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Each Baby Counts, the maternity care improvement programme run by the Royal College of Obstetricians and Gynaecologists (RCOG) which aims to reduce the number of stillbirths, neonatal deaths and babies who are brain-damaged at birth, has published its latest report.
The ‘Each Baby Counts 2019 Progress Report’, which was published in March 2020 but relates to births in 2017, reports that 1130 full term babies died or suffered hypoxic ischaemic brain injury (HIE) around the time of birth. Each Baby Counts reviewers believed that 72% of the babies whose births were reviewed could have had a better outcome if they had received better care.
It is important to remember that Each Baby Counts’ reports only include babies whose injuries meet their injury criteria and are diagnosed within the first seven days of life.
Each Baby Counts statistics for birth injuries to full term babies in 2017
There was very little improvement in the number of birth injuries in 2017 from previous years.
Out of 677,192 term (not premature) babies born in the UK in 2017:
- 130 babies died during labour;
- 150 babies were born alive but died within their first week of life;
- 850 babies suffered severe brain injury which was diagnosed in the first seven days of life and met Each Baby Counts’ criteria:
- diagnosis of grade III hypoxic-ischaemic encephalopathy (HIE) - brain injury caused by oxygen deprivation immediately birth before or around the time of birth; or
- received active cooling – a recognised treatment given to newborn babies to reduce their hypoxic brain injury; or
- had decreased central tone (floppiness) and was comatose and had seizures (fits) – signs of brain injury from lack of oxygen at birth.
72% of injured babies in 2017 might have had different outcomes with better care
On the information they received from NHS trusts who reported these injured babies, Each Baby Counts were able to review 986 of the 1130 reported cases.
- In 714 of the 986 reviewed cases, the baby might have had a better outcome with different care. The proportion of injured babies who might have avoided their injury with better care was 72% in 2017, compared with 71% in 2016, and 76% in 2015.
- Only 468 babies' cases were reported with enough information about their neonatal care for them to be reviewed by Each Baby Counts neonatologists. In 176 (40%) of those cases, the Each Baby Counts neonatologist reviewer believed that different neonatal care might have made a difference to the baby’s outcome.
- Babies who might have avoided injury with better care were found to have been affected by up to 22 different contributing factors. As with previous reports into maternity safety, in nearly all cases, these factors related to:
Each Baby Counts: only 50% of parents involved in hospital reviews of birth injury to their baby in 2017
Despite recommendations dating back to Each Baby Counts’ first report in 2016 highlighting the importance of involving parents in local investigations into babies’ birth injuries, the latest Each Baby Counts review found that in half of the 986 cases of stillbirth, neonatal death and severe brain injury to babies which occurred in 2017, the baby’s parents were not invited to contribute to the hospital’s own investigation of the injury.
How failure to escalate (ask for help, increase risk level or take action) seriously harmed babies in 2017
Each Baby Counts found that ‘failure to escalate’ contributed to more than one third of the 986 cases of severe harm to babies that it reviewed from 2017. Clinical escalation, its contribution to these babies’ birth injuries and the importance of escalation processes for safe maternity care were chosen as the major area for detailed analysis and recommended improvement in this latest report.
What is escalation?
In a maternity setting, escalation involves recognising and acting quickly on signs of deterioration or worrying developments in the mother or unborn baby’s condition. This may mean calling for help from colleagues who are more senior, more experienced or from other specialist areas of medicine, such as a midwife calling for help from an obstetrician, so that correct action is taken at the right time to prevent harm to the patient.
Reliable and timely escalation is essential for multidisciplinary teams to provide safe maternity care. This means that staff must be able to recognise clinical deterioration and be aware that the situation requires them to involve senior members of the multidisciplinary maternity team. They must be able to communicate the need for help quickly and clearly to the right team member, and there must be the staff and resources available to delivery the necessary care.
Why are mothers and babies injured in childbirth from NHS mistakes in escalation?
Each Baby Counts found that problems with escalation, arising from human factors and behaviour, workload and workforce challenges, and communication failures contributed to more than a third of incidents involving serious birth injury to babies.
Human factors and behaviour
‘Human factors’ refers to ways in which maternity staff behave, often under pressure, when faced with an urgent or emergency situation which require escalation. Many of these mistakes have been recognised as common threats to maternity safety in previous Each Baby Counts and other reports.
These included ‘cognitive biases’ or habitual patterns of thinking which led to the midwife or doctor missing an important sign or deterioration and being unaware of the need to escalate. The most common of these errors was ‘fixation’, for example, when the maternity team was so fixed on achieving an unassisted vaginal delivery (to avoid the risk of perineal injury from forceps) that they delayed taking urgent action to deliver the baby when the fetal heart monitor showed abnormalities in the unborn baby’s heart rate. ‘Fixation’ also led to delays in calling for help from an obstetrician (doctor) and increasing a mother’s level of care from low risk to high risk.
‘Confirmation bias’ led to failure to recognise and act on signs of maternal or fetal compromise abnormalities, such as on the fetal heart monitor (CTG), on the assumption that the labour was progressing normally. In one example, risks and new signs of uterine rupture were mistaken for signs of the second stage of labour (when the mother feels the urge to push). The team failed to consider the effect of the new signs on the mother’s condition as a whole and this led to delay in taking emergency action to deliver the baby.
Diagnostic (bandwagon) errors occurred when, for example, a second midwife who was called to help locate the absent fetal heart accepted the first midwife’s assumption that it was an equipment error and wasted time finding other equipment instead of calling for emergency obstetric help which would have led to urgent delivery of the baby.
Other human factors included ‘loss of situational awareness’, such as where registrars were so focussed on trying to deliver a distressed baby with forceps that they lost track of time, during which the baby suffered hypoxic brain damage.
Lack of teamwork led to injury when junior members of a multidisciplinary (involving more than one type of maternity specialist) team didn’t recognise the need to call for help. Teamwork failed when midwives felt unable to call a team member whom they didn’t know or where a hierarchy existed which meant that they had to call the next up in seniority, such as a labour ward supervisor who then decided whether to call a doctor in an emergency situation.
Lack of confidence in challenging a senior colleague’s decision often led to injury, for example, when a midwife correctly escalated a deteriorating patient to a doctor, who then incorrectly ‘de-escalated’ the situation by assuming the CTG was normal and delayed the decision to deliver the distressed baby.
Workload and workforce challenges
Inadequate staff levels and resources, such as rooms and beds, for the number of patients and level of clinical input required to meet each patient’s needs, contributed to the incidents of serious harm to babies in 2017.
Registrars were called by worried midwives to review their patients but often were not available as they were with other patients or busy in theatre. Having unsuccessfully attempted to escalate a situation to the registrar, critical delays occurred whilst the midwife or junior doctor waited until the registrar became available. This happened even in cases where urgent intervention, such as an emergency delivery, was needed to prevent harm to the baby. Failings included widespread reluctance amongst overloaded registrars and other members of the maternity team to call for help from the consultant.
Other communication problems which contributed to deaths and serious brain injury of babies in 2017 included situations where urgent action, such as the need to deliver a baby urgently by caesarean section, was de-escalated and delayed as a result of key information being lost during handovers of care from one maternity team to another.
During emergency escalation, such as crash calls for neonatal resuscitation, critical delays arose when maternity team members were unaware of the correct procedure for calling for emergency help. Examples included where maternity staff used the patient call bell instead of the emergency buzzer to call for help, or failed to specify the type of emergency call, resulting in the arrival of the emergency obstetric team rather than the neonatal team.
What improvements does Each Baby Counts latest report recommend?
As with previous reports, the RCOG’s Each Baby Counts 2019 Progress Report provides a very thorough list of recommendations targeted towards helping maternity staff, teams and organisations improve how they escalate maternity safety situations to improve safety in maternity care.
Boyes Turner’s team are experienced in helping babies harmed by mistakes in maternity care
As specialists in helping children whose cerebral palsy and lifelong neurological disability was caused by mistakes in maternity care, we welcome RCOG’s ongoing commitment to shine a light on the true causes of these tragedies, the openness of their reports and their recommendations for improvements in care.
As in previous years, we are saddened by the extent of the suffering. The scenarios described in the Each Baby Counts’ 2019 Progress Report are all too familiar. Sadly, many of our clients are amongst those whose injuries are reported. We welcome all genuine efforts to learn from their experiences in the hope that this will lead to a reduction in harm from widespread improvements in maternity care.
Meanwhile, we remain committed to helping brain-injured children recover their full entitlement to compensation, as this is often their only guaranteed means of provision of adequate adapted housing, equipment, essential therapies and care. Our compassionate and highly skilled lawyers work hard to obtain apologies, admissions of liability and early interim payments for our clients, far sooner and in greater sums than can be achieved via NHS Early Intervention or elsewhere.
If you are caring for a child with cerebral palsy and would like to find out how we can help you, contact us by email at email@example.com.
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