Centre For Maternal And Child Enquiries Research Articles

Causes of antepartum stillbirth in women of advanced maternal age

ObjectivesTo breakdown the causes of antepartum stillbirth by maternal age. Study designObservational study. SettingUK. SampleAnonymised national data on 2850 cases of antepartum stillbirth in 2009. Statistical analysisThe association between cause of stillbirth and maternal age was examined using an adjusted multinomial logistic regression model. Risk ratios were calculated relative to stillbirth due to haemorrhage. Main outcome measuresAntepartum stillbirths classified by the Centre for Maternal and Child Enquiries (CMACE) classification. ResultsStillbirths in women aged 35 years and over are more likely to be due to major congenital anomalies (relative risk ratio (RRR) 2.0, 95% CI 1.3–3.0), mechanical causes (RRR 1.6, 95% CI 1.0–2.6), maternal disorders (RRR 2.1, 95% CI 1.2–3.6) or associated obstetric factors (RRR 2.1, 95% CI 1.1–3.9) than women less than 35. Women aged 35 years and over have a statistically significant increased risk of stillbirth due to major congenital anomalies (OR relative to live birth 1.6, 95% CI 1.3–1.9) and maternal disorders (OR 1.7, 95% CI 1.2–2.4) than younger women. Women aged 35 years and over were 30% more likely to experience a term stillbirth than women <35 years (OR 1.3, 95% CI 1.1–1.5). Stillbirth due to congenital anomaly was statistically significantly more likely in women ≥35 years. ConclusionsAdvanced maternal age is a significant risk factor for antepartum stillbirth particularly at term. Attention should be given to stillbirth due to mechanical causes, maternal disorders and associated obstetric factors in such women.

Managing Maternal Cardiac Arrest in Canada

Fortunately, maternal mortality is a rare occurrence in the developed world and even more uncommon when the mortality is due to maternal cardiac arrest – the estimated rate is 1:20,000-1:30,000 pregnancies. When maternal cardiac arrest occurs, the lives of both the parturient and fetus are at risk. Consequently, there is a very brief window of opportunity for return of hemodynamic stability before the risk of permanent harm to the mother and fetus begins. Despite parturients being younger than the typical patient experiencing cardiac arrest, there are a variety of complex reasons why survival is reported at less than 10%. Substandard care, poor resuscitation attempts, and lack of compliance with accepted resuscitation algorithms have been common themes in the Centre for Maternal and Child Enquiries (CMACE) triennial reports out of the United Kingdom (UK). Importantly, commentary and management strategies have followed the publication of each report, and progress has been made over time to improve how providers manage these rare events. In 2000, the American Heart Association (AHA) clearly spelled out the rationale to advocate proceeding with an emergent Cesarean delivery after four minutes of maternal cardiac arrest. In 2010, the AHA developed a separate maternal cardiac arrest algorithm. While it is true that the evidence – first put forth in 1986 – is from case series and there will always be individual cases where a longer period of lack of blood flow to the uterus still results in a live intact neonate, it has been reported that a fetus more than 24-25 weeks’ gestation experiencing more than ten minutes of absent blood flow will generally experience neurological (and other) deficits. More importantly, evacuation of the gravid uterus makes successful maternal resuscitation much more likely regardless of gestational age. In a resuscitation scenario during which the application of good-quality chest compressions produces no palpable maternal pulse, uterine evacuation should be expedited. The release of aortocaval compression and autotransfusion effects may potentially facilitate attempts at maternal resuscitation. In this issue of the Journal, Baghirzada and Balki describe the experience with maternal cardiac arrest in their Canadian institution over a 12-year period. One of their conclusions is that the four-minute rule need not be applied too rigorously, as they provide evidence for intact neonatal survival up to 14 min after loss of maternal circulation. These observations are consistent with other case reports. The authors not only identified poor documentation for each of the five cases, but they also reported the difficulty in organizing and mobilizing the team to initiate the emergent Cesarean delivery within four minutes post-arrest. Rather than conclude that perhaps it is acceptable to delay the decision and start of surgery, there are other lessons to be learned; for example, all practitioners practicing in a hospital providing obstetrical services need to carry out a critical appraisal of their overall readiness to manage maternal cardiac arrest. If there are no clear, concise, and precise guidelines, it has been well documented that the entire team will be challenged to proceed in a protocol during management of cardiac arrest in any patient. This is recognized in the latest R. Preston, MD (&) Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Rm 3300 JPPN, 910 W 10th Avenue, Vancouver, BC V5Z 1M9, Canada e-mail: roanne.preston@ubc.ca

PMM.39 Evaluating the effectiveness of a leaflet educating women on obesity and pregnancy. Are we intervening pre-pregnancy fulfilling the new Centre for Maternal and Child Enquiries (CMACE) recommendation?

The prevalence of maternal obesity has increased to 16–19% in the early 2000s; it is one of the most common risk factors for maternal and fetal morbidity and mortality. About...

Advances in prenatal diagnostics.

Advances in prenatal diagnostics.

Managing maternal cardiac arrest in Canada: – we’re doing OK, but we can do better

Fortunately, maternal mortality is a rare occurrence in the developed world and even more uncommon when the mortality is due to maternal cardiac arrest – the estimated rate is 1:20,000-1:30,000 pregnancies. When maternal cardiac arrest occurs, the lives of both the parturient and fetus are at risk. Consequently, there is a very brief window of opportunity for return of hemodynamic stability before the risk of permanent harm to the mother and fetus begins. Despite parturients being younger than the typical patient experiencing cardiac arrest, there are a variety of complex reasons why survival is reported at less than 10%. Substandard care, poor resuscitation attempts, and lack of compliance with accepted resuscitation algorithms have been common themes in the Centre for Maternal and Child Enquiries (CMACE) triennial reports out of the United Kingdom (UK). Importantly, commentary and management strategies have followed the publication of each report, and progress has been made over time to improve how providers manage these rare events. In 2000, the American Heart Association (AHA) clearly spelled out the rationale to advocate proceeding with an emergent Cesarean delivery after four minutes of maternal cardiac arrest. In 2010, the AHA developed a separate maternal cardiac arrest algorithm. While it is true that the evidence – first put forth in 1986 – is from case series and there will always be individual cases where a longer period of lack of blood flow to the uterus still results in a live intact neonate, it has been reported that a fetus more than 24-25 weeks’ gestation experiencing more than ten minutes of absent blood flow will generally experience neurological (and other) deficits. More importantly, evacuation of the gravid uterus makes successful maternal resuscitation much more likely regardless of gestational age. In a resuscitation scenario during which the application of good-quality chest compressions produces no palpable maternal pulse, uterine evacuation should be expedited. The release of aortocaval compression and autotransfusion effects may potentially facilitate attempts at maternal resuscitation. In this issue of the Journal, Baghirzada and Balki describe the experience with maternal cardiac arrest in their Canadian institution over a 12-year period. One of their conclusions is that the four-minute rule need not be applied too rigorously, as they provide evidence for intact neonatal survival up to 14 min after loss of maternal circulation. These observations are consistent with other case reports. The authors not only identified poor documentation for each of the five cases, but they also reported the difficulty in organizing and mobilizing the team to initiate the emergent Cesarean delivery within four minutes post-arrest. Rather than conclude that perhaps it is acceptable to delay the decision and start of surgery, there are other lessons to be learned; for example, all practitioners practicing in a hospital providing obstetrical services need to carry out a critical appraisal of their overall readiness to manage maternal cardiac arrest. If there are no clear, concise, and precise guidelines, it has been well documented that the entire team will be challenged to proceed in a protocol during management of cardiac arrest in any patient. This is recognized in the latest R. Preston, MD (&) Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Rm 3300 JPPN, 910 W 10th Avenue, Vancouver, BC V5Z 1M9, Canada e-mail: roanne.preston@ubc.ca

Following in Florence Nightingale's influential footsteps

British Journal of MidwiferyVol. 21, No. 9 Student CommentFollowing in Florence Nightingale's influential footstepsElizabeth NieldElizabeth NieldSearch for more papers by this authorElizabeth NieldPublished Online:27 Sep 2013https://doi.org/10.12968/bjom.2013.21.9.660AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Department of Health (2010) Equity and excellence: Liberating the NHS. Her Majesty's Stationery Office, London Google ScholarDepartment of Health (2012) Compassion in practice: Nursing, midwifery and care staff our vision and strategy. Department of Health, London Google ScholarLee G, Clark A, Thompson DR (2013) Florence Nightingale – never more relevant than today. Journal of Advanced Nursing 69(2): 245–6 Crossref, Google ScholarLewis G (2011) The women who died 2006-2008, chapter 1:30-56. In: Centre for Maternal and Child Enquiries (CMACE) Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 118(Supplement 1): 30–56 Google ScholarMcDonald L (2006) Florence Nightingale: Maternal mortality and gender politics. Paper for the History of Nursing Conference of the Canadian Association for the History of Nursing, St Paul's Hospital, Vancouver, BC Google ScholarNursing and Midwifery Council (2002) Statistical analysis of the register: 1 April 2001–31 March 2002. NMC, London Google ScholarNursing and Midwifery Council (2008a) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC, London Google ScholarNursing and Midwifery Council (2008b) Statistical analysis of the register: 1 April 2007–31 March 2008. NMC, London Google ScholarRoyal College of Midwives (2008) Campaign for normal birth. RCM, London Google ScholarRoyal Statistical Society (2012) History. www.rss.org.uk/site/cms/contentCategoryView.asp?category=42 (accessed 1 August 2013) Google ScholarThe Florence Nightingale Foundation (2013) History. www.florence-nightingale-foundation.org.uk/content/page/13/ (accessed 1 August 2013) Google Scholar FiguresReferencesRelatedDetails 1 September 2013Volume 21Issue 9ISSN (print): 0969-4900ISSN (online): 2052-4307 Metrics History Published online 27 September 2013 Published in print 1 September 2013 Information© MA Healthcare LimitedPDF download

PM.16 Ultrasound Colour-Flow Doppler in Initial Assessment of Morbidly Adherent Placenta Followed by Selective MR Imaging: A Case Series

Morbidly adherent placenta (MAP) is the abnormal attachment of the placenta to the uterine wall in which trophoblastic cells invade the uterine tissues. MAP is rare, affecting 1 in 2500...

Postpartum haemorrhage and haematological management

Postpartum haemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide. Recent report of the Centre for Maternal and Child Enquiries (CMACE) in the United Kingdom, which was previously called Confidential Enquiries into Maternal and Child Health (CEMACH), confirmed a reduction in maternal deaths during the last Triennium (2006–2008). This is attributed to improvements in timely diagnosis and prompt and aggressive treatment. PPH is now the sixth most common direct cause of maternal deaths in the U.K. World Health Organization (WHO) estimates that postpartum haemorrhage accounts for 25% of maternal deaths worldwide. Substandard care and ‘too little being done too late’ remain a significant contributor of maternal deaths.Primary PPH refers to a blood loss from the genital tract of 500 ml or more within 24 h of delivery (or >1000 ml during caesarean section). Secondary PPH refers to an excessive blood loss between 24 h and 6 weeks after birth. Massive PPH refers to a blood loss of over 2000 ml (or >30% of blood volume) and is associated with increased maternal morbidity and mortality. A timely, multi-disciplinary and systematic approach to restore the volume, clotting system and the oxygen carrying capacity of blood, whilst steps are taken to arrest bleeding, is essential to save life.Primary postpartum haemorrhage is caused by uterine atony, genital tract trauma, retained placental tissue and membranes after birth or coagulopathy. The latter may not only be a cause of PPH, but also could be an effect of massive haemorrhage due to a ‘washout phenomenon’. Rapid and profuse bleeding results in loss of platelets and clotting factors, that get ‘washed out’. This may lead to a depletion of coagulation factors and resultant bleeding.

Late intra-uterine death (IUD) in women with diabetes is associated with low placental weight

ObjectiveMaternal diabetes substantially increases the risk of late IUD. A greater understanding of the underlying mechanism might allow identification of pregnancies at increased risk. We have studied post-mortem reports to...

From CEMD to CEMACH to CMACE to…? Where now for the Confidential Enquiries into Maternal Deaths?

From CEMD to CEMACH to CMACE to…? Where now for the Confidential Enquiries into Maternal Deaths?

Acquiring cultural competency in caring for black African women

The recent findings of the Centre for Maternal and Child Enquiries (CMACE) (2011) report ‘Savings Mothers’ Lives’ has highlighted the high mortality rates among women of black African ethnicity, particularly those who have newly arrived in the UK. Failure to engage with maternity services was found to be a common trend with this group of women, and this may be linked to cultural differences in expectations of healthcare services. Of the 28 black African mothers who died from direct or indirect causes related to pregnancy between 2006 and 2008, only 9 were UK citizens; significantly, the remaining 19 women were recently arrived immigrants, refugees or asylum seekers ( CMACE, 2011 ). In recent years, a greater emphasis has been placed on health professionals recognizing and appreciating diversity in order to acquire cultural competency. Cultural knowledge is the most important construct of cultural competence for health professionals, being crucial for the accurate appreciation of a patient’s worldview ( Okrentowich, 2007 ). This review explores issues around immigrant black African women’s health in the UK during pregnancy and stresses the benefits for midwives to acquire a level of knowledge and awareness of black African culture to enable the provision of culturally‐appropriate maternity care.

Effects of Syntocinon use in active management of third stage labour

Following the publication of guidance from the National Institute for Health and Clinical Excellence (NICE) (2007) , Syntometrine was withdrawn in practice for routine use as part of the active management of the third stage and replaced with Syntocinon 10 international units (iu). While it was recognized that these guidelines related to the care of low-risk women, from the evidence reviewed there did not appear to be any reason not to recommend the use of Syntocinon for the majority of women. Concern about perceived increase in major postpartum haemorrhage (&gt;100 ml) resulted in a retrospective comparative study of primary postpartum haemorrhage (PPH) rates and blood transfusion rates. This study found a statistically significant increase in estimated blood loss (EBL) above 1000 ml from 2008 to 2010 (0.59% vs. 1.74%). Nevertheless, there was no statistically significant increase in blood transfusion rates. Possible reasons for this increase are suggested, including: the limitations of the present study compared to previous studies; the experience of staff using Syntocinon 10iu; as well as the attitude of staff toward this practice change. In view of these issues, the researchers do not believe that these results provide robust evidence to revert to using Syntometrine, contrary to the recommendations of the Centre for Maternal and Child Enquiries (CMACE) (2011) .

An audit of awareness about maternal sepsis in a UK district general hospital

The UK national body, which reviews maternal mortality (Centre for Maternal and Child Enquiries (CMACE)), has recently published their 2006 to 2008 report. This highlighted an increase in maternal sepsis, making it the leading cause of direct death amongst peripartum women in the UK (26 out of a total 107 direct deaths) [1]. The Surviving Sepsis Campaign (SSC) published updated sepsis resuscitation and management bundles in 2008 [2]. We decided to audit awareness about sepsis amongst staff caring for perpartum women.

Direct maternal deaths due to puerperal fever: Back to the future?

The triennial review of maternal deaths 2006–2008 has just been published by the Centre for Maternal and Child Enquiries (CMACE) (2011) , and demonstrates that genital tract infection is now the leading cause of direct maternal deaths. This article looks back to the period before the discovery of antibiotics in the late 1930s when infection—or puerperal fever as it was known—was the leading cause of maternal death. The article explores how the problem of puerperal fever was perceived and dealt with, and suggests that knowledge of the past may help us to deal with future challenges.

Anaesthetic deaths in the CMACE (Centre for Maternal and Child Enquiries) Saving Mothers’ Lives report 2006–08

Anaesthetic deaths in the CMACE (Centre for Maternal and Child Enquiries) Saving Mothers’ Lives report 2006–08

CMACE: improving the health of mothers, babies and children

This article introduces the Centre for Maternal and Child enquiries (CMACE) which is continuing the work previously carried out by the Confidential Enquiry into Maternal and Child Health (CEMACH). Details of the CMACE work programme are given, including independently-funded projects and those funded by the National Patient Safety Agency.