A recent investigation has suggested the failure to properly monitor baby’s heart rates during labour is one reason why some newborns are dying on UK maternity wards.
The Each Baby Count inquiry carried out by the Royal College of Obstetricians and Gynaecologists assessed over 700 recent neonatal deaths and injuries.
The report looked at 1,136 stillbirths, neonatal deaths and brain injuries that occurred on UK maternity units during 2015:
- 126 babies were stillborn.
- 156 died within the first seven days after birth.
- 854 babies had severe brain injury (based on information available within the first seven days after birth. It is not known how many might have significant long-term disability).
727 cases were reviewed in-depth and it is confirmed that there were problems with the assessment accuracy of foetal wellbeing during labour.
Alongside this were consistent issues with staffs lack of knowledge, understanding and processing of complex situations, including interpreting baby heart-rate patterns (on traces from CTG machines). There were cited as significant factors.
Alfie Field was left with brain damage and later died after doctors failed to spot problems with his heart rate during labour.
Mother, Kym Field, from Cambridgeshire, recalls: “As soon as Alfie was born he was handed to paediatric doctors. He was then briefly shown to us before being whisked away.”
After an inquest into Alfies death, the mother admits, “Our baby’s death was down to a collection of errors and negligence.”
The Each Baby Counts report recommends:
- All low-risk women are assessed on admission in labour to see what foetal monitoring is needed.
- Staff get annual training on interpreting baby heart-rate traces (CTGs).
- A senior member of staff must maintain oversight of the activity on the delivery suite.
- All trusts and health boards should inform the parents of any local review taking place and invite them to contribute.
In October 2016, the government launched a Maternity Safety Action Plan to provide resources for trusts to improve their approach to maternity safety, including an £8m fund for maternity safety training.
Janet Scott, from the stillbirth and neonatal death charity Sands, said the report findings were deeply concerning and urges trusts, health boards and governments across the UK to ensure this level of support and resourcing is brought about urgently.
Source: The BBC