Hour-long delays to emergency surgery

Five women who suffered major obstetric haemorrhage endured delays ranging from 10-100 minutes accessing theatre, according to a national audit examining the incidence of life-threatening complications in maternity units.

The finding, contained in the 2012/2013 annual report Severe Maternal Morbidity (SMM) in Ireland, comes at a time when maternity services are under the spotlight following a number of controversial baby deaths in the Midlands Regional Hospital, Portlaoise, and Cavan General Hospital.

Earlier this week, the Irish Nurses and Midwives Organisation said there were ongoing issues accessing a second theatre out-of-hours in Cavan, which caters for both surgical and obstetric emergencies.

The report, by the Cork-based National Perinatal Epidemiology Centre, also found a four-fold increase in the number of women who developed septic shock — up from four cases in 2011 and 2012, to 16 cases in 2013.

The report’s authors said this may be due to “a true increase in incidence” or “an increased awareness and recognition of sepsis”.

Sepsis was the cause of death in the high-profile case of Indian woman Savita Halappanavar, who died in October 2012 amid claims that she had been refused an abortion. Her death led to national protests and a change in the country’s abortion laws.

The second report from the national audit of SMM found over the three years of the audit (2011-2013) covering 615 cases of SMM that:

• The incidence of life-threatening complications increased from 3.8 per 1,000 maternities to 4.75;
• In the cases of 20 women who endured massive obstetric haemorrhage, management of the case did not adhere to unit protocol, although in the majority of cases, protocol was followed;
• Among babies born to women with SMM, one in 20 infants died, giving a perinatal mortality rate eight times the rate observed for all births in Ireland.

Also of concern was the finding that although there has been an increase in the presence of obstetricians attending women who suffered major obstetric haemorrhage, the reverse was the case in women identified as high-risk prior to childbirth, where there was a decrease in the reported presence of an obstetrician at delivery.

Of the 42 women where complications led to a hysterectomy after childbirth, 80% had a previous caesarean section and for most of these cases a factor was the placenta adhering to the uterus wall. The authors said this finding suggests as C-section rates continue to rise, “there may be an associated increase” in the rate of peripartum hysterectomy

NPEC director Richard Greene said feedback from maternity units in relation to the audit was positive — that it was regarded as a valuable tool for making improvements, highlighting inconsistencies and prompting internal reviews.

The report makes nine recommendations including that the HSE provide funding to ensure staffing levels allow doctors protected time to carry out audits. The report says, “Robust clinical audit of perinatal outcomes in all maternity units in Ireland is vital for patient care”.

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