Each Baby Counts report on anaesthetic care - maternity safety depends on teamwork

Following the publication in 2017 of the landmark report, Each Baby Counts, the Royal College of Obstetricians and Gynaecologists (RCOG) has now reported on the anaesthetic aspects of care given to the mothers of 49 of the babies who were originally reviewed.

The RCOG’s Each Baby Counts programme aims to halve the number of full-term stillbirths, babies who die in the neonatal period or are left severely disabled from birth-related brain injury by 2020. The 2017 report found that 76% of the 1,136 babies who suffered these injuries in 2015 might have had a different outcome with different care. The anaesthetic care review was prioritised after the initial report identified that anaesthetists had been involved in only 11% of local investigations following stillbirth, neonatal death and birth-related brain injury, raising concerns that investigation teams consisting solely of obstetric and/or midwifery staff may have missed any lessons to be learned arising from the affected babies’ mothers’ anaesthetic care.

Of the 49 mothers reviewed for this anaesthetic report:

  • 20 had (attempted) epidurals and for 11 of those 20, the epidural provided inadequate pain relief.
  • 21 had spinal, combined spinal-epidural or attempted spinal anaesthesia, which was difficult or inadequate for ten of them.  
  • 30 were delivered under general anaesthetic, including five (mostly low risk for airway problems) with failed endotracheal intubation.
  • 30 of the 44 women with known BMI were overweight or obese and 17 were obese.
  • 38 underwent caesarean section, including seven after failed trial of operative vaginal birth.
  • Eight babies were delivered with forceps.
  • Three had unassisted vaginal births.
  • 37 of the babies were left with severe brain injury
  • Six were stillborn.
  • Six died in the neonatal period.

Delays in anaesthetic care may have exacerbated injury to compromised babies during labour

Whilst none of the 49 babies’ outcomes were directly caused by failings in anaesthetic care, the report emphasises that the anaesthetic delays occurred in circumstances where there were already concerns about the wellbeing of the fetus and may have exacerbated the injury to the babies.

Maternity safety depends on teamwork

The report concluded that its clear message can be summarised by the opening statement from the 2000 Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI);

the safety of modern obstetric care is based on teamwork . . . the anaesthetist is a key member of the perinatal management team

Failings in communication and lack of teamwork between obstetric, midwifery and anaesthetic staff were a recurring theme and clearly contributed to critical delays in the care of the mothers, with devastating outcomes for their otherwise healthy, full term babies.

Obstetricians must make anaesthetists aware of the urgent need for delivery

In the reviewed cases, anaesthetic delays arose from lack of communication in relation to the urgency of the need for delivery. For operative vaginal delivery (e.g. forceps) there is no commonly understood classification of urgency, as there is for caesarean section where ‘category 1’ signals that the mother or baby’s life is at risk and ‘category 4’ implies that the procedure can be undertaken when convenient. The anaesthetists were, therefore, unaware of the how urgently the obstetric team needed the operative vaginal delivery to take place.

The report recommended that anaesthetists should always be informed of the degree of urgency of delivery, with the obstetrician communicating directly with the anaesthetist where they want delivery to be expedited.  A task-focussed anaesthetist might not be aware of the time and, as noted by the 2000 CESDI, obstetricians and midwives can be reluctant to interrupt anaesthetists who are involved in other tasks, but where delivery is required urgently the obstetrician must take responsibility for communicating the urgency to the anaesthetist to avoid additional delay.

Each Baby Counts recommended that, as an aid to communication, the same classification of urgency that is used for caesarean section should be applied to all operative deliveries, whether vaginal (e.g. forceps) or abdominal (caesarean section).

Each Baby Counts also identified multiple occasions when the need for a category 1 (emergency) delivery was not adequately communicated to busy anaesthetists who, consequently, failed re-prioritise the order in which they attended patients, leading to delays. In other cases, the deadline for emergency delivery was allowed to slip as the staff dealt with other emergencies within the labour ward or elsewhere.

The report emphasised that all who work in maternity, where multiple, simultaneous emergencies are not uncommon, must understand the implications of the categories of urgency, escalating early to allow time for additional staff to come from home or from other areas of the hospital if necessary.

Improved communication about the urgency of delivery would also enable anaesthetists to make informed choices about the most appropriate and time-saving method of anaesthesia. This would avoid the scenario encountered in several of the reviewed cases where attempts were made to top up ineffective epidurals when it became clear that an emergency caesarean section was needed, delaying surgery further whilst waiting for effective anaesthesia. Similarly, if a trial of instrumental (forceps or Ventouse) delivery is to take place in theatre where the fetus is distressed (and might need immediate, emergency caesarean delivery if the instrumental delivery is unsuccessful) the anaesthetist should be made aware of the urgency of the delivery to avoid using a pudendal block which would not provide sufficient anaesthesia if an emergency caesarean section is required.

Delays were also evident where changes in urgency and category of caesarean section were made but their context incorrectly communicated, affecting the anaesthetist’s choice of anaesthesia which led to critical delays. In some cases, deterioration in the fetal condition which should have increased the urgency went unnoticed whilst anaesthesia was established owing to failure to continuously monitor the fetal heart-rate.

In keeping with the original Each Baby Counts report, the anaesthetic review highlighted the need for teamwide situational awareness, recommending that a senior team member should maintain a ‘helicopter view’ of all activity on the delivery suite, to avoid new information being overlooked and collective failure to identify simple solutions to problems when other team members are engaged in complex technical tasks. The need for teamwork and situational awareness was also found to be lacking in the way local investigations following adverse incidents were carried out.

Boyes Turner’s cerebral palsy and birth injury specialists welcome the valuable work being carried out by the RCOG’s Each Baby Counts programme. We support the recommendations of this anaesthetic review which reflect our own observations and experience of these tragic cases in which failings in teamwork, communication and forward planning lead to such devastating harm .

If you are caring for a child or young adult with cerebral palsy or birth-related disability, contact us on cerebralpalsy@boyesturner.com

I have to say I was extremely impressed with the service in what was a very difficult time for myself and my family. The advice and support I had from the team was fantastic and invaluable. They put mine and my wife's mind at rest on many occasions and got a great result for us. Thank you from all of us.

Mr Horne

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