CEMACH

Chapter 18: Emergency medicine

Diana Hulbert

Introduction

For the first time in the more than 50-year history of these Reports a summary chapter has been written specifically for Emergency Department (ED) practitioners. It is also the first time that a consultant in emergency medicine has reviewed the relevant maternal deaths to distil lessons and recommendations of particular relevance to staff working in emergency medicine services. Issues concerning the care provided for pregnant women in the ED have been highlighted in earlier Reports and this chapter endorses and strengthens these previous recommendations.

The aim of this new chapter is to draw attention to key messages in the Report of relevance to the emergency services and to highlight issues relating to pregnant or recently delivered women that particularly affect ED clinicians and other staff working in emergency medicine. It cannot provide an exhaustive overview of all the Report’s findings but ED staff should be aware of the key recommendations and overarching risk factors highlighted in Chapter 1 as well as acting on the findings in this Chapter.

Emergency services

Emergency services in the UK are provided in the community by general practice and the ambulance services, in minor injuries units and in Emergency Departments (EDs). Minor injuries units are usually staffed by nurse practitioners working autonomously but some are also managed by local GPs or secondary care doctors. Some of these units are overseen by consultants in emergency medicine, but usually in a managerial rather than a clinical role.  There are clear criteria and guidelines for the referral from minor injuries units to the local ED for any patient whose condition causes concern. Some have specific guidelines for pregnant women, but this is not universal.

In the ED various methods and levels of assessment are available for all patients depending on the severity of their presenting complaint. A patient can be seen entirely within the ED and discharged home, admitted to a short stay ward (also called a clinical decision unit or observation ward) for a period of observation and to await the outcome of specific tests or referred to an inpatient specialty team, usually for admission. In most EDs, pregnant women who need admission will be referred to a gynaecology ward up to a specified number of weeks of gestation and to the labour ward thereafter.

Occasionally a woman may be referred directly by her GP or midwife to an on-call team, usually the obstetric team but sometimes, as happened in one of the cases in this Report, to the on-call medical team. Most women who have been directly referred will not be seen in the ED but will be taken straight to the designated medical admissions centre to be seen by the on-call physicians. This centre may be called the Acute Medical Unit, the Emergency Medical Unit, the Acute Admissions Unit or the Medical Admissions Unit. For example:

A new, older, mother was admitted to an acute admissions unit by her GP with breathlessness, pyrexia and hypotension two or three weeks after a normal delivery. A differential diagnosis of pneumonia or pulmonary embolism was made but a very few hours after admission she was transferred to a gynaecology ward where she later arrested and died. Autopsy showed a pulmonary embolism.

This mother was clearly very unwell and should have been managed in a high dependency area. It is possible that being pregnant or postpartum can cloud the issues for clinicians but it is important that a patient is treated in an environment appropriate to their medical status.

Pregnant women referred directly to the gynaecology or obstetrics team will generally be seen in a gynaecology admissions unit, an Early Pregnancy Unit, the triage area on the labour ward or on a general ward. This will depend on the round-the-clock availability of such facilities as well as the woman’s gestation, presenting problem and apparent severity of the illness. Some women may be seen by the specialist teams within the confines of the ED but not by emergency medicine clinicians themselves. This was the case for a small number of the women whose cases were reviewed for this Report.