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  • 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

    PatientSafetyLearning Team
    • UK
    • Data, research and analysis
    • Pre-existing
    • Original author
    • No
    • Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries Across the UK
    • 01/12/20
    • Health and care staff, Patient safety leads, Researchers/academics


    This report, the seventh MBRRACE-UK annual report of the Confidential Enquiry into Maternal Deaths and Morbidity, includes surveillance data on women who died during or up to one year after pregnancy between 2016 and 2018 in the UK.

    In addition, it also includes Confidential Enquiries into the care of women who died between 2016 and 2018 in the UK and Ireland from epilepsy and stroke, general medical and surgical disorders, anaesthetic causes, haemorrhage, amniotic fluid embolism and sepsis. The report also includes a Morbidity Confidential Enquiry into the care of women with pulmonary embolism.


    The majority of recommendations which MBRRACE-UK assessors have identified to improve care are drawn directly from existing guidance or reports and denote areas where implementation of existing guidance needs strengthening. In a small number of instances, actions are needed for which national guidelines are not available. These are included below. To access the report and the full list of recommendations, please click on the link at the bottom of this page. 

    New recommendations to improve care:

    For professional organisations

    1. Develop guidance to ensure SUDEP awareness, risk assessment and risk minimisation is standard care for women with epilepsy before, during and after pregnancy and ensure this is embedded in pathways of care. [ACTION: Royal Colleges of Obstetricians and Gynaecologists, Physicians].

    2. Develop guidance to indicate the need for definitive radiological diagnosis in women who have an inconclusive VQ scan [ACTION: Royal Colleges of Physicians, Radiologists, Obstetricians and Gynaecologists].

    3. Produce guidance on which bedside tests should be used for assessment of coagulation and the required training to perform and interpret those tests [ACTION: Royal Colleges of Anaesthetists, Obstetricians and Gynaecologists, Physicians]

    4. Establish a mechanism to disseminate the learning from this report, not only to maternity staff, but more widely to GPs, emergency department practitioners, physicians and surgeons [ACTION: Academy of Medical Royal Colleges].

    For policy makers, service planners/commissioners and service managers

    5. Develop clear standards of care for joint maternity and neurology services, which allow for: early referral in pregnancy, particularly if pregnancy is unplanned, to optimise anti-epileptic drug regimens; rapid referral for neurology review if women have worsening epilepsy symptoms; pathways for immediate advice for junior staff out of hours; postnatal review to ensure anti-epileptic drug doses are appropriately adjusted [ACTION: NHSE/I and equivalents in the devolved nations and Ireland].

    6. Ensure each regional maternal medicine network has a pathway to enable women to access their designated epilepsy care team within a maximum of two weeks. [ACTION: Maternal Medicine Networks and equivalent structures in Ireland and the devolved nations].

    7. Ensure all maternity units have access to an epilepsy team [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards].

    8. Establish pathways to facilitate rapid specialist stroke care for women with stroke diagnosed in inpatient maternity settings [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards].

    9. Provide specialist multidisciplinary care for pregnant women who have had bariatric surgery by a team who have expertise in bariatric disorders [ACTION: Service Planners/Commissioners, Hospitals/Trusts/Health Boards].

    10. Use the scenarios identified from review of the care of women who died for ‘skills and drills’ training [ACTION: Hospitals/Trusts/Health Boards].

    11. Ensure early senior involvement in the care of women with extremely preterm prelabour rupture of membranes and a full explanation of the risks and benefits of continuing the pregnancy. This should include discussion of termination of pregnancy [ACTION: Hospitals/Trusts/Health Boards].

    For health professionals

    12. Regard nocturnal seizures as a ‘red flag’ indicating women with epilepsy need urgent referral to an epilepsy service or obstetric physician [ACTION: All Health Professionals].

    13. Ensure that women on prophylactic and treatment dose anticoagulation have a structured management

    plan to guide practitioners during the antenatal, intrapartum and postpartum period [ACTION: All HealthProfessionals].

    14. Ensure at least one senior clinician takes a ‘helicopter view’ of the management of a woman with major obstetric haemorrhage to coordinate all aspects of care [ACTION: All Health Professionals].

    iv MBRRACE-UK - Saving Lives, Improving Mothers’ Care 2020

    15. Ensure that the response to obstetric haemorrhage is tailored to the proportionate blood loss as a percentage of circulating blood volume based on a woman’s body weight [ACTION: All Health Professionals].

    16. Do not perform controlled cord traction if there are no signs of placental separation (blood loss and lengthening of the cord) and take steps to manage the placenta as retained [ACTION: All Health Professionals].

    17. Be aware that signs of uterine inversion include pain when attempting to deliver the placenta, a rapid deterioration of maternal condition and a loss of fundal height without delivery of the placenta [ACTION: All Health Professionals].

    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 https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10_ONLINE_VERSION_1404.pdf
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