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Unexplained loss of situational awareness
  In one review that was analysed, it was found that everyone present at a difficult vaginal breech delivery failed to appreciate a pathological CTG for over 1 hour.   The delivery was complex and completed by the consultant as the fetal head
Cognitive overload as a loss of situational awareness
  Situation At this point the team (obstetricians, anaesthetist and co-ordinating midwife) felt that delivery suite was busy and had many complex problems, but that they were managing it safely and effectively and did not consider escalating the
Dealing with technical difficulties in obtaining adequate continuous CTG tracings
A further theme was the management of mothers when there was difficulty obtaining adequate continuous CTG tracings. Time can be lost by blaming the equipment for a CTG abnormality and significant events can be missed if maternity providers do not react
Recommendations – stress and fatigue
  Recommendation 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
Resuscitation competence
  Situation A baby was born at 41 weeks of gestation with no spontaneous respirations. There was a significant delay in intubation even once a lack of respiratory drive was recognised. Once the decision was made to intubate, the endotracheal tube,
Decision making surrounding therapeutic hypothermia
  The reviewers found that, at times, the information contained within the local reviews lacked detail on whether or not criteria were met to initiate therapeutic hypothermia treatment.   The reviewers considered that such clinical decisions
Key NHS resources and references
NHS resources NHS Improvement: ‘Civility and Respect Toolkit’ Social Partnership Forum: Creating a culture of civility, compassion & respect An Alliance Against Bullying, Undermining and Harassment in the NHS NHS Scotland: Bullying and Harassment
The final results for the babies born in 2018 who have been reported to Each Baby Counts are presented in Figure 1: Figure 1: Final results for babies born in 2018 who were reported to the Each Baby Counts programme 651,587 term babies born in
Analysis of local reviews
The information for 1093 (95%) of the 1145 babies reported for 2018 was fully completed by a lead reporter on the Each Baby Counts online reporting system. The other 52 reports on the system were started but were not completed by the lead
Twenty-five semi-structured interviews were carried out to explore the views and thoughts of a number of key stakeholders involved either directly in the programme or in wider maternity safety work. Topics for discussion included the aim and purpose of

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