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Key recommendations

Key recommendations for reporting and reviewing

  • All eligible babies should be reported to Each Baby Counts within 5 working days.
  • All local reviews of Each Baby Counts babies should contain sufficient information to determine the quality of the care provided.
  • All trusts and health boards should inform the parents of any local review taking place and invite them to contribute in accordance with their wishes.
  • All local reviews must have the involvement of an external panel member.
  • All reviews of liveborn Each Baby Counts babies must involve neonatologists/neonatal nurses.


Key recommendations for care

Intermittent auscultation

  • Women who are apparently 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 development of IT tools that bring together data from across a trust’s systems to support accurate, easily accessible risk assessment should be prioritised.
  • NICE guidance on when to switch from intermittent auscultation to continuous cardiotogography (CTG) monitoring should be followed. This requires regular reassessment of risk during labour.


Continuous cardiotocography (CTG)

  • Staff tasked with CTG interpretation must have documented evidence of annual training.
  • Key management decisions should not be based on CTG interpretation alone. Healthcare professionals must take into account the full picture, including the mother’s history, stage and progress in labour, any antenatal risk factors and any other signs the baby may not be coping with labour.


Situational awareness

  • All members of the clinical team working on the delivery suite need to understand the key principles (perception, comprehension, projection) of maintaining situational awareness to ensure the safe management of complex clinical situations.

  • A senior member of staff must maintain oversight of the activity on the delivery suite, especially when others are engaged in complex technical tasks. Ensuring someone takes this ‘helicopter view’ will prevent important details or new information from being overlooked and allow problems to be anticipated earlier.


Stress and fatigue

  • Decision making is more difficult when staff feel stressed and/or tired. A different perspective improves the chances of making a safe decision. Clinical staff should be empowered to seek out advice from a colleague not involved in the situation who can give an unbiased perspective (either in person or over the phone).
  • When managing a complex or unusual situation involving the transfer of care or multiple specialities, conduct a ‘safety huddle’ – a structured briefing for the leaders of key clinical teams. This will ensure everyone understands their roles and responsibilities and shares key clinical information relevant to patient safety.


Neonatal care

  • If therapeutic hypothermia is being considered, continuous monitoring of core temperature must be undertaken. Early efforts to passively cool the baby should also be considered (turn off the heater, take off the hat).
  • The paediatric/neonatal team must be informed of pertinent risk factors for a compromised baby in a timely and consistent manner.