More can be done to prevent stillbirths, neonatal deaths and brain injuries during childbirth, the Royal College of Obstetricians and Gynaecologists says today.
The report is part of the College’s Each Baby Counts national quality improvement programme, launched in 2014. It contains an analysis of 2,500 assessments of the care of 1,136 babies born in the UK in 2015, of whom 126 who were stillborn, 156 died in their first week, and 854 babies who sustained severe brain injury*.
The team conclude that 76% of these babies "might have had a different outcome with different care".
Details are published today (21 June). Report author, Professor Zarko Alfirevic, says: "Problems with accurate assessment of foetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting foetal heartrate patterns, have been cited as factors in many of the cases we have investigated.
"This is the first time the Each Baby Counts team has been in a position to identify and share the lessons learned across the whole UK maternity service. However, until every incident is thoroughly investigated and important lessons identified locally, our understanding of the national picture will remain incomplete.
"The focus of a local investigation should be on finding system-wide solutions for improving the quality of care, rather than actions focusing only on individuals."
The report builds on an interim report last year by including a range of recommendations that may prevent these incidents in the future.
These include formally assessing all low risk women on admission to determine the most appropriate foetal monitoring method; following NICE guidance on the possible need for continuous monitoring during labour; and ensuring all staff have appropriate annual training.
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