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most common causes of coincidental death are road traffic accidents and murder. The 2006–2008 report recommended that all pregnant women should be advised to wear a three‐point seat belt in a motor vehicle and the 2014–2016 report again recommended that routine enquiry about domestic abuse should be made at booking or during pregnancy. All women should be seen alone at least once in pregnancy. If an injury, like a black eye, is noticed, staff should ask sympathetically – but directly – how it was caused and should be prepared to offer support. All women who were murdered between 2014 and 2016 were murdered by a partner or former partner, and the rapid report into SARS‐CoV‐2‐associated deaths also noted two deaths due to domestic violence. It remains important that women are given the opportunity to disclose domestic abuse, and that they are appropriately referred for support if they do.

2.8 Quality of care

      The CEMD assessors try to be realistic when assessing the quality of care, and now focus attention on whether improvements in care could have been expected to affect the outcome, rather than grading care as substandard. The proportion of deaths where improvements in care could reasonably have been expected to affect outcome was 51% in the 2020 report, while 29% were considered to have good care. The main shortcomings remain: lack of clinical knowledge and failure to recognise high‐risk clinical signs, and failure to identify very sick women with failure to escalate to senior support or sufficiently rapidly to other specialists.

In recent years, hospitals have undertaken their own investigations of ‘serious untoward incidents’ and these reports have been made available to the CEMD. The quality of these reports has been highly variable and a previous report commented that some were, ‘Not worth the paper they were written on and a few [were] actually whitewashes or cover‐ups for unacceptable situations.’ Learning lessons from maternal deaths is not easy when they occur in your own hospital. MBRRACE‐UK has made specific recommendations about these local reviews since 2015, including the recommendation that there are external panel members to ensure local review is robust and lessons are learned.

2.9 The international dimension

There are over 300 000 maternal deaths annually worldwide, of which 99% are in developing countries. The leading causes are shown in Table 2.5.

Table 2.5 Causes of maternal deaths worldwide

      Source: Data from Maternal mortality, 2015, World Health Organization. https://data.unicef.org/topic/maternal‐health/maternal‐mortality/

Cause	Percentage (%)
Haemorrhage	27
Sepsis	11
Unsafe abortion	8
Pre‐eclampsia/eclampsia	14
Embolism	3
Other direct causes	10
Indirect causes	28

      The underlying problems include: lack of access to contraception, lack of primary care or transport facilities and inadequate equipment and staffing in district hospitals. The United Nations has made the reduction of maternal mortality one of its Millennium Development Goals. The worldwide proportion of births with a trained attendant has risen to 61%, but much remains to be done.

      The UK Confidential Enquiries are globally respected as an example of good practice and several countries – for example South Africa, Moldova and Kazakhstan – have set up their own enquiries adapted from the UK model.

2.10 Summary

      The common assumption that safe childbirth is a side effect of national prosperity is wrong: with prosperity we see increasing numbers of women with co‐morbidities, an increase in age of the pregnant population, and most notably an increase in obesity. While complications such as thrombosis can often be prevented, this is not always the case. Other pathology such as haemorrhage (which can sometimes be prevented or minimised by prompt recognition and timely intervention) can still be catastrophic, and conditions such as pre‐eclampsia cannot be prevented completely. In all these, and many more situations, prompt and effective treatment is saving lives routinely on a daily basis throughout the UK. When a death does occur, the public expects exhaustive analysis: sometimes this reinforces old lessons, but often new lessons emerge. One conclusion is clear from reviewing CEMD reports from the past 60 years: when vigilance is relaxed, people die.

2.11 Further reading

      1 Knight M, Bunch K, Cairns A, et al. (eds), on behalf of MBRRACE‐UK. Saving Lives, Improving Mothers’ Care Rapid Report: Learning from SARS‐CoV‐2‐related and Associated Maternal Deaths in the UK March–May 2020. Oxford: National Perinatal Epidemiology Unit, University of Oxford, 2020.

      2 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.

      3 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.

CHAPTER 3 Structured approach to emergencies in the obstetric patient

      Algorithm 3.1 Structured approach to emergencies in the obstetric patient

      Learning outcomes

      After reading this chapter, you will be able to:

       Identify the correct sequence to be followed in assessing and managing seriously ill or seriously injured patients

       Outline the concept of the primary and secondary surveys

3.1 Introduction

      The structured approach refers to the ‘ABCDE’ approach to life saving. The aim of the structured approach is to provide a system of assessment and management that is effective, and simple to remember, in the heat of an emergency. It can be applied to any patient with a threat to life, be that from illness or injury. Assessment is divided into primary survey and secondary survey. The approach is the same for all: adults, children, the elderly and pregnant women.

      Primary survey

      The system follows a simple ABCDE approach, with resuscitation taking place as problems are identified, i.e. a process of simultaneous evaluation and resuscitation.

      The primary survey uncovers immediately life‐threatening problems by priority, i.e. in the order in which they will most quickly kill. The medical sequence in the ABCDE approach is that an Airway problem will kill the patient more quickly than a Breathing problem, which in turn

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