Learning from Catastrophe

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Learning from Catastrophe

  1. 1. LEARNING FROM CATASTROPHE
  2. 2. “Why Mothers Die” – CEMD(UK) – 1997-99 The CEMD (Malaysia) 1995-96 The Impoverished Developing World(WHO)
  3. 3. MMR/100,000 in UK Late 30s. 420 Late 50s. 41 Early 2000s. 11
  4. 4. MMR/100,000 Risk of Mat.Death 1 in World 400 75 Developed 21 2500 Developing 440 60 Impoverished 1000 16 ---------------------------- Singapore 9 5400 UK 11 4600 Malaysia 44 270 South Africa 70 85 India 440 55
  5. 5. AIMS –To Establish 1. The Main Cause of Death 2. Whether Substandard Care present 3. To reduce Maternal Mortality and Morbidity ratios still further by – - recommending improved care - directing future research and audit 4. To illuminate Success where results have improved.
  6. 6. Maternal Deaths Direct Death – due to obstetric complications or obstetric problems in management occurring in pregnancy or within 42 days of the end of pregnancy Indirect Death – resulting from pre-existing disease or disease that developed during or was aggravated by pregnancy but was not due to direct obstetric causes Late Death – due to Direct or Indirect causes but occurring between 6 weeks and a year after pregnancy Coincidental/Fortuitous Death – due to unrelated causes occurring in pregnancy or in the puerperium The ratio used in the UK is the no. of deaths/100,000 maternities ie.mothers delivered of live or still-born babes after 24/52 In Malaysia – the denominator used is the number of babies born
  7. 7. Maternal Mortality Rates - Malaysia MMR/100,000 1930 1300 1950 540 1970 139 1991/92 44.0 / 47.8 1993/94 45.8 / 39 1995/96 46.9 / 40.0
  8. 8. Maternal Mortality –Malaysia 1995- 96 Direct Deaths (378) Haemorrhage - PPH 104 / 22% Obstetric Pulm Emb (AFE 22%) 74 / 16% Hypertensive Disease 61 / 13% Obstetric Trauma 19 / 4.2% Abortion 16 / 3.2% Puerperal Sepsis 16 / 3.2% Haemorrhage - APH 14 / 3% Anaesthetic 11 / 2.2% Ectopic 10 / 2.2% Indirect Deaths(93) Medical conditions 80 / 16.9% ( 48 had heart disease : of these, 19 had Rh. Heart D. Direct +Indirect Deaths = MMR of43.8/100,000
  9. 9. Maternal Death by Citizenship Citizen 79.5% Non citizen 17% Unknown 3.6% MMRs by Ethnic Groups Race % MMR Malay 48 39.5 Chinese 9.5 26.6 Indian 6.6 43.9 Ethnic/Mixed 17 69.3 Others 16.5 60.2 MMRs from PPH v. Ethnic groups Malay - 5.16 Indian - 4.61 Chinese - 3.87 Others - 129.5
  10. 10. Other Features of Interest MMR/100,000 Age – 25-29 (21%) 25.5 40-44 (13%) 136.7 45-49 (4%) 277.5 ------------------------------ Parity- Prims (21%) 28 Multips (60%) 42 Grand Multips (20%) 71 ------------------------------ Place of Birth State Hospital (63%) 37 Private Hospital(9%) 20.2 Home (24%) 75.7
  11. 11. Substandard Care Remediable Clinical Factors - 53% -inadequate/inappropriate/delayed treatment -failure to inform seniors -inappropriate delegation to juniors Contributory non clinical factors Facility/Personnel factors - 20% -absence of O&G Specialist -inadequate staff experience -remoteness/inaccessibility -Unavailable blood Patient factors - 30% -non compliance to advice,admission and/or treatment
  12. 12. Haemorrhage (Substandard Care - 71%) Constant vigilance is required : Check Hb ante natally Identify the mothers at high risk for PPH. Previous PPH is the best predictor Each unit must have clear written Guidelines and regular drills for the management of PPH and massive haemorrhage Have adequate IV access and at least 6 units of blood Senior staff- Obstetrician and Anaesthetist - should be informed early in an emergency situation – and should come in Utero-tonics and bimanual compression are basic in Management If surgery is required consider a Brace type suture early on before the more complex procedures, int. iliac ligation or hysterectomy.If concerned call a colleague for assistance Consider UAE if appropriate and available
  13. 13. Haemorrhage Senior staff should be in theatre for elective surgery where there is a high risk of haemorrhage. Beware placenta praevia and the scarred uterus.Difficult cases must not be delegated Particularly in Malaysia – Midwifes to be trained in venous access - Retrieval teams to be made available - If distance is a problem at risk mothers to stay in pre- delivery centres or Hospital to await delivery - Remember the importance of Family Planning in the over 40s and in the grand- multipara
  14. 14. Pulmonary Thromboembolism Substandard Care – 57% Pulmonary embolism can occur early in pregnancy - and after Vaginal Delivery Know the at-risk patients – BMI 30 ; past or family history of VTE etc. Prophylaxis for all at Caesarean Section Display Guidelines throughout the Unit Use thrombo-prophylaxis more widely All must think thrombo-embolism If clinically suspected - treat first then investigate Investigate properly!
  15. 15. Heart Disease in Pregnancy Substandard Care –12% The joint most common cause of Maternal Death in the UK – The fourth most common cause in Malaysia Women may minimize or deny symptoms All-important to diagnose before pregnancy or at least at Booking Clinic – can be notoriously difficult Counseling and Family Planning should be emphasized Women with pulm.hypertension are at great risk Multidisciplinary care is required ; team-work is all important Balloon or surgical valvotomy becomes indicated if Mitral Stenosis is not responding to medical treatment
  16. 16. Hypertensive Disease of Pregnancy Substandard Care - 80% Watch mod. to severe PET closely Watch multiple pregnancy closely The pregnant patient with headache and epigastric pain – requires BP and proteinuria check as a minimum check – all health-care providers should be made aware of this Beware automated BP readings alone Treat hypertensive crises effectively – hydralazine; labetalol MgSO4 is anticonvulsant of choice to prevent fits; Valium to abort fits Run the patient “dry” : Beware fluid -overload Have clear written Guide lines and regular drills for Management of severe/fulminating pre-ecl/eclampsia
  17. 17. Genital Tract Sepsis Substandard Care – 50% Beware the insidious onset of low grade pyrexia Careful assessment required of P.R.O.M. with fever / tachycardia With P.R.O.M. keep vaginal (aseptic) assessments to the minimum Use prophylactic antibiotics for CS Where pyrexial - take repeated specimens including blood culture for bacteriology
  18. 18. Ectopic Pregnancy Substandard Care 65% All Health-care workers - beware atypical presentations Urine dipstick testing for bHCG Laporoscopic surgery only if competent Don’t delegate difficult cases Call for senior help in good time Avoid unnecessary/unsupervised late night operating – if experienced staff not available Beware Cx Ectopics
  19. 19. Obstetric Trauma - CEMM Malaysia 19995/96 Remediable clinical factors in 70% Prstaglandins and Oxytocics must be used only with extreme caution in the grandmultiperous mother or in the presence of a previous scar Mismanagement of the 3rd stage contributes significantly to uterine inversion. All birth attendants must know correct management Uterine “massage” during labour by untrained birth attendants should be banned Beware disproportion in the patient with a scarred uterus
  20. 20. Thank you for your interest

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