Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer

The Poms have just released the 8th triennial report into Maternal Deaths in the UK.  It is worth reading if you do regular antenatal care or Obs and have 3 hours to spare (maybe during a troublesome second stage?).  If you prefer the shorter version to can read the Executive Summary (21 pages).  However there are a few key points to know and the team have boiled it down to 10 key recommendations.

Overal mortality was improved and this included in some disadvantaged groups.  The big jump in serious mortality came from genital tract sepsis, thromboembolic disease was improved.  The role of communication and process failure came under the spotlight with the following list of recurrent themes:

poor or non-existent team working

• inappropriate delegation to junior staff

• inappropriate or too short consultations by phone

• the lack of sharing of relevant information between health professionals, including between General Practitioners (GPs) and the maternity team

• poor interpersonal skills.

The “human element” remains one of the toughest areas to fix in many areas of practice and Obstetrics is no exception.  Difficult to roll out a new protocol which will cut the rate of human errors.  Personally I have found the “In-Time” courses are great for learning how to work as a team and avoid a few traps.

One observation from the recent Airway disaster report that might be worth noting – the simple act of discussing potentially difficult cases with a colleague can sometimes be enough to avoid oversights / errors which might otherwise lead to a poor outcome for the patient.  I think that for the generalist, those of us who practice in isolation, this is especially pertinent.




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