Unfamiliarity breeds infection
Wed 5th Dec 2007 by Ben Palmer.I have now downloaded a copy of "Saving Mothers' Lives" and am reading through it. A few paragraphs under the Genital tract sepsis chapter have caught my attention:
"As in previous Reports there was failure or delay in diagnosing sepsis, failure to appreciate the severity of the woman’s condition with resultant delays in referral to hospital, delays in administration of appropriate antibiotic treatment and late or no involvement of senior medical staff. There were some cases where doctors said they were already so busy dealing with other urgent problems that they were unable to see women for some time after admission. It was also clear that many doctors, midwives and community midwives were unfamiliar with the signs and symptoms of sepsis, did not realise when a woman was deteriorating or critically ill and failed to appreciate how quickly the clinical condition of a septic woman can deteriorate. There were also failures to take routine basic observations, to recognise abnormal fetal cardiotocograph (CTG) patterns and to ask for senior advice at an early stage."
"These cases of classical puerperal sepsis due to Group A haemolytic streptococcal infection demonstrate that by the time sepsis is clinically obvious, infection is already well established and deterioration into widespread septicaemia, metabolic acidosis, coagulopathy and multi-organ failure is very rapid and often irreversible. The best defence against this situation is awareness of the early signs of sepsis and early recognition by routine regular basic clinical observations. Earlier detection of pyrexia might have made a difference in these three cases. Postnatal observations of pulse, temperature, BP, respiration, and lochia should be done regularly while the woman is still in hospital and for several days after discharge by her community carers. This is particularly important in women who leave hospital a few hours after birth, ‘early discharge’, or if a woman complains of feeling feverish or unwell."
"In the past, puerperal sepsis or ‘childbed fever’ was a leading cause of maternal death and its signs and symptoms were widely known. Antisepsis, antibiotics and changing practice over the years mean that genital tract sepsis has become much less common and death is rare. The fear and respect with which it as held in the past by obstetricians, midwives and patients has disappeared from our collective memory. Action is now required to raise awareness of the signs and symptoms of sepsis and recognition of critical illness among staff in maternity units or in the community, Emergency Departments, and among GPs and health visitors.
The cases in this Report clearly demonstrate that genital tract sepsis is still a problem, that is repeatedly missed and there is often failure to treat women early and aggressively enough. Some of these maternal deaths may have been prevented if the signs and symptoms of sepsis and developing septicaemic shock had been recognised and treated earlier. Nevertheless the clinical picture of life-threatening sepsis often develops very rapidly and in many of the cases the outcome could not have been prevented."
There are more sections that could well have been cut and pasted from the previous report. And the one before. Why did I ever wonder if there was a point to raising awareness of sepsis? I have a very strong sense of deja vu. I hope these recommendations are followed in the future.
December 5th, 2007 at 23:11
I've just been reading the Cemach Report, your blog and its excerpts from the Report.
It jumps out at me that some of the recommendations made in the Report in fact reflect in detail exactly what happened as part of the routine, normal care of mothers in the days when I had my children in the 1970s.
It was normal for mothers either to be kept in hospital under close observation for 7-10 days, or to be kept in hospital for 48 hours and then discharged, once the midwives' twice daily home visits had been fixed up so that the mother was seen for the first 10 days after delivery. Sometimes mothers could be discharged after 24 hours in cases where it had been checked that there was proper help at home e.g. an independent midwife. In all cases, after giving birth we were not allowed out of bed for a minimum of six hours.
If we were discharged after a week, the midwives would come in until the baby was 10 days old to check both mother and baby. By check, I mean that temperature, pulse and blood pressure were taken twice a day, the lochia was checked, and we could talk over any problems or anxieties. It was what I call 'care' in its proper sense. It is amazing that it is now necessary for a report to recommend that:
"The best defence against this situation is awareness of the early signs of sepsis and early recognition by routine regular basic clinical observations. Postnatal observations of pulse, temperature, BP, respiration, and lochia should be done regularly while the woman is still in hospital and for several days after discharge by her community carers."
... All that was routine in the 70s.
At least they are recommending what you might call simple common sense. But it can't be thought of as progress; it’s more a question of returning to normality.