UK Confidential Enquiry Research Articles

Strategies for the prevention of maternal death from venous thromboembolism clinical recommendations based on current literature.

Venous thromboembolism (VTE) is one of the leading causes of direct maternal deaths. It has been estimated that approximately 50% of these deaths are potentially preventable. The UK Confidential Enquiries into Maternal Deaths and the National Partnership for Maternal Safety have proposed strategies for the prevention of maternal deaths from VTE based on current guideline recommendations. The main strategies include: - Early recognition and comprehensive assessment of risk factors for VTE at different times from the beginning of pregnancy until patient's discharge from hospital. - Appropriate risk stratification using standardized VTE risk assessment tools (e.g. the Royal College Scoring System). - Risk-based antenatal and postnatal heparin thromboprophylaxis adjusting the heparin dosage and the duration of prophylaxis to the individual patient's risk. - Adequate management of heparin prophylaxis before and after delivery. - Preference of universal rather than selective post-cesarean heparin thromboprophylaxis and application of perioperative mechanical prophylaxis. - Avoidance of gaps in the postpartum prescription of heparin. - Good communication and cooperation between primary and secondary care including community midwifery staff in the postpartum period. - Immediate intravenous administration of (unfractionated) heparin, if pulmonary embolism is suspected. - Critical analysis of all thromboembolic events, particularly in association with maternal death to learn from failures and to realize, if and where improvement is needed. Adequate pharmacological thromboprophylaxis has the potential to reduce the risk of VTE by 60-70% in pregnant women at increased risk.

Women who decline blood during labour: Review of findings and lessons learnt from 52 years of Confidential Enquiries into maternal mortality in the United Kingdom (1962–2019)

ObjectivePatients who decline blood products because of their religious beliefs pose a unique challenge in the context of obstetric haemorrhage. Four large series assessing maternal outcomes in Jehovah’s Witnesses from USA, UK, Netherlands and Japan estimate that maternal mortality is increased by between 44 and 160-fold. A review of maternal deaths from obstetric haemorrhage was undertaken in mothers who decline blood transfusion, using UK Confidential Enquiries into Maternal Deaths reports (1967–2019) in order to identify common trends and lessons learnt. DesignRetrospective review using 18 triennial Confidential Enquiries in Maternal Deaths reports between 1967 and 2019. ResultsFifteen maternal deaths from haemorrhage were reported in patients who declined blood products for religious beliefs in the 52 years reviewed. Common themes noted included delay in senior escalation, hesitation to perform life-saving hysterectomy and loss of situational awareness. Placental abruptions (3/15) and curettage for secondary postpartum haemorrhage (2/15) especially warrant senior input and cooperation with Jehovah’s Witness Hospital Liaison Committees is recommended. ConclusionsGuidelines from the UK’s Royal College of Obstetricians and Gynaecologists and Royal College of Surgeons highlight the need for collaborative, Montgomery-competent discussions during the antenatal period, as well as the engagement of local Jehovah’s Witness Hospital Liaison committees. Consultant-led care, antenatal optimisation of haemoglobin and techniques to mitigate blood loss at delivery are paramount. We advocate using a lower threshold for hysterectomy than was used in the cases analysed, for example when the haemoglobin level drops below 8–9 g/l in the context of ongoing bleeding. As patients increasingly begin to decline blood products for non-religious reasons, the lessons learnt in the management of Jehovah’s Witnesses are becoming ever more relevant.

A guide to caesarean wound healing

A guide to caesarean wound healing

P.55 Service evaluation of accidental dural puncture follow-up and outcomes in the Royal Gwent Hospital

Introduction: Post-dural puncture headache (PDPH) is among the most common complications of neuraxial obstetric anaesthesia, with symptoms ranging from mild headache to severe impairment. Following reports of maternal death associated with PDPH, [1] Knight M, Kenyon S, Brocklehurst P, et al. (Eds.) MBRRACE-UK. Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. NPEU University of Oxford 2014. Google Scholar the Royal Gwent Hospital introduced a more stringent protocol for follow up of patients with accidental dural puncture (ADP), in conjunction with the introduction of 18G Tuohy needles as standard, aiming to improve outcomes following ADP. [2] Russell IF. A prospective controlled study of continuous spinal analgesia versus repeat epidural analgesia after accidental dural puncture in labour. Int J Obset Anesth 2012;21:7–16. Google Scholar This service evaluation aims to review our compliance with the new follow-up protocol and review rates and management of PDPH following ADP.

P.35 Post-dural puncture headache in a DGH: A decade after MBRRACE-UK

Introduction: The 2009-2012 MBRRACE-UK report identified 2 post dural puncture headache (PDPH) case fatalities that lacked appropriate follow-up. [1] Knight M, Kenyon S, Brocklehurst P, et al. (eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-12. Oxford National Perinatal Epidemiology Unit. University of Oxford 2014 Google Scholar We audited our PDPH incidence and management, and compared this the standards set by the Obstetric Anaesthetists’ Association (OAA), national data as well as our six previous audits. 2 OAA. Treatment of Obstetric Post Dural Puncture Headache; 2018. https://www.oaa-anaes.ac.uk/assets/_managed/cms/files/Guidelines/New%20PDPH% 20Guidelines.pdf Google Scholar , 3 OAA. Epidural information card; 2016. https://www.labourpains.com/Epidural-Information-Card Google Scholar

P.85 Re-audit of the management of blood product administration for major obstetric haemorrhage

Introduction: Major obstetric haemorrhage (MOH) is a leading cause of morbidity and mortality worldwide accounting for 12.6% of direct maternal deaths in the 2015-17 MBRRACE-UK report. [1] Knight M, Bunch K, Tuffnell D et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care-Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015–17. Oxford: The National Perinatal Epidemiology Unit, University of Oxford 2020. Google Scholar Point-of-care (POC) testing (ROTEM/TEG) has been recommended by the RCOA, OAA and Association of Anaesthetists, to improve patient care, allowing cost-effective, real-time haemostatic resuscitation. Local hospital policy for MOH recommends 1:1 transfusion of RBC:FFP or as directed by TEG. Following a 2016 audit, [2] Niewiarowski J, Russell R. Management of blood product administration for major obstetric haemorrhage. OAA Obstetric Anaesthesia 2017. https://www.epostersonline.com/oaa2017/node/690?view=true Google Scholar a visual aid using TEG traces was designed to guide blood product replacement. Re-audit in 2018, [3] Niewiarowski J, Smith A, Russell R. Improving the management of blood product administration for major obstetric haemorrhage. Int J Obstet Anesth 2019;39/S1:S50. Google Scholar showed significant improvement in protocol adherence and led to the purchase of two TEG6 machines. This audit aimed to re-evaluate adherence to hospital guidelines and use of TEG6 to streamline transfusion of blood products.

P.61 Evaluation of major obstetric haemorrhage management in a tertiary unit

Introduction: Major obstetric haemorrhage (MOH) is a leading cause maternal morbidity/mortality. [1] Knight M, Bunch K, Tuffnell D et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care- Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015 –17. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2019. Google Scholar Optimal blood and blood product transfusion is pivotal to preventing coagulopathy, and complements pharmacological/surgical treatments. We reviewed management of MOH in our unit.

P.102 Uterotonic drug use: a snapshot of clinical practice within obstetric departments in the UK

Introduction: Postpartum haemorrhage (PPH) is the third highest cause of direct maternal death in the UK and Ireland. [1] Knight M, Bunch K, Tuffnell D et al on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17. Google Scholar Uterine atony is the leading cause of PPH. A range of uterotonic drugs are used for the prevention and treatment of PPH. There has been wide variation, within the UK and internationally, on the use of uterotonic agents. 2 West R, West S, Simons R, McGlennan A. Impact of dose finding studies on anaesthetic prescribing practice of oxytocin in the United Kingdom. Anaesthesia 2013; 68: 1021 –5. Google Scholar , 3 Thorneloe B, Carvalho JCA, Downey K, Balki M. Uterotonic drug usage in Canada: a snapshot of the practice in obstetric units of university-affiliated hospitals. Int J Obstet Anesth. 2019;37:45-51. Google Scholar A publication to guide the use of uterotonic agents during caesarean section has recently been published. [4] Heesen M, Carvalho B, Carvalho JCA, et al. International consensus statement on the use of uterotonic agents during caesarean section. Anaesthesia. 2019;74:1305-19. Google Scholar

P.115 Timing is everything: Labour epidurals and anticoagulants

Introduction: The latest MBRRACE report advocates the need for pregnant women on prophylactic and treatment dose anticoagulation to have a structured management plan during the peripartum period. [1] Knight M, Bunch K, Tuffnell D, et al. (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016 – 18. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2020. Google Scholar In our district general hospital, peripartum documentation is a mix of paper and electronic records. Further to this all drug prescriptions are charted on an electronic system. An Association of Anaesthetists guideline exists for the timing of neuraxial anaesthesia and anticoagulants. [2] AAGBI: Regional anaesthesia and patients with abnormalities of coagulation 2013. https://anaesthetists.org/Home/Resources-publications/Guidelines. Google Scholar This is pertinent on the labour ward where epidurals are commonplace and patients are often prescribed anticoagulation. Clear communication within the labour ward multidisciplinary team (MDT) is paramount in ensuring the safe timing of neuraxial anaesthesia. There are serious implications if these guidelines are not followed which could have devastating consequences for the patient.

P.33 A five-year review of parturients with valvular heart disease: Experience in a tertiary obstetric centre

Introduction: Cardiac disease remains the leading cause of indirect maternal death and the commonest cause of maternal death worldwide. [1] MBRRACE-UK. Saving Lives, Improving Mothers’ Care-Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015 –17. Oxford: The National Perinatal Epidemiology Unit, University of Oxford 2020. Google Scholar It is therefore important to identify and optimise patients with cardiac disease during their pregnancy and birth. For this project, we reviewed the anaesthetic management and outcomes of parturients with valvular heart disease presenting to our institution over a five-year period.

MBRRACE‐UK update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2020

MBRRACE‐UK update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2020

Year of the nurse: highlighting careers, nurse-led work and innovation in cardiovascular nursing

British Journal of Cardiac NursingVol. 15, No. 10 Year of the NurseYear of the nurse: highlighting careers, nurse-led work and innovation in cardiovascular nursingMaggie SimpsonMaggie SimpsonCorrespondance to: E-mail Address: [email protected]Search for more papers by this authorMaggie SimpsonPublished Online:24 Oct 2020https://doi.org/10.12968/bjca.2020.0134AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Knight M, Bunch K, Tuffnell D et al. (eds). Saving lives, improving mothers' care: lessons learned to inform maternity care from the uk and ireland confidential enquiries into maternal deaths and morbidity 2015-17. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2019 Google ScholarRegitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J et al.. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J. 2018;39(34):3165–3241. https//doi.org/10.1093/eurheartj/ehy340 Crossref, Google Scholar FiguresReferencesRelatedDetails 2 October 2020Volume 15Issue 10ISSN (online): 2052-2207 Metrics History Published online 24 October 2020 Published in print 2 October 2020 Information© MA Healthcare LimitedPDF download

MBRRACE‐UK update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2019

MBRRACE‐UK update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2019

UK Confidential Enquiry into Maternal Deaths: Still Learning to Save Mothers’ Lives

(Anaesthesia. 2018;73:407–420) This editorial summarized results from the fourth report of the Confidential Enquiry into Maternal Deaths and Morbidity from the MBRRACE-UK collaboration and provided commentary about some of the findings.

Introduction of a modified obstetric early warning system ­(­MOEWS­)­ at an Ethiopian referral hospital: a feasibility assessment

Early warning scores are points-based or colour-coded systems used to detect changes in physiological parameters and prompt earlier recognition and management of deteriorating patients. Vital signs recorded within a coloured...

MBRRACE‐UK Update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2018

MBRRACE‐UK Update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2018

The findings of the MBRRACE-UK confidential enquiry into Maternal Deaths and Morbidity

Reports from the UK Confidential Enquiries into Maternal Deaths and Morbidity are now published annually. In 2013–15, the maternal mortality rate was 8.8 per 100,000 maternities. Over two thirds of women died from medical and mental health causes and less than one third from obstetric causes. Cardiac disease remained the leading cause of maternal death in the UK. With the majority of women dying from pre-existing conditions, there remain multiple opportunities to reduce women's risk of complications in pregnancy through early and forward planning of the care of women with known pre-existing medical and mental health problems. Provision of appropriate advice and optimisation of medication prior to pregnancy, referral early in pregnancy for the appropriate specialist advice and planning of antenatal, intrapartum and postnatal care and effective postnatal provision of advice concerning risks and planning for future pregnancies are the key improvements needed to prevent women dying in the future.

A View From the UK: The UK and Ireland Confidential Enquiry into Maternal Deaths and Morbidity.

The UK Confidential Enquiry into Maternal Deaths has been in operation for more than 60 years, during which time maternal mortality rates have fallen 10-fold. The program includes two aspects, surveillance and confidential case review, providing different information to aid quality improvement in maternity care. The enquiry now also reviews the care of women with specific severe morbidities. Recommendations have very clearly led to improved outcomes for women, most notably shown in the very low mortality rate due to hypertensive and related disorders of pregnancy. Maternal cardiac disease and mental health problems remain the major areas still to be addressed.

UK Confidential Enquiry into Maternal Deaths – still learning to save mothers’ lives

UK Confidential Enquiry into Maternal Deaths – still learning to save mothers’ lives

MBRRACE‐UK Update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2017

The latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths, the fourth in the new annual report format, and the first to repeat the 3‐yearly thematic cycle, was published in December,1 and includes surveillance and Confidential Enquiries covering the period 2013–15. Once again the report includes reviews into the care of women who died during or after pregnancy in the Republic of Ireland as well as the UK. Following the annual topic‐specific format, this report includes topic‐specific reviews into the care of women who died from neurological conditions, other medical and surgical conditions, sepsis, anaesthetic complications, haemorrhage and amniotic fluid embolism, as well as Confidential Enquiries into the care of women with morbidity due to uncontrolled epilepsy in pregnancy and those with severe postpartum mental illness.