HSIB reports on delayed emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery

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Healthcare watchdog, HSIB, have published their latest national investigation report,  Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery.

The national investigation was launched following HSIB’s maternity investigation into the care of a mother and her baby who was born by emergency caesarean section after significant blood loss in labour. The need for an emergency blood transfusion to restore the baby’s blood (and oxygen) circulation was not recognised whilst attempts were made to resuscitate the lifeless baby, leading to a delay in this life-saving intervention.

HSIB identified that emergency neonatal blood transfusion has featured in more than 20 of their individual maternity safety investigations. Boyes Turner’s birth injury and cerebral palsy claims specialists also have experience of claims involving babies needing emergency neonatal blood transfusion after acute oxygen deprivation during birth. We recently secured a liability settlement for a brain-injured child in one of these highly specialist and complex cases.

HSIB’s report highlights the safety risk associated with delays in emergency neonatal blood transfusions during neonatal resuscitation, which can lead to hypoxic brain injuries or early neonatal death. Early recognition of the need for emergency neonatal blood transfusion and timely intervention can improve the outcome for these children. A European Neonatal Transfusion Network is currently being set up to explore safety issues related to neonatal blood transfusion.

Brain injury from blood loss during pregnancy and birth

Blood loss to the baby before or during birth can cause brain injury or lead to the baby’s death. If the baby’s circulating blood volume – the total amount of fluid circulating through the baby’s veins, arteries, capillaries and heart – is reduced, they may not have enough blood to carry the oxygen to their brain and other areas of the body. When this happens, resuscitation may not be enough to keep the baby alive or supply enough oxygen to the brain before permanent injury occurs, without an emergency neonatal blood transfusion. 

Heavy or sudden vaginal bleeding after 24 weeks of pregnancy, also known as antepartum (meaning before birth) haemorrhage or APH, affects 3-5% of pregnancies. The bleeding may come from the fetus (unborn baby) or the mother. Placental abruption (where the placenta separates from the wall of the uterus before the baby is born) and placenta praevia (where the placenta is positioned low in the mother’s uterus and obstructs the cervix) are important and dangerous causes of APH.  However, in many cases, when APH occurs the cause of the bleeding is unknown.  APH is dangerous because even small amounts of blood loss can severely affect the baby’s health.

In the case which triggered HSIB’s investigation, examination of the placenta after birth suggested that there was an unusual connection between the umbilical cord blood vessels and the placenta (known as velamentous cord insertion or VCI). This meant that the cord blood vessels were more exposed than usual and positioned close to the cervix (known as vasa praevia) and may have ruptured during labour. This caused the bleeding and injury to the baby.   

Routine ‘anomaly’ ultrasound scans, which check the unborn baby’s development during pregnancy, do not include checking the insertion of the umbilical cord into the placenta or vasa praevia. Having previously rejected the need for vasa praevia screening as part of the routine fetal anomaly scan, the UK National Screening Committee are due to review this issue again.

HSIB’s reference event – the mother and baby’s experience

HSIB’s report describes the hospital care of a mother during her second pregnancy. Her previous episodes of vaginal bleeding at 13 weeks and then at just over 36 weeks were apparently handled in accordance with guidelines, but did not form part of HSIB’s investigation into delays in the baby’s emergency neonatal blood transfusion following a further severe APH (bleeding) during labour. At just over 36 weeks of pregnancy, the mother’s waters broke and she was admitted back to the hospital’s maternity assessment unit. CTG fetal heart monitoring was started and her rupture of the membranes confirmed. Whilst walking to the toilet she felt the baby move and heavy vaginal bleeding. She called for help and was taken by wheelchair to the labour ward, where the fetal heartbeat could not be found.  Midwives and doctors responded to an emergency call, and although the heartbeat could not be picked up by the CTG, an abnormally low heartbeat was identified on an ultrasound scan. The baby was delivered within 12 minutes by emergency caesarean section. The paediatric (child specialist) registrar arrived just before the caesarean section took place and was told by the midwives that the mother had had a significant APH of 300ml to 500ml and that the baby’s heartbeat could not be identified on the CTG. They were not told that the baby’s heartbeat had been identified on the scan before the caesarean section.

The baby had no heartbeat at birth and made no effort to breathe. The paediatric team cleared the baby’s airway and after a minute had no response from attempts to stimulate the baby. Attempts were made to call the on-call consultant paediatrician by emergency bleep, by a midwife going to the neonatal unit to find them and by the paediatric registrar calling them on their mobile phone.  A second on-call paediatric consultant, located off-site, was also contacted and asked to come to the hospital.

The placenta was delivered, but without blood in the umbilical cord no samples could be taken for testing. Whilst resuscitation efforts continued the consultant paediatrician assessed the baby. The baby was given an intraosseous (into the bone) blood transfusion at 23 minutes old. Baby’s colour changed to pale pink on the administration of the blood. At 30 minutes the baby’s heartbeat still had not been heard but breathing support was continued as she was making some efforts to breathe. During discussions between the two consultants about whether to continue resuscitation efforts, a faint heartbeat was heard. Resuscitation continued and she was transferred to the SCBU. She needed further resuscitation, blood transfusions and cooling. She was transferred to a regional NICU where she was found to have multi organ failure from HIE and died at two days old.

Key findings from HSIB’s investigation

HSIB’s investigation found that the baby’s acute blood loss before birth and significantly depleted circulating blood volume meant that resuscitation would not be effective until her blood volume was corrected by a blood transfusion. This finally took place at 23 minutes after birth. HSIB’s advisors were unable to say whether delay affected the baby’s outcome. The incomplete handover information that the paediatric registrar received on arrival in theatre, and seeing the midwives shaking their heads as they struggled to find a heartbeat reinforced the doctor’s belief that they were probably dealing with a stillborn baby. Escalation was hampered by the obstetric and paediatric teams’ different processes for contacting a consultant at night, with midwives unaware of the different paediatric processes.

The effectiveness of resuscitation drugs in this severely unwell, newborn baby was hampered by the incorrect use of  a peripheral rather than umbilical venous catheter (via a tube into the vein in the baby’s cord, which gives the medicine closer to the baby’s heart), as recommended by the UK’s Resuscitation Council. The limited experience of the team and the urgency of the situation contributed to this decision. Although the midwives found evidence on the placenta that a ruptured velamentous cord insertion (VCI) had caused the blood loss, the obstetrician (performing the caesarean section) and the paediatric team were not told. This delayed their understanding of the cause of the baby’s condition at birth.

HSIB’s findings – learning for the wider maternity care system

HSIB highlighted that the timing of the administration of this baby’s eventual emergency neonatal blood transfusion was probably affected by ineffective communication between teams during handover, during escalation and in relation to evidence of the cause of the baby’s condition on the placenta. The fact that the maternity (obstetric, anaesthetic, midwifery etc) and paediatric (including neonatal) teams did not train together and had no opportunity to practise how they would communicate with each other in simulated emergency scenarios, may have contributed to these failings and lack of awareness.

The importance of multi-disciplinary training for maternity safety has been highlighted repeatedly, including by the NHS’s Saving Babies Lives’ care bundle, the Ockenden Review, and the NHS Maternity Transformation Programme’s competency framework. NHS Resolution's own maternity incentive scheme guidance to trusts, initially recommended providing ‘multi-professional system testing’ attended by anaesthetic, maternity and neonatal teams, but the inclusion of the neonatal team was later removed from the guidance when it was amended during the COVID-19 pandemic.

Lack of multidisciplinary training across maternity and neonatal/paediatric teams still features as a common theme identified in HSIB’s maternity investigations. HSIB advised that including neonatal teams in multidisciplinary training, as standard, would promote a shared understanding of relevant clinical information and ways of working. HSIB recommended that NHS Resolution amends its maternity incentive scheme guidance to include the neonatal team as one of the professions required to attend multi-professional training.

HSIB also recommended that the Resuscitation Council (UK)’s Newborn Life Support training course and newborn life support guidance reminds neonatal resuscitation teams to consider fetal blood loss where neonatal resuscitation includes chest compressions. 

If you or your child have been severely injured as a result of negligent care before, during or soon after birth, and would like to talk to one of our solicitors, free and confidentially, about making a claim, contact us here.


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