This report presents key findings and recommendations based on the analysis of data from 2016 relating to the care given to mothers and babies throughout the UK, to ensure each baby receives the safest possible care during labour.
- Key findings: Of the nearly 700,000 babies born in 2016, 1,123 babies fulfilled the Each Baby Counts criteria. There were 124 stillbirths, 145 babies who died early and 854 babies who sustained severe brain injuries during labour at term (babies born after 37 completed weeks of gestation).
- Improved reporting: The quality of reporting improved by 14% from 2015, with more reports containing sufficient information for review.
- Care outcomes: The number of incidents where different care might have led to a different outcome still remains too high, with 71% babies who might have had a different outcome with different care.
- Interdependency of factors: For the babies reported to Each Baby Counts, the reviewers concluded that there was rarely one single cause of the stillbirth, early neonatal death or brain injury. The report identified an average of seven critical contributory factors for each baby where different care might have had made a difference to the outcome.
- Family involvement: There was also an increase in the number of parents who were invited to take part in reviews in 2016 – up to 41% from 34% in 2015. But in almost a quarter of instances parents were not involved, or even made aware, of reviews taking place.
The 2016 report includes a ‘deep dive’ into three focused areas, adherence to guidelines, and barriers to reporting and anaesthetic care.
- Guidelines: In almost half (45%) of these affected babies, guidelines and best practice were not followed. Reasons for not following guidelines included gaps in training, lack of recognition of problems, heavy workload, staffing levels and local guidelines not being based on best available evidence.
- Anaesthesia: The report found that anaesthetists were not involved in reviews of care in most cases, despites circumstances where anaesthesia was a core aspect of the care provided. The report identified gaps and delays in handover between shifts and variation in the participation of anaesthetists in the labour ward review.
- Barriers to reporting: The Each Baby Counts programme has improved its knowledge and understanding of the issues which affect reporting of cases. Factors included a lack of resources, time and guidance.
Key recommendations for clinical care
The recommendations below have been identified through detailed thematic analysis of the reviews submitted to Each Baby Counts. They address critical factors in the care of many of the Each Baby Counts babies that may have prevented their death or brain injury. This report focuses on guidelines and anaesthetic care.
- Workload: The labour ward coordinator must remain supernumerary at all times and should not be caring for women during the antenatal, intrapartum or postnatal period.
- Escalating high activity: There must be a clear escalation policy in place and a culture that empowers staff to escalate when the workload is becoming difficult to manage. All members of staff, irrespective of their role or grade, should feel empowered to inform senior midwives, managers and consultants when concerns arise both within their own specialty but also on behalf of another specialty. The consultant obstetrician should always be informed when labour ward activity is high.
- Cross-site communication: Women receiving care from multiple units must have an individualised management plan for antenatal, labour and postnatal care that outlines the roles and responsibilities of each site to avoid any confusion. All sites should be able to readily access a woman’s notes whether they be hand-held or electronic.
- Local guidelines: There must be a clear policy to ensure that local guidelines are updated in line with national guidance. Appropriate resources and staff time must be allocated to facilitate this. Where units decide to deviate from national guidance, this should be clearly documented and units should undertake regular review of local deviations from national guidance. All guidelines should be reviewed in light of incidents to ensure that they improve care as intended.
- Migration of boundaries: Teams should protect against migration of boundaries by ensuring that real practice reflects practice as described in guidelines. Audit identifies where migrations from safe practice are occurring, but it is only through a process of quality improvement or changing unworkable guidelines that these migrations can be corrected.
- Recommendations for future reviews: This full analysis of the 2016 data underlines the recommendations for reviews highlighted previously. Improving the quality of local reviews will improve the lessons learned and, ultimately, improve care.
Barriers to reporting to Each Baby Counts
- Neonatal input: Assess your local processes for involving neonatal team members in the review of Each Baby Counts babies to see whether this needs to be improved to ensure a collaborative multidisciplinary approach. This could include identifying an Each Baby Counts neonatal lead for each unit.
- Local reviews: 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 Each Baby Counts eligible babies who are stillborn or who die within the first 7 days of life should be reviewed using the Perinatal Mortality Review Tool (PMRT).
- There is an urgent need for a PMRT-style tool that includes morbidity to be commissioned by the UK healthcare system.
- All reviews should involve an obstetric anaesthetist and should include review of the detailed anaesthetic record.