“When something goes wrong during labour at the end of a healthy pregnancy, and a baby dies or experiences a serious brain injury, what should be one of life’s happiest events turns to devastating tragedy. As parents, we go through something for which we had no preparation. We are in a blur of distress and shock. We cannot believe this could happen to our baby, carried with care and love for nine months, but it has. And in 2015, it happened to 1136 babies.”
Each Baby Counts: a parent’s perspective.
In 2014, the Royal College of Obstetricians and Gynaecologists (RCOG) announced the launch of a quality improvement programme, Each Baby Counts. The stated aim of the initiative is to halve the number of babies who die or are left severely disabled as a result of preventable incidents occurring during term labour (that is labour after 37 weeks’ gestation) by 2020.
The RCOG’s findings from the first year have recently been published and highlighted the inconsistent approach taken to local investigation of these incidents and sadly how many families have not been fully involved in those reviews. Two charities supporting families affected by birth injuries and stillbirths, Sands and Campaign for Safer Births, have jointly commented: “The vast majority of parents want desperately to know what happened, even when the truth is difficult. After all we have already experienced the worst. But too many of us are left with poor explanations and unanswered questions. We want our babies’ lives to matter and to see hospitals determined to learn from these grave mistakes that have changed our lives. The Each Baby Counts report shines a spotlight on how many things go wrong and where care might improve. We want to know that things will be better for the next parents whose labour and birth are like ours. To make this happen, there have to be thorough reviews of every baby’s case that involves us, the parents … the only ones present at every stage. There needs to be learning, and a commitment to change, at every level.”
The report makes a number of recommendations with regard to the quality of care provision covering human factors, fetal monitoring and interpretation of the cardiotocography (CTG) trace.
Firstly, the role played by human factors should not be underestimated. All members of the obstetric and midwifery team need to maintain situational awareness and a senior team member should maintain oversight of the activity in the delivery suite by taking a ‘helicopter view’. This should allow problems to be anticipated earlier and dealt with quicker. Staff find decision making more difficult when they are tired or stressed, and so should feel supported and able to seek advice from colleagues as required. ‘Safety huddles’ are also recommended for managing complex or unusual situations. The structured briefings for leaders of key clinical teams mean that they can share important clinical information relevant to patient safety so that everyone in the medical team can understand their role.
The report has considered the key question of whether continuous CTG monitoring should be provided during labour and if not required initially, such that intermittent auscultation is satisfactory, what will then trigger a need to switch to a continuous CTG. The conclusion is that women who are deemed at low risk should have a formal fetal risk assessment on admission in labour irrespective of the place of birth to determine the most appropriate fetal monitoring method. The NICE Guidelines of 2017 on ‘Intrapartum Care for Healthy Women and Babies’ must be considered. These provide a list of factors which require clinicians to offer continuous CTG, including:
The report also highlighted the importance of CTG interpretation training and the requirement for clinicians to have documented evidence of this annual training. CTG traces should be interpreted using the ‘Dr C Bravado’ acronym, with regards to determination of the risk, contractions, baseline rate, variability, accelerations, decelerations and overall impression/plan. Clinicians are reminded not to interpret the CTG trace in a vacuum and to always consider the overall presentation, to discuss how labour is progressing with the mother, and to take her preferences into account.
Alison Johnson, associate director in Penningtons Manches’ clinical negligence team who represents families with birth injury claims, said: “Reading through the very interesting findings of the RCOG report made me think of the many parents I have worked with and perhaps how different their situations may now be, had the recommendations been in place and followed at the time of their children’s births. It is of course wonderful to see positive steps being taken to reduce the incidence of such tragedies.”