A report published today found that 1,136 babies out of over 720,000 born at term during 2015 died during labour or within the first 7 days, or suffered severe brain injury. Reviewers concluded that three quarters of these babies might have had a different outcome with different care.
The Royal College of Obstetricians & Gynaecologists’ national quality improvement programme, Each Baby Counts, was set up in October 2014 to reduce by 50% the number of babies who die or are left severely disabled as a result of preventable incidents occurring during term labour (after 37 weeks) by 2020.
A detailed analysis of all stillbirths, neonatal deaths and brain injuries that occurred during childbirth in 2015 has identified key clinical actions needed to improve the quality of care and prevent future cases.
“It is a profound tragedy whenever a death, disability or illness of a baby results from incidents during labour.
The emotional cost to each family is incalculable and we owe it to them to properly investigate what happened and ensure the individuals and the healthcare trusts involved take the steps needed to avoid making the same mistakes again.”
The report includes recommendations highlighting critical factors in the care of many of the Each Baby Counts babies that may prevent these incidents in the future. The recommendations are aimed at doctors and midwives working in maternity units across the UK and centre around:
- Fetal monitoring – formally assessing all low risk women on admission in labour to determine the most appropriate fetal monitoring method; following NICE guidance on when to switch between intermittent and continuous monitoring during labour; ensuring all staff have documented evidence of appropriate annual training.
- Neonatal care – paediatric/neonatal teams informed of pertinent risk factors in a timely and consistent manner.
- Human factors– understanding ‘situational awareness’ to ensure the safe management of complex clinical decisions; key members of staff maintaining appropriate clinical oversight; seeking a different perspective to support decision making, particularly when staff feel stressed or tired; ensuring everyone understands their roles and responsibilities when managing a complex or unusual situation.
“These findings are simply devastating. That so many babies born at term are dying or sustaining life-changing brain injuries when, with different care, these tragedies would not happen, is appalling. Every single one of these babies have families whose lives have been irrevocably changed as a result of avoidable harms.
I welcome the publication of the report and its recommendations to stop future babies suffering the same fate. I fully support the call that Trusts, doctors, midwives and other healthcare professionals ensure its recommendations for clinical practice are implemented and followed at all times.”
You can download the summary report by clicking here.