Confidential Enquiry Into Maternal And Child Health Research Articles

Diabetes and Pregnancy

Diabetes and Pregnancy

Promoting Mother's Psychological Health after Fetal Loss-Descriptive Case Reports

Life is the biggest gift of God and the process of giving birth is praise-worthy. Therefore, maternal mortality and morbidity is alarming and need extensive interventions. The psychosocial and psychological perspectives of childbirth need attention and vigorous trainings for health- care workers. Many countries are working to improve standards of their living and to curtail subsequent life threatening illness associated with pregnancy and birth. For that, different reporting, evaluating and practicing guidelines made to check the present practices that have greater impact on health-care industries and on patients. One of the widely eminent is CEMACH (Confidential Enquiry into Maternal and Child Health). According to Weindling [1], CEMACH was established in April 2003. Previously it worked as CESDI (the Confidential Enquiry into Stillbirths and deaths in infancy) and CEMD (the Confidential Enquiry into Maternal Deaths). Formerly, the ministry of health had not reported adequately and timely about the maternal deaths but it started its formalized reporting in the year 1952.

Analysing newly‐published diabetes audits: are care standards being achieved?

Analysing newly‐published diabetes audits: are care standards being achieved?

Burden of Clostridium difficile infection in the United States.

for the CHIPS Study Group Since publication of their article, the authors report no further potential conflict of interest. 1. Lewis G, ed. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer — 2003-2005: the seventh report on confidential enquiries into maternal deaths in the United Kingdom. London: The Confidential Enquiry into Maternal and Child Health (CEMACH), December 2007 (http://www.hqip.org.uk/ assets/NCAPOP-Library/CMACE-Reports/18.-December-2007 -Saving-Mothers-Lives-reviewing-maternal-deaths-to-make -motherhood-safer-2003-2005-Executive-Summary.pdf).

Local anaesthetic systemic toxicity

Access the CPD MCQs for this issue online here ### Key points Well-placed local anaesthetics (LAs) can yield great clinical benefits. But systemic toxicity related to their use can be devastating. The highly publicized case in 2004 of Mayra Cabrera, a theatre nurse who died shortly after delivery of her baby boy when her epidural infusion of bupivacaine was mistakenly connected to her i.v. line, reminds us to be vigilant and to learn from such rare events. While prevention is clearly the most important element in avoiding morbidity and mortality associated with local anaesthetic systemic toxicity (LAST), such cases still occur despite best practice. Knowing how to manage these uncommon events is vital. In this review, we cover LA toxicity, its incidence, clinical features, risk factors, prevention, and management and examine i.v. lipid emulsion (ILE) therapy in more detail. LAST has been recognized for more than a hundred years, but the precise incidence is currently unknown. In 1928, the American Medical Association reported 40 deaths attributable to LAs.1 Cocaine was responsible for half of these deaths, but procaine was also implicated. These findings prompted the search for less toxic agents. Lidocaine, first synthesized in 1944, was the first amide LA to be used clinically. However, in 1979, the potentially fatal toxicity of amide LAs was highlighted by Albright.2 More recently, studies from 1993 …

Critique of the pre-hospital obstetric emergency training course: ALSG

Pre-hospital obstetric incidents account for a significant number of emergency calls to the ambulance service, with obstetric emergencies being one of the most challenging situations that pre-hospital practitioners encounter. The mortality associated to obstetric emergencies has shown significant decline over recent years due to improved obstetric education, advances in surgery and improved maternal care. Additionally, the development of the Confidential Enquiry into Maternal and Child Health (CEMACH) has identified patterns of sub-optimal practice and has provided recommendations on how to improve the maternity services and obstetric care available to all pregnant patients. One of the most influential recommendations to come out of this document was the apparent need to improve education of basic, intermediate and advanced life support in obstetric emergencies, which lead to the introduction of advanced obstetrics and gynaecology becoming compulsory elements within the paramedic curriculum. The need for organisation and ambulance trusts to provide specialist training into obstetric emergencies was also identified within this enquiry (Confidential Enquiry into Maternal and Child Health, 2007; Advanced Life Support Group, 2010). In order facilitate the development of prehospital obstetric education; several programmes have been written which allowed for paramedics to maintain their continuous personal development through the competition of a short ‘crash course’ in obstetric care. One of the most successful courses of this type available to prehospital clinicians is the pre-hospital emergency training course (POET) delivered by the advanced life support group. Within this article, a review of this course will take place in order for readers to gain an understanding into the course content and the benefits of undertaking such course as part of the clinician’s continuous personal development. The authors of this article have recently completed the POET course, held in Manchester, which was the inspiration for this piece.

The Management of Gestational Diabetes

The incidence of gestational diabetes is increasing, with higher obesity in the pregnant population, lifestyle changes and migration thought to underlie this. Recent large studies, such as the MiG, HAPO and ACHOIS trials, have furthered our understanding of both the implications of the disease and the management options available. Previous CEMACH (Confidential Enquiries into Maternal and Child Health) studies of diabetes in pregnancy have shown a significant proportion of patients receiving sub-optimal care. We aim to summarise the current standard of management strategies in pregnancy, whilst acknowledging controversies and limitations in the existing evidence. Antenatal management involves service organisation to provide multi-disciplinary team reviews to address glycaemic control, fetal monitoring and associated conditions such as obesity and hypertensive disorders of pregnancy. The use of diet, exercise, oral hypoglycaemic agents and insulins will be discussed, along with specific considerations for the management of preterm labour and administration of corticosteroids for fetal lung maturity. The timing and management of labour, including mechanisms of delivery, will be covered, including neonatal considerations and the use of breast feeding. Finally, a discussion of appropriate post delivery care will consider the prevention of, and screening for, the development of type 2 diabetes.

The silent killer: exploring amniotic fuid embolism

This article discusses amniotic fluid embolism—a rare and widely misdiagnosed disease, using a case study to direct the practicalities of treating and caring for a woman who has had amniotic fluid embolism. It examines the poorly understood aetiology and pathophysiology of the disease, along with the varying spectrum, risk factors, systemic response, diagnosis and treatment of the disease. It uses recent confidential enquiry into maternal and child health (CEMACH) reports to illustrate the trends in mortality and morbidity related to this disease, considering the outcomes and prognosis for women and babies who have had amniotic fluid embolism. It also considers the importance and need for inclusion of amniotic fluid embolism within midwifery education programmes and continuing professional development to reduce the high mortality and morbidity rates associated with this disease.

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?

Pregnancy in women with Type 1 and Type 2 diabetes in Dublin

The Confidential Enquiry into Maternal and Child Health (CEMACH) reported outcomes of pregnancies in women with pre-gestational diabetes (PGDM) in the UK (n = 3,733). This study aimed to compare CEMACH outcomes with PGDM pregnancies in Dublin. Retrospective chart review of all PGDM pregnancies. Comparison to CEMACH are shown in brackets. One hundred and ten PGDM women delivered in Dublin. Thirty (27%) had T2 diabetes (vs. 27%). Fifty-nine (53%) women had a booking HbA1c less than 7% (vs. 66%). Nineteen women (17.3%) had a first trimester miscarriage (vs. 8.5%). Of the 91 remaining women, 71 (78%) women underwent induction of labour (vs. 38.9%). Fifty-four women (59.3%) were delivered by caesarean section (vs. 67.4%). Two infants (2.1%) were macrosomic (vs. 5.7%). There was one intrauterine death (0.1 vs. 0.6%) and no maternal deaths (vs. five). These results serve to underline the continued importance of multidisciplinary care for pregnant women with diabetes.

Audit on outcome of midwife-led gestational diabetes care

The aim was to compare the pregnancy outcomes of gestational diabetic women who received midwife-led care to those who received specific treatment from multidisciplinary teams and to determine the progress of gestational diabetes mellitus (GDM) to type 2 diabetes mellitus (T2DM). A retrospective audit was used on a cohort of 291 gestational diabetic women at an east London maternity unit. Outcome measures were ethnicity; attendance at the clinics; mode of deliveries; premature birth requiring admission to neonatal unit; macrosomia and diagnosis of T2DM 6 weeks post delivery. The highest proportion of GDM were Bangladeshi (81.7%) and African (7.9%) compared to (4.1%) Caucasian. This is representative of the ethnic group of T2DM in the 2005 Confidential Enquiries into Maternal and Child Health (CEMACH) report. Clinic attendances during the first 6 months were reduced by 50% with significantly shorter waiting times. Sixty-two percent of the women delivered vaginally; 31% by caesarian section and 6% of women had assisted deliveries. Adverse pregnancy outcomes—macrosomic babies (1%, 3/298) and premature babies (4.1%, 13/298) born at 29–35 weeks—were lower in women receiving treatment. Four percent (12/219) women progressed to T2DM at 6 weeks post delivery. The National Institute for Health and Clinical Excellence (NICE) (2003) do not recommend routine screening. If nothing else, these 4% of women are the same women at risk of unrecognized, undiagnosed and untreated T2DM. CEMACH (2005) data suggested these women have particularly poor outcomes. The evidence of this audit led to the following changes in the diagnostic value for impaired glucose tolerance: the biochemistry value for 2 hours post 75g glucose is now equal to or more than 7.8mmol/L (World Health Organization, 1999; NICE, 2008). The gap identified in the criteria for selective screening is to screen all women from minority ethnic group including South Asian, Middle Eastern, African and Black Caribbean.

Part 12: Cardiac Arrest in Special Situations

This section of the 2010 AHA Guidelines for CPR and ECC addresses cardiac arrest in situations that require special treatments or procedures beyond those provided during basic life support (BLS) and advanced cardiovascular life support (ACLS). We have included 15 specific cardiac arrest situations. The first several sections discuss cardiac arrest associated with internal physiological or metabolic conditions, such as asthma (12.1), anaphylaxis (12.2), pregnancy (12.3), morbid obesity (12.4), pulmonary embolism (PE) (12.5), and electrolyte imbalance (12.6). The next several sections relate to resuscitation and treatment of cardiac arrest associated with external or environmentally related circumstances, such as ingestion of toxic substances (12.7), trauma (12.8), accidental hypothermia (12.9), avalanche (12.10), drowning (12.11), and electric shock/lightning strikes (12.12). The last 3 sections review management of cardiac arrest that may occur during special situations affecting the heart, including percutaneous coronary intervention (PCI) (12.13), cardiac tamponade (12.14), and cardiac surgery (12.15). Asthma is responsible for more than 2 million visits to the emergency department (ED) in the United States each year, with 1 in 4 patients requiring admission to a hospital.1 Annually there are 5,000 to 6,000 asthma-related deaths in the United States, many occurring in the prehospital setting.2 Severe asthma accounts for approximately 2% to 20% of admissions to intensive care units, with up to one third of these patients requiring intubation and mechanical ventilation.3 This section focuses on the evaluation and treatment of patients with near-fatal asthma. Several consensus groups have developed excellent guidelines for the management of asthma that are available on the World Wide Web: ### Pathophysiology The pathophysiology of asthma consists of 3 key abnormalities: Complications of severe asthma, such as tension pneumothorax, lobar atelectasis, pneumonia, and pulmonary edema, can contribute to fatalities. Severe asthma exacerbations are commonly associated with …

Spurious fetal movement after late fetal death

One in 200 babies are born dead in the UK (Confidential Enquiry into Maternal and Child Health (CEMACH), 2009). There were 4 037 stillbirths in 2007, an average of more than 10 per day. This compares with the much lower rate of 1 in 10 000 for sudden infant death (CEMACH, 2009)

CEMACH 2003–5 Saving Mothers' Lives: lessons for anaesthetists

The Confidential Enquiry into Maternal and Child Health (CEMACH) reviews every death in the UK occurring during pregnancy and up to 42 days post-partum. Originally titled Confidential Enquiries into Maternal Deaths (CEMD), this series of Reports is the longest running audit in the world. It covers every triennium since 1952, with sequential Reports having established the leading causes of maternal mortality and recommended change where appropriate. Up to 1985, only deaths in England and Wales were considered; thereafter, the whole UK was included. The maternal mortality rate (MMR) is defined as the number of maternal deaths per 100 000 maternities. This has markedly reduced over the last 50 yr. In 1952–4, there were 1094 maternal deaths (MMR 53.29), whereas the latest Report 2003–5 records 295 deaths (MMR 13.95) of which 132 were direct and 163 were indirect. However, most of this dramatic improvement in MMR occurred early and was mainly attributable to advances in public health and medicine (Fig. 1). Unfortunately, if we compare total deaths (223) and MMR (9.83) for the 1985–7 Report with those in the current Report 2003–5, we see that over the last 20 yr, there has been an increase in both total deaths and MMR. Suggested explanations for the failure of MMR to decline since the last (2000–2) CEMACH Report include increasing maternal age at delivery, obesity, poor overall health status, difficulty in accessing maternity care, and the increase in immigrant mothers. One in four mothers now delivering in the UK has been born outside the UK. Whether these factors can explain the increase in MMR since 1985 is not known. In addition, the Scottish morbidity data indicate that for every maternal death, there are 60 ‘near-misses’ (rate of severe morbidity 5.3/1000 maternities). CEMACH historically divides maternal deaths into direct deaths from conditions directly related to pregnancy and indirect deaths from conditions unrelated to pregnancy but exacerbated by it. Deaths occurring during pregnancy or within 6 weeks of birth, which were not due to or affected by pregnancy are called coincidental deaths. Deaths from any cause that occurred between 6 weeks and 1 yr after delivery are termed late deaths. Most late deaths are unrelated to pregnancy and therefore termed late coincidental deaths. This complex structure sometimes obscures causality. A ‘late’ death beyond the arbitrary 42-day post-natal period is often not counted in the quoted figures, even though the death is clearly attributable to the initial event after the patient has survived for a protracted period on the intensive therapy unit (ITU). Figure 2 therefore shows the less familiar—but more informative— leading causes of maternal deaths as direct/ indirect plus relevant late deaths, with the proportion receiving major substandard care (defined as treatment—or lack of—which contributed significantly to the death of the mother, and where different treatment may have altered the outcome).

Meows – time to review the trigger threshold?

IntroductionThe 2003–2005 Confidential Enquiry into Maternal and Child Health (CEMACH) encouraged ‘the routine use of a national obstetric early warning chart’. Our trust trialled the CEMACH example of a MEOWS...

Early warning system to help prevent unexpected hospital deaths

A confidential review of UK childhood deaths examined 89 hospital deaths in detail and deemed 63 (71 per cent) to be avoidable or potentially avoidable (Confidential Enquiry into Maternal and Child Health (CEMACH) 2007), with the failure to recognise the child’s deterioration cited as a major contributing factor. This prompted CEMACH to recommend the use of a paediatric early warning system (PEWS) in all hospitalised children. Although similar systems are well established for hospitalised adults, little has been published in paediatrics and this paper is a welcome addition to the literature.

Setting maternity care standards for women with obesity in pregnancy

Obesity is associated with an increased risk of pregnancy-related complications that affect both the mother and baby. National clinical care guidelines have been developed by the Centre for Maternal and Child Enquiries, as part of its Confidential Enquiry into Maternal and Child Health (CEMACH) programme. These guidelines are intended to minimise and manage the risks associated with maternal obesity, and they were developed using formal consensus methods based on the Delphi technique. A multidisciplinary group of 25 members participated in the iterative process. Standards of care were based on the best available evidence and expert clinical knowledge and experience. This article describes the process used to develop standards of maternity care for women with obesity, and the resulting recommendations are presented.

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.

A national survey of obstetric early warning systems in the United Kingdom

Background Despite recommendations in the two most recent Confidential Enquiries into Maternal and Child Health (CEMACH) reports, and improvements in patient care using early warning scoring systems (EWS) in the general adult population, no validated system currently exists for the obstetric population. Methods We performed an Obstetric Anaesthetists’ Association (OAA) approved postal survey of all UK consultant-led obstetric anaesthetic units in November 2007 to assess opinions on the value and of such a system and how it could be implemented, and invited comments and samples of systems already in use. Results The response rate was 71%. Of those who replied a median usefulness score of 80% for a standardised national obstetric EWS was demonstrated. Eighty-nine percent of units thought it would be possible to implement a system, and although 96% of UK hospitals already use a non-obstetric EWS, only 23% of respondents thought this to be relevant to obstetric physiology and disease. Nine units returned copies of their obstetric EWS. Using extracts from some of the submitted versions we have designed and implemented a system locally and submitted it to the OAA for consideration. Conclusions The survey results support CEMACH recommendations for a nationally agreed obstetric EWS.

Pre-Eclampsia

Pre-eclampsia is a multisystem syndrome of unknown aetiology peculiar to pregnancy. Between 2003–5, the report on confidential enquiries into maternal and child health (CEMACH) recorded 18 deaths in the UK as a result of pre-eclampsia or eclampsia (0.85 per 100 000 maternities), making this the second leading cause of maternal death. In 72% of these cases, care was deemed substandard.