This
should ensure that staff are acquainted with local protocols, procedures,
equipment etc.
Annual appraisal reports should be audited with the aim of ensuring that 100% had their training requirements assessed with regard to the above.
Return to list of recommendations.
9.
Early Warning Scoring System.
The Report stated that there is an urgent need to develop a system for obstetrics reflecting those used in other disciplines.
These are used to promote early detection of serious illness.
While this is being done, Trusts should use one of the systems describes in chapter 19 on critical care.
Return to list of recommendations.
The Report reckoned that
there is need for urgent guidelines on:
obesity in pregnancy,
sepsis in pregnancy,
pain and bleeding in early pregnancy.
Return to list of recommendations.