Action call to stop babies dying due to mistakes in labour

The study, from the Royal College of Obstetricians and Gynaecologists (RCOG), calls for a raft of actions to immediately reduce the numbers of babies dying or suffering brain injuries due to problems or mistakes in labour.

Experts said there were an average of six factors that contributed to poor outcomes for each of the 1,136 babies born in 2015 that were studied for the RCOG’s Each Baby Counts initiative.

Of these babies,126 were stillborn, 156 died within the first seven days after birth and 854 babies suffered severe brain injury.

Some 76% of 727 babies where full information was available may have had a “different outcome with different care”, the RCOG said.

The Each Baby Counts initiative aims to halve the number of babies who die or are left severely disabled as a result of preventable incidents occurring during full-term labour by 2020.

Problems identified by experts included issues with foetal heart rate monitoring.

The RCOG is calling for NHS trusts to ensure all staff have documented evidence of appropriate annual training in this area.

It also wants all low-risk women to be assessed on admission to the labour ward for whether they need intermittent or continuous monitoring.

Mistakes in foetal heart rate monitoring are at the centre of a probe into seven baby deaths between 2014 and 2016 at Shrewsbury and Telford Hospital NHS Trust.

Dr Ed Prosser-Snelling, the quality improvement lead for Each Baby Counts, said interpreting heart rate traces can be difficult.

He said: “The main problem is that if you show two people the same the monitoring trace, they are likely to give you two separate answers.”

However, he said there were were “countless reports” detailing failings in interpreting heart rate traces.

“We know that people do get it wrong,” he said. “Whether it’s because they are not properly trained or whether it’s because it’s difficult is hard to pin down.

“I think it’s probably a bit of both.”

Dr Prosser-Snelling said there was a need for staff to “make a holistic assessment” during labour, looking at all factors such as the mother’s heart rate, whether she has a temperature and facts that are already known, such as the woman’s body mass index and the outcome of previous deliveries.

Other recommendations are for senior staff such as the senior registrar, consultant or senior midwife, to have a “helicopter view” of what is going on at the time of delivery.

This is to prevent the “communication between the neonatal team becomes lost in the noise”, he said.

The report also calls for improved “situational awareness”, such as seeking different points of view if staff feel stressed or tired, and ensuring everyone understands their roles and responsibilities when managing a complex or unusual situation.

An analysis of local reviews for the babies in the study found that a quarter did not contain sufficient information to draw conclusions about the quality of care provided.

Of 727 thoroughly conducted local reviews, parents were only invited to be involved in 34% of them, with 19% of parents not even told an investigation was going on.

Dr Prosser-Snelling said all parents should be told an investigation is going on and should be invited to attend, though not compelled to do so.

The report also repeats a recommendation for external panel members - such as from another trust or a non-executive director - to sit on local reviews.

The report found that external panel members were involved in only 9% of reviews, which could lead to the “perception that people could be marking their own homework,” Dr Prosser-Snelling said.

Professor Lesley Regan, president of the Royal College of Obstetricians and Gynaecologists, said: “The Each Baby Counts programme was intended as a ground-breaking, long-term inquiry that will deliver improvements to maternity care over time, and we do not waver from this challenge.

“It is a profound tragedy whenever a death, disability or illness of a baby results from incidents during labour.”

Co-principal investigator Professor Zarko Alfirevic said: “Problems with accurate assessment of foetal well-being during labour and consistent issues with staff understanding and processing of complex situations, including interpreting foetal heart rate patterns, have been cited as factors in many of the cases we have investigated.”

Janet Scott, research and prevention lead at the charity Sands, said: “I am deeply shocked by this unacceptable rate of harm to babies in labour. The failure to carry out thorough reviews of what happened is inexcusable and must change.

“Judging by the quality of reviews done, many parents are not getting clear answers about events leading up to the death or harm of their baby.

“It’s essential that parents’ perspectives of their care are part of the lesson learning process.

“Parents remember, often with searing clarity, the events surrounding their baby’s delivery and their version of events and questions must be taken seriously.”