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Saving Mothers' Lives Confidential Enquiry into Maternal and Child Health Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer - 2003-2005 December 2007 The Seventh Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom CEMACH Mission statement Our aim is to improve the health of mothers, babies and children by carrying out confi dential enquiries on a nationwide basis and by widely disseminating our fi ndings and recommendations. Please cite this work as: Lewis, G (ed) 2007. The Confi dential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer - 2003-2005. The Seventh Report on Confi dential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH. This work was undertaken by CEMACH. The work was funded by the National Patient Safety Agency Centre, the Scottish Programme for Clinical Effectiveness in Reproductive Heath and by the Department of Health, Social Services and Public Safety of Northern Ireland. The views expressed in this publication are those of the Enquiry and not necessarily those of its funding bodies. All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of CEMACH, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK [www.cla.co.uk] Enquiries concerning reproduction outside the terms stated here should be sent to CEMACH at the address printed on this page. Making duplicate copies of this Report for legitimate clinical or other non-commercial purposes within the UK National Health Service is permitted provided that CEMACH is identifi ed as the originator of the information. Making alterations to any of the information contained within, or using the information in any other work or publication without prior permission, will be a direct breach of copyright and may result in civil action. The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant laws and regulation and therefore free for general use. Product liability: CEMACH can give no guarantee for information about drug dosage and application thereof contained in this guideline. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Published December 2007 CEMACH, Chiltern Court, 188 Baker Street, London, NW1 5SD Tel: 0207 486 1191 Fax: 0207 486 6543 Email: [email protected] Website: www.cemach.org.uk Designed and produced by Interface. Bristol Tel 0117 923 2235. ISBN: 978-0-9533536-8-2 Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer – 2003-2005 The Seventh Report of the Confi dential Enquiries into Maternal Deaths in the United Kingdom Director and Editor Judy Shakespeare MRCP FRCGP Gwyneth Lewis MSc MRCGP FFPH FRCOG Michael de Swiet MD FRCP FRCOG Central Assessors and Authors Harry Millward-Sadler FRCPath MHSH Thomas Clutton-Brock MRCP FRCA Robin Vlies FRCSEd FRCOG Griselda Cooper OBE FRCA FRCOG Other authors and contributors James Drife MD FRCOG FRCPEd FRCSEd FCOG(SA) Naufi l Alam BSc (Hons) MSc Grace Edwards RN RM ADM Cert Ed Med PhD Valerie Beale RN RM Dip Man MSc Ann Harper OBE MD FRCPI FRCOG David Bogod FRCA LLM Diana Hulbert FRCS FFAEM Victoria Brace MRCOG William Liston Nirupa Dattani FRCOG BSc MPhil Alison Macfarlane Dawn Kernaghan BA Dip Stat C Stat FFPH MRCOG James Neilson Alison Miller MD FRCOG RN RM RDM Catherine Nelson-Piercy Jo Modder FRCP FRCOG MRCOG John McClure Judy Myles FRCA BAO FRCPsych Margaret Oates Jane Rogers DPM FRCPsych BA PhD DPSM SRN RM Gillian Penney Kate Sallah MD FRCOG MFFP MBE RN RM ADM MPH iii Contents Acknowledgements ................................................................................................................................... vi Foreword ................................................................................................................................................... vii Top ten recommendations ...................................................................................................................... viii Introduction ............................................................................................................................................ xviii Background ......................................................................................................................................... xviii Aims and objectives of the Enquiry .......................................................................................................xxi Defi nitions and methods for calculating maternal mortality rates ........................................................xxiv Key fi ndings for 2003-05 1. Summary and overall fi ndings Gwyneth Lewis ................................................................................... 1 Key fi ndings for 2003-05 ......................................................................................................................... 3 The clinical reasons why mothers died ................................................................................................... 7 Leading causes of maternal deaths: 2003-05 ......................................................................................... 9 The care the mothers received ................................................................................................................9 Underlying health status ........................................................................................................................ 22 Vulnerability ........................................................................................................................................... 29 Discussion and conclusions .................................................................................................................. 43 Acknowledgements ............................................................................................................................... 45 References ............................................................................................................................................ 46 Annex 1:1. The changing face of motherhood in the UK; trends in reproductive epidemiology Alison Macfarlane ....................................................................... 48 Maternal deaths Directly related to pregnancy 2. Thrombosis and thromboembolism James Drife .............................................................................. 55 Annex 2:1. Summary of the RCOG guidelines for thromboprophylaxis during pregnancy, labour and after vaginal delivery and caesarean section. ....................................67 3. Pre-eclampsia and eclampsia James Neilson ................................................................................... 72 4. Haemorrhage William Liston ................................................................................................................ 78 5. Amniotic fl uid embolism Robin Vlies ................................................................................................. 86 6. Early pregnancy deaths James Neilson ............................................................................................. 92 7. Genital tract sepsis Ann Harper .......................................................................................................... 97 8. Anaesthesia Griselda Cooper and John McClure.............................................................................. 107 iv Contents Maternal deaths Indirectly related to pregnancy 9. Cardiac disease Catherine Nelson-Piercy .........................................................................................117 10. Other Indirect deaths Michael de Swiet ........................................................................................... 131 11. Deaths from malignancy Gwyneth Lewis ........................................................................................ 145 12. Deaths from psychiatric causes Margaret Oates ........................................................................... 152 Suicide Margaret Oates ......................................................................................................................154 Substance misuse Judy Myles ........................................................................................................... 165 13. Domestic abuse Gwyneth Lewis ...................................................................................................... 173 Annex 13:1. National guidelines for England for the identifi cation and management of domestic abuse in pregnancy ............................................................................179 Deaths unrelated to pregnancy 14. Coincidental and Late deaths Gwyneth Lewis ................................................................................ 180 Key issues and lessons for specifi c health services and/or health professionals 15. Pathology Harry Millward-Sadler ..................................................................................................... 184 16. Midwifery Grace Edwards ................................................................................................................. 199 17. General Practice Judy Shakespeare ...............................................................................................
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