Skip to main content

Each baby Counts 2015 report top banner Each baby Counts 2015 report top banner

Each baby Counts 2015 report banner border

Communication of risk factors



For a baby delivered at 41 weeks by category 1 caesarean section under general anaesthesia, there was a failure to communicate the significance of abnormalities on the CTG trace and a profound fetal bradycardia, which meant that the delivery was attended only by a junior paediatric trainee.

Had these additional risk factors been communicated, this might have led to the delivery being attended by a team of people, including those of appropriate seniority, ensuring a more timely and robust resuscitation process. Efforts to resuscitate the baby were stopped shortly after birth.

The mother of a baby born at 41 weeks had a high temperature and was receiving intravenous antibiotics during labour. The baby’s delivery was delayed because of shoulder dystocia and the neonatal team arrived after the baby had been born. Absence of the neonatal team during delivery caused a delay in intubation and the neonatal team was not made aware of the possible diagnosis of sepsis for both the mother and the baby. The baby was actively cooled for 72 hours and discharged home on day 7.


The reviewers observed a number of instances where senior paediatricians were not involved early in the care of babies. The reviewers considered that the delivery of care for these babies might have been improved had a more senior member of staff been involved in their care at an earlier stage.

Things you can do

The communication of relevant risk factors is vital when neonatal assistance is requested at a birth. Provision of this information in a timely manner will help the neonatal team assess who should attend.

To ensure effective communication in all instances, information should be provided in an SBAR[i] format or using a similar structured communication tool in all maternity units. This may also provide further potential for clinical audit and service improvement.





[i] Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf 2006;32(3):167–75.