“Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection” A review of the report from the Healthcare Safety Investigation Branch
The Healthcare Safety Investigation Branch (HSIB) investigate circumstances where the mother and/or baby have suffered an adverse event during pregnancy and/or childbirth. They periodically release reports into the risks and resulting issues that face maternity units, pregnant women and newborn babies when in NHS care. These are known as the Maternity National Learning reports.
In this report, HSIB have specifically reviewed the management of mothers carrying Group B Streptococcus (GBS) bacteria, which is an innocuous bacteria that naturally occurs within the body, usually in the intestines of 20-40% of the population as a whole.
Around 20% of women worldwide carry this in their vagina and while carrying GBS can often be without any complication to the mother, GBS can be serious and even life threating to a baby if contracted. GBS may either be contracted by the baby when passing through the birth canal or may pass into the amniotic fluid. If GBS has been detected during labour or birth, intrapartum antibiotic prophylaxis (IAP) is an effective method of treating and reducing risk of neonatal infection. Despite this, there is no current recommendation for routine screening during pregnancy and resultingly, babies are being exposed to the potential risks of GBS carriage and transmission.
The HSIB report has identified problems in each stage of maternity care and provision and has issued recommendations:-
- At the antenatal stage, it has been observed that a large proportion of women are not being fully advised of the risks that come with GBS contraction, and that the information that was being provided was not always accessible to all. The HSIB have recommended that GBS leaflets are distributed in all languages known of in the local area to ensure that all expectant mothers are aware of the risks to both themselves and their baby.
- In addition to written communications, there is also the recommendation of verbal communications to ensure that the risk is clearly understood and that mothers are given the opportunity to ask any questions that they may have.
- It was noted that local practice is not necessarily in line with national guidance. Examples have been found where medical staff are unaware of the best practice in treating GBS found in a mother due to the lack of clarity on guidelines; for example treatment for GBS found in urine is different from that detected from a vaginal swab. This difference in treatment has led to care that is not in line with national guidelines and has resulted in the HSIB recommending that guidelines must be clearly distributed to all staff to minimise risk.
- The report recommends improved management of early labour. It has been seen that medical staff are advising mothers to stay at home in the early stages of labour, however by not admitting the mother sooner rather than later there is no way to monitor the need for clinical intervention. Furthermore, mothers are not always being asked of their GBS status by triage staff. The staff may speak to multiple people such as the mother and their birthing partner when completing telephone triage, or the mother/birthing partner may speak to multiple members of staff who fail to check on GBS status. The HSIB have recommended that telephone triage be structured to ensure that all relevant information is captured.
- The management of prelabour rupture of membranes (PROM, waters breaking) during intrapartum care has been identified by HSIB as another risk factor, with investigations providing examples of mothers whose waters have broken have not been invited into the hospital until they are in established labour. There have been cases where mothers who are colonised with GBS have passed this on to their baby at this point, however the opportunity for treatment prior to giving birth has been missed. Additionally, mothers have reported that they have not been advised of the procedure to follow following PROM and have not been advised of the risks associated with this. The HSIB have recommended that NHS trusts communicate with mothers and birthing partners to ensure that they are aware of the risks.
- As with antenatal care, the lack of uniform guidelines for treatment across all local areas has led to the recommendation that each trust reviews national guidelines for care and offer immediate induction of labour to all mothers whose waters have broken.
- The final recommendation made by HSIB in relation to intrapartum care concerned delays in IAP (Intrapartum Anitbiotic Prophylaxis) administration due to a lack of staffing and heavy workloads. An example of this delay having a devastating effect on a baby is in a case where there was a 50-minute delay between mother’s admission to the maternity ward and the administration of IAP. HSIB have recommended that when mothers are found to be GBS positive, antibiotics should be prescribed and administered within an hour of admission when in established labour; where risk factors are identified, there should be an early administration of IAP and mothers who are aware of their GBS status should be made aware of what to expect upon admission in order to empower them to ensure they receive the correct care.
- HSIB investigations have found that postnatally, there have been cases of delayed recognition of early onset neonatal infection. Instances have been recorded whether the vital information of temperature, oxygen saturation levels and grunting to name a few are not being recorded on the Newborn Early Warning Trigger and Track (NEWTT) chart. It has been recommended that each trust should use the NEWTT charts to ensure that any deteriorations are noted as a result. Additionally, reluctance to feed should be noted as a symptom of potential sepsis and that infant feeding training should be given to women to ensure that deterioration and neonatal collapse is further picked up. HSIB have recommended that there should be a system introduced by Trusts to ensure that communication is effective in all disciplines and that all clinical plans are communicated to the correct staff member to carry them out.
We are pleased to see that recommendations are being made in reference to the safety of both mother and child during maternity care, particularly as we see cases involving such risk factors daily. We at RWK Goodman warmly welcome any changes that can be made to improve patient safety and hope that local NHS trusts take the recommendations into account to minimise the number of GBS related birth injuries.
RWK Goodman have a clinical negligence team with specialism in birth injuries. For more information, you can click here for information of GBS claims.
If you would like further information on the HSIB reports and birth injury claims, you can click here to read our HSIB guide or contact us for further, personalised legal advice.