Maternal death

Effective management is important in the rare event of maternal death.

Professionals who are involved in providing both primary and secondary care play an important role in participating in the on-going confidential enquiry into maternal deaths (MBRRACE) firstly by recognising that a maternal death has occurred and secondly by ensuring that the appropriate people have been notified. Classification of maternal death is not always obvious. Therefore it is necessary to have clear definition of the inclusion criteria.

• A maternal death is defined as the death of a woman while pregnant or within 1 year of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
• A direct death is defined as death resulting from obstetric complications of the pregnant stage (pregnancy, labour and puerperium), from interventions, omission, incorrect treatment or from a chain of events resulting from any of the above.
• An indirect death is defined as a death resulting from previous existing disease or disease that developed during pregnancy but which was aggravated by the physiological effects of the pregnancy. These include cases of self-harm as a consequence of postnatal depression.
• A late death is defined as death occurring between 42 days and one year after termination of pregnancy, miscarriage or delivery that is due to Direct or Indirect maternal causes.
• A coincidental death is defined as a death from unrelated causes, which happens to occur in pregnancy or the Puerperium in some malignancies, domestic violence and road traffic accidents etc.

It is important to involve and disseminate information on the notification of, and management of, the subsequent enquiry into a maternal death to the following professionals who may have cared for the woman:

• Obstetricians and Gynaecologists
• Midwives (both hospital and community)
• General Practitioners
• Health Visitors
• Community Nurses
• Practice Nurses
• Psychiatrists and Community
• Psychiatric Nurses
• Physicians
• Surgeons
• Managers of maternity or obstetric trusts
• Hospital Chaplain
• Mortuary Department
• Hospital Nurses
• Accident and Emergency Staff
• Registrars and Senior House Officers
• Intensive Care Unit Staff
• Pathology Consultants

A maternal death may occur in the community or in the hospital.

The enquiry is started by the Director of Public Health for the district in which the woman lived. If the woman was not resident in the hospital’s local district, the local Director of Public Health will ensure that the Director of Public Health in the area of residence is notified.

The responsibility for notifying the Director of Public Health that a maternal death has occurred rests with either the consultant, midwife or general practitioner treating the woman during her final illness, if the death occurs within one year following the end of her pregnancy.

It does not matter if more than one professional notified the Director of Public Health, as case ascertainment is more important than duplication of notification.

Appoint a co-ordinator

For maternal deaths occurring in hospital, it is advisable for the director of the relevant department to appoint one person who has overall responsibility for ensuring that the local policies are followed. The policy should detail who will act as co-ordinator for the particular department.

As a maternal death may occur in a variety of clinical areas within the hospital setting, e.g. ICU or A&Emergency, it may be advisable to nominate a Senior Midwife or Supervisor of Midwives to undertake the role of co-ordinator.

The role of the co-ordinator may be both complex and demanding and the co-ordinator should be released from their normal duties for the duration of this process.

Actions

The co-ordinator must ensure that a confidential and accurate record of each part of the procedure that has been followed is maintained. 

The development of a quick checklist containing dates and times may be useful and the co-ordinator should then ensure the checklist is completed.

An experienced member of staff is nominated to act as the relatives main point of contact to prevent conflicting information being given.

The consultant on-call should be contacted and must meet the relatives as soon as possible. If the woman already has a named consultant, he or she should be informed when next on duty.

The mortuary department should be informed that a maternal death has occurred and to expect the patient. The mortuary attendant may inform the pathologist on-call. If not, it will be the responsibility of the woman’s consultant to do so.

Post-mortem

Guidelines for the procedures to be followed in a maternal autopsy are available from the Royal College of Pathologists. If at all possible, a post-mortem should be undertaken in order to confirm the cause of death. The consultant present should seek permission for a post-mortem from the woman’s next of kin. If the cause of the death is unknown, The Procurator Fiscal is informed and he/she will be responsible for ordering a post-mortem.

The case notes and all documentation should be completed, photocopied and secured at the first opportunity. It should be noted that the Procurator Fiscal may decide to hold a hearing on the case. If this happens, the case notes and documentation will be sent to the Procurator Fiscal office.

Additional actions

Staff involved in the case may require support. Local policies may already be in place to address this issue. If policies do not exist, then support may be sought from personnel such as the hospital chaplain or the provider staff counsellor.

Definition and registration of stillbirth

In the event of the baby dying in the uterus, the following should be taken into consideration:

The definition of stillbirth does not include the removal of a dead baby from its dead mother at post-mortem for the purpose of ascertaining the cause of death. This is because the post-mortem is being carried out on the mother rather than the baby. Therefore, registration of a baby in these circumstances over 24 weeks gestation, as a death is not legally required. This advice has been given by the Registrar General (Office for National Statistics).

However, consideration must be shown for the wishes of the family. A medical practitioner may issue a death certificate for the dead baby as stillborn. Most Registrars of Births, Deaths and Marriages will comply but local policies in this respect should be checked in order to prevent confusion and further distress for the family.

A printable version with space for date and initials is available here.

Maternal death checklist

• Nominate staff member as relatives' contact
• Contact obstetric consultant on-call
• Ensure relatives are seen by consultant - if not woman's own consultant, then inform her named consultant when next on duty
• Inform mortuary department
• Arrange for relatives to see deceased
• Follow Royal College of Pathologists' guidelines to obtain consent for post-mortem
• Ensure completion of Critical Incident Report and initiate internal investigation, if appropriate
• Complete, photocopy and secure case-notes and all documentation as soon as possible
• Opportunity for photos, hand and foot prints etc. of baby should be offered to partner/next of kin, where appropriate (see stillbirth guidelines)
• Opportunity for chaplain or own religious advisor to be notified
• Inform community midwife, GP and other appropriate persons
• Offer counselling and support staff involved

As the majority of pathologists will tend to remove the baby from the mother’s body at post-mortem, it is sensible for the local stillbirth/neonatal death procedure to be followed whether the baby is to be registered as a death or not. It would also be helpful for the normal CESDI procedure to be followed.

The relative may wish for their local minister, priest, vicar, rabbi or whoever is applicable for the religious denomination to be notified. They may also wish for this person to be with them at the hospital. If they are uncertain or would like someone of faith to be with them, the hospital chaplain should be contacted.

The following should also be notified when next on duty:

• The Trust Chief Executive Officer
• The Clinical Director
• The Consumer Affairs, Complaints and Risk Manager
• The community midwife and GP involved in the patient's care, if applicable
• Clinical managers, particularly in case they receive a query in relation to the case

Arrangements should be made for the woman’s family to meet as soon as possible with her consultant. At least one further meeting should be arranged for when the results of investigations are available, in order for the findings to be comprehensively discussed with the woman’s close relatives.