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, reveals a summary report from the Royal College of Obstetricians and Gynaecologists’ (RCOG) Each Baby Counts initiative.
Each Baby Counts is a national quality improvement programme, launched in October 2014, aiming to halve 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.
The investigation team has now conducted 2,500 expert assessments of the local reviews into the care of 1,136 babies born in the UK in 2015 – 126 who were stillborn, 156 who died within the first seven days after birth and 854 babies who met the eligibility criteria for severe brain injury.
The reviewers concluded that three quarters of these babies - 76% - might have had a different outcome with different care. This finding was based on 727 babies where the local investigation provided sufficient information to draw conclusions about the quality of care. A quarter of the local investigations were not thorough enough to allow full assessment.
Co-principal investigator, Professor Zarko Alfirevic, consultant obstetrician at Liverpool Women's Hospital, said: “Problems with accurate assessment of fetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting fetal heartrate patterns, have been cited as factors in many of the cases we have investigated.
“This is the first time the Each Baby Counts team has been in a position to identify and share the lessons learned across the whole UK maternity service. However, until every incident is thoroughly investigated and important lessons identified locally, our understanding of the national picture will remain incomplete. The focus of a local investigation should be on finding system-wide solutions for improving the quality of care, rather than actions focusing only on individuals.”
While last year’s interim report made a number of recommendations about how to ensure future investigations are as consistent and effective as possible, this full report of 2015 data goes much further and 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.
Professor Alfirevic continued: “We urge everyone working in maternity care to ensure the report’s recommendations are followed at all times. Trusts and health boards have a role to play in supporting their staff to implement the recommendations, ensuring staff tasked with fetal monitoring interpretation receive annual training, promoting the development of non-clinical skills such as situational awareness and providing multi-disciplinary training to support good team working.
“Our next steps are to seek feedback and work with the maternity teams on implementation. To make a real difference, specific implementation tools are needed together with ongoing support for Trusts and health boards to embed them into practice. This requires specific skills, dedicated time and significant funding.”
Professor Lesley Regan, President of the Royal College of Obstetricians and Gynaecologists, said: “Each Baby Counts is a crucial element of the changing safety culture within the NHS. The RCOG and its partners are serious about improving the safety of maternity services but to make this happen we need the full and total commitment from governments across the UK. As an urgent priority, maternity units need to be adequately resourced – without this, Trusts, Health Boards and healthcare professionals will struggle to implement these recommendations.”
