Confidential Enquiry Into Maternal And Child Health Research Articles

Recognizing and responding to acute illness: using early warning scores

The reports on the Confidential Enquiries into Maternal and Child Health (CEMACH) (Lewis, 2004; 2007) have recommended using early warning scores (EWS) in conjunction with vital signs monitoring, similar to those commonly used in the general adult inpatient population. This is a challenging process for midwives, obstetricians and critical care staff. Collaborative planning, working and multi-disciplinary training at Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) led to the successful implementation of EWS alongside a structured and graded response algorithm. All obstetric inpatients at MCHFT now have a standardized approach to vital signs monitoring using EWS.

Preventing Child Deaths

Preventing Child Deaths

Why Children Die: the report of a pilot confidential enquiry into child death by CEMACH (Confidential Enquiry into Maternal and Child Health)

The Confidential Enquiry into Maternal and Child Health (CEMACH) has published a report entitled ‘Why Children Die: A Pilot Study’. The report contains the results of a large confidential enquiry into child death across one-third of England, all of Wales and all of Northern Ireland in 2006. The report contains a quantitative analysis of 957 deaths which shows some regional and ethnic variation in death rates. Also despite high rates of pre-existent and perhaps life-limiting illness/disability, most children die in hospital, with only small numbers in hospices. Child suicide rates were higher than expected and only one-quarter of these cases were known to mental health services. The report also contains a qualitative analysis of a sample of cases ( n = 126) which were subjected review by multidisciplinary panels. Avoidable factors were found in 26% and potentially avoidable in a further 43%. A recurring avoidable factor in relation to healthcare was ‘failed recognition of serious illness’ by healthcare workers not trained in paediatrics or not supervised by trained individuals.

The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer 2003–2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the UK

The confidential enquiry into maternal deaths, like much in England, has a long history. It makes gripping reading for anyone working in the field of obstetrics and, more importantly, has set a world standard for Obstetric audit. The case ascertainment by The Confidential Enquiry into Maternal and Child Health is unique, since deaths are proactively investigated not just ascertained from death certificate alone. This has doubled the number of cases investigated.

Anaesthesia chapter from Saving Mothers' Lives; reviewing maternal deaths to make pregnancy safer

This chapter concerning maternal mortality due to anaesthesia, reprinted with permission from Saving Mothers' Lives, is the 18th in a series of reports within the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. In the years 2003-05 there were six women who died from problems directly related to anaesthesia, which is the same as the 2000-02 triennium. Obesity was a factor in four of these women who died. Two of these deaths were in women in early pregnancy, who received general anaesthesia for gynaecological surgery by inexperienced anaesthetists who failed to manage the airway and ventilation adequately. When trainee anaesthetists are relatively inexperienced their consultants must know the limits of their competence and when close supervision and help may be needed. One death was due to bupivacaine toxicity due to a drug administration error when a bag of dilute local anaesthetic was thought to be intravenous fluid. In a further 31 cases poor perioperative management may have contributed to death. Obesity was again a relevant factor. Other cases could be categorized into poor recognition of women being sick and poor clinical management of haemorrhage, sepsis and of pre-eclampsia. Early warning scores of vital signs may help identify the mother who is seriously ill. Learning points are highlighted in relation to the clinical management of these obstetric complications.

Pre-existing (type 1 and type 2) diabetes in pregnancy

The prevalence rates of both type 1 and type 2 diabetes mellitus are increasing in the UK. These rates are resulting in a higher number of women with pregnancy complicated by pre-existing diabetes being seen in maternity clinics. Specifically, there is a continuing marked increase in the number of women with type 2 diabetes and pregnancy. Confidential Enquiry into Maternal and Child Health (CEMACH) has recently reported findings from a large study of pregnancy outcome in women with type 1 and type 2 diabetes. We review the current understanding of diabetes in pregnancy, and discuss the CEMACH findings and current and future developments in the delivery of pre-conception and diabetes care in established pregnancy in the UK.

Can we improve maternal outcome for high-risk obstetric patients?

Despite advances in medical, obstetric and anesthetic care, the maternal mortality rate in the US and UK has remained relatively static over the past few decades. 1–3 One explanation for the minimal progress being made to reduce maternal mortality in the developed world is the increasing number of high-risk patients becoming pregnant. This has been associated with advancing maternal age, obesity and increasing numbers of those with significant co-morbidity surviving to childbearing age. The management of high-risk obstetric patients provides one of the most challenging aspects of clinical practice in obstetric anesthesia. The variable presentation and wide spectrum of obstetric-related complications often necessitate anesthetic intervention in an acute setting. High-risk patients may be referred for anesthetic assessment at any time during the antenatal or peripartum periods, and the late timing of referral can lead to inadequate investigation and treatment before delivery. Meanwhile, anesthetic interventions have become increasingly likely with the exponential increase in labor epidural and cesarean delivery rates in the US. 4 Careful clinical decision-making and management may reduce the likelihood of these high-risk patients developing life-threatening conditions and severe maternal morbidity or mortality. The importance of early identification and management of these cases is emphasized in the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. 3 This peer

(Still) time to organise training in airway management in the UK

(Still) time to organise training in airway management in the UK

Pregnancy in women with diabetes—after the CEMACH report, what now?

The second of three studies being undertaken by the Confidential Enquiry into Maternal and Child Health (CEMACH) has recently reported its findings and recommendations. The standards of diabetes and maternal care and the outcomes of 3808 pregnancies in England, Wales and Northern Ireland are described. Pre-pregnancy planning and care before conception is poor. Stillbirth rate (26.8 per thousand) and perinatal mortality (41.8 per thousand) were 4-5 times higher than the background population, and congenital anomaly (41.8 per thousand) double the background rate. Type 2 diabetes now represents 27.3% of pre-gestational diabetes and more often of ethnic minority and deprived background than Type 1 diabetes. The ideals of the Diabetes National Service Framework and the target of the Saint Vincent declaration are far from being achieved. Much can be done to improve the outcomes of pregnancy within existing resources with better systems and organization of care. However, if significant progress is to be made, it is incumbent upon health-care professionals and health-care commissioners to direct resources specifically at improving pre-pregnancy and maternity services. Research is needed firstly to analyse in greater detail the wealth of data collected in the CEMACH survey and consider the implications of health-care costs. Further research to discover ways of reducing the adverse outcomes is urgently required. The need to educate, motivate and bring about improved pre-pregnancy care in women with diabetes is a priority.

Supplementary oxygen during Caesarean section

We read with interest the recent letter of Edsell and Erasmus [1]. Our original paper [2] was the first national survey of practices relating to the use of the common gas outlet for administration of supplementary oxygen during Caesarean section under regional anaesthesia. The principle aim of this survey was to highlight the potential risks of the practice of disconnecting the standard anaesthetic circuit from the common gas outlet in order to use the common gas outlet to deliver supplemental oxygen for a procedure conducted under regional anaesthesia. This practice exposes the patient to two potentially unnecessary risks. The first is that of using a circuit which has been disconnected from the common gas outlet and not subsequently reconnected, and the second, the inadvertent administration of volatile anaesthetic agent to a patient having a procedure conducted under regional anaesthesia. Whilst the safety precaution of attaching the proximal end of the breathing system (the fresh gas flow connection) to the distal end of the circuit, as advocated by Edsell and Erasmus, may make the first scenario less likely, it relies on every user to remember to do this every time the circuit is disconnected, and so does not totally eliminate the risk of it occurring. Furthermore, by persisting with the use of the common gas outlet, their precaution does nothing to reduce the potential risk of inadvertent volatile anaesthetic admission. The most recently published Confidential Enquiry into Maternal and Child Health (CEMACH) report [3] recommends a separate oxygen supply should be used for the delivery of supplementary oxygen during regional anaesthesia. This follows the sad and potentially avoidable death of a mother in which a disconnected breathing circuit was at least partly implicated. Our original article [2] was inspired by a critical incident in our own hospital involving a disconnected breathing circuit, and concluded with a similar recommendation. There cannot now be any doubt that the practice of using the common gas outlet for the administration of supplemental oxygen to patients undergoing procedures under regional anaesthesia is fraught with potential for disaster. The solution is very simple and recommendations have been made. Supplemental oxygen for procedures conducted under regional anaesthesia must be administered from a dedicated source separate from the common gas outlet and standard anaesthetic breathing circuit. The practice of using the common gas outlet for this purpose should cease immediately. Units that do not have anaesthetic machines with a separate oxygen source should either upgrade their machines or provide a free-standing oxygen cylinder. We believe a statement to this effect from the Royal College of Anaesthetists and the Association of Anaesthetists could help protect all concerned from further tragedy.

Are we surrogate mothers, form fillers or practitioners?

Everyone knows that there is a chronic shortage of midwives. In some areas there are problems with recruitment and in others there are problems with retention. Midwives are also under continual pressure to provide a service expanding out of proportion. Antenatally, more is required from the midwife in offering informed choice so women are aware of all they are entitled to as well as what is locally available. Giving advice on screening results and on lifestyle changes, exploring mental health and social circumstances all impact on maternal mortality (Confidential Enquiry into Maternal and Child Health (CEMACH), 2004) are an essential role of the midwife in the 21st century. It is therefore necessary to explore a more effective ‘use’ of the midwife.

Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000–2002, the Confidential Enquiries into Maternal Deaths in the United Kingdom : Chapter 9: Anaesthesia

This is the first of two extracts from Why Mothers Die 2000-2002, issued on 12 November 2004 by the Confidential enquiry into Maternal and Child Health (CEMACH), reproduced with permission. The full report can be accessed via their web site: http://www.cemach.org.uk/

Maternal deaths from anaesthesia. An extract from Why Mothers Die 2000–2002, the Confidential Enquiries into Maternal Deaths in the United Kingdom : Chapter 17: Trends in intensive care

This is the second of two extracts from Why Mothers Die 2000-2002, issued on 12 November 2004 by the Confidential enquiry into Maternal and Child Health (CEMACH), reproduced with permission. The full report can be accessed via their web site: http://www.cemach.org.uk/

Learning lessons from ‘Why Mothers Die’

The ‘Why Mothers Die’ Report (2000 – 2002) from the Confidential Enquiry into Maternal and Child Health (CEMACH) (RCOG, 2004), was launched on 12 November 2004 at the Royal College of Obstetricians and Gynaecologists (RCOG). This is the latest report by the Confidential Enquiry into Maternal Deaths (CEMD), the first having been published in 1957 when the risk of a mother dying was 1 in 1500.