AN analysis of 727 births resulting in death or brain injury found that 76 per cent might have had a better outcome with different care.
This is a key finding in a summary report published by Each Baby Counts, a national quality improvement initiative sponsored by the Royal College of Obstetricians and Gynaecologists (RCOG).
Investigators conducted 2,500 expert assessments of local reviews into the care of 1,136 babies born in the UK in 2015 – 126 who were stillborn, 156 who died within the first seven days after birth and 854 babies who met the eligibility criteria for severe brain injury.
The reviewers concluded that three quarters (76 per cent) might have had a different outcome with different care. This finding was based on 727 babies where the local investigation provided sufficient information to draw conclusions about the quality of care. A quarter of the local investigations were not thorough enough to allow full assessment.
The report recommends improved fetal monitoring with better training and assessment to determine when to switch between intermittent and continuous monitoring during labour. Paediatric/neonatal teams also need to be informed of pertinent risk factors in a timely and consistent manner.
The report calls for better awareness of human factors including understanding "situational awareness" to ensure the safe management of complex clinical decisions, with key members of staff maintaining appropriate clinical oversight and the importance of seeking a different perspective to support decision-making, particularly when staff feel stressed or tired.
Co-principal investigator, Professor Zarko Alfirevic, consultant obstetrician at Liverpool Women's Hospital, said: "Problems with accurate assessment of fetal wellbeing during labour and consistent issues with staff understanding and processing of complex situations, including interpreting fetal 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."
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