孕产妇死亡评审结果分析

An analysis of audit result of maternal mortality

目的通过孕产妇死亡评审及时发现和掌握各个环节中存在的问题,为上级部门针对性地提出干预措施及管理办法提供准确依据,降低孕产妇死亡率。方法根据“湖南省孕产妇死亡管理办法”规定,对上报到州级的资料依据世界卫生组织的“十二格法”进行评审分析。结果2006年评审的14例孕产妇死亡病例:羊水栓塞3例,子痫2例,产后出血、输卵管妊娠破裂、子宫不全内翻各1例,麻醉意外、重度贫血、肺部感染、脑梗塞、脑出血、肾功能衰竭各1例,直接产科死因8例,占57.14%,间接产科死因6例,占42.86%;可避免死亡8例,占57.14%;创造条件可避免死亡3例,占21.43%;不可避免死亡,占21.43%。结论建立稳定的妇幼卫生经费保障机制,加强妇幼保健三级网络建设;提高产科医护人员专业技术水平及产科质量;加强各部门间的协调、支持,保障母婴安全。

Objective By auditing maternal mortality, to find and grasp problems in each link timely, so as to provide an exact basis for drawing up interventions and management acts of the higher authority to reduce maternal mortality rate. Methods According to The Regulation of Maternal Mortality in Hunan province, the data presented to prefectural level were audited and analyzed according to Twelve Lattice Law of WHO. Results In 14 cases of maternal mortalities in 2006, 3 cases of maternal mortalities were due to amniotic fluid embolism, 2 due to eclampsia, 1 postpartum hemorrhage, 1 ruptured tubal pregnancy, 1 incomplete inversion of uterus, 1 unexpected anesthetic accident, 1 severe anemia, 1 infection of lung, 1 cerebral infarction, 1 cerebral hemorrhage, 1 renal failure, Of which, 8 cases of maternal mortalities were due to direct obstetric causes, accounting for 57.14% ; 6 cases due to indirect obstetric causes, accounting for 42. 86% ; 8 cases of maternal mortalities might be avoided, accounting for 57.14% ; 3 cases of maternal mortalities could be avoided by creating conditions, accounting for 21.43% ; the inevitable maternal mortalities accounted for 21.43%. Conclusion A stable maternity and child hygiene funds guarantee mechanism should be built, three-level network construction of mother and child health care should be reinforced. The special technical skill of doctors and nurses in obstetric department and obstetric quality should be improved. The interdisplinary co-operation and support should be reinforced to ensure safety of the mother and the baby.