The national investigation
Cardiac arrest (when a person’s heart suddenly stops pumping blood around their body) is very rare in pregnancy. It occurs in 1 in 36,000 pregnancies, which is approximately 20 maternal cardiac arrests each year in the UK. The reported survival rate in the UK for pregnant mothers who have a cardiac arrest is 58%. Timely resuscitation and rapid perimortem caesarean section are key factors that support care of the mother and baby.
This national learning report brings together and analyses the findings and safety recommendations from 21 of our maternal death investigations. They all involve mothers where a perimortem caesarean section was undertaken during their care.
Our national learning reports can be used by healthcare leaders, policymakers, and the public to:
- aid their knowledge of systemic patient safety risks
- understand the underlying contributing factors
- inform decision making to improve patient safety
- explore wider patient safety processes.
The information in national learning reports is also used to inform future HSIB investigations or programmes of work.
Perimortem caesarean section
A caesarean section is an operation where a baby is born through a cut made in a mother’s abdomen and womb.
Perimortem caesarean section (PMCS), also known as resuscitative hysterotomy, is a procedure that is carried out either during a maternal cardiac arrest or before an impending cardiac arrest. This is done to increase the chance of successfully resuscitating a mother and potentially improving her survival and that of her baby.
The rarity of this emergency intervention provides a challenge for healthcare professionals. They may be required to perform the PMCS in any care setting (such as in hospital, in the community or in the home) in a time-sensitive manner.
We will explore the factors that may be associated with undertaking a PMCS. This is to support wider knowledge and understanding amongst healthcare professionals involved in situation of a maternal cardiac arrest.
National learning report summary
Our national learning report will consider:
- The ability of the healthcare system to support a PMCS to be undertaken in a timely manner as part of ongoing resuscitation of a mother in cardiac arrest, regardless of location of care.
- The clinical intervention, environment, equipment, and communication to support teams undertaking a PMCS.
- Potential barriers in accessing emergency care that may impact on timely PMCS delivery.