CME Module 17: Maternal Morbidity and Mortality: Lessons learned from Accidents, Error and Unxpected Events Next >



Despite improvements in the heath and safety, when we look back historically, moving the birthing process from home to hospitals was clearly one of the major advances in medicine and has gone a long way in saving the lives of mothers and their babies. However, every year some pregnant women will still die and it goes without saying that every death is a tragedy as these are, for the most part, women in the prime of their life. If we are to learn from these tragic cases, then we must first determine why mothers die. What were the causes?  We must also determine if any mistakes in their care were made; in essence, were there any avoidable factors that contributed to the death. It goes without saying that mistakes are inevitable, we all make them, but we must also be able to look at these errors in the spirit of hindsight, which is, of course, always much clearer. Given the same situation, we all might all have “gone down the same path”. However, if we can review the cases in the spirit of hindsight, then there is much to be gained. I believe that the mistakes we make are truly the best teachers and remain imprinted on our brain in a way that nothing else can. 

Traditionally a great deal of the information on why mothers die has come from the United Kingdom Triennial Reports, now known as The Confidential Enquiry into Maternal and Child Health (CHEMACH)1. Additional resources used for this module included the Second Annual Report from the Maternal and Perinatal Death Review Committee to the Ontario Chief Coroner and the ASA Obstetrical Closed Claims Analysis. On reviewing these documents it is clear that the lessons to be learned are not new. This suggests that we all need to be reminded of the basics in medicine and anesthesia and also that any lesson that might save the life of a mother deserves repeating.


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