November 4, 2021

“Neonatal collapse alongside skin-to-skin contact.” A review of the report from the Healthcare Safety Investigation Branch

The Healthcare Safety Investigation Branch (HSIB) is an independent body funded by the NHS to investigate circumstances where there has been an adverse event during pregnancy and/or childbirth. They routinely release reports, known as the Maternity National Learning reports, that identify the risks and issues faced by expectant mothers and newborn babies; making recommendations to improve patient safety.

This HSIB report reviews early deterioration in the newborn, which may go undiagnosed. Sudden unexpected postnatal collapse (SUPC) is rare but can be life threatening. The British Association of Perinatal Medicine defines SUPC as a “term or near-term” baby who meets the following criteria “1. well at birth, 2. collapses unexpectedly in a state of severe collapse involving heart and lungs, 3. resuscitation with positive-pressure ventilation is required, 4. collapses within the first 7 days of life and dies OR goes on to require intensive care/develops encephalopathy”. It has been suggested that 73% of SUPC events occur within the first 2 hours of life.

The HSIB report investigates the link between skin-to-skin contact and SUPC. Of the cases investigated that met SUPC criteria, 12 were in relation to skin-to-skin contact, with 6 of these suggesting that the positioning of the baby at this time had an impact. Skin-to-skin contact is a practice recommended by numerous bodies worldwide including the World Health Organisation (WHO), Public Health England (PHE) and UNICEF UK, who have accredited the UK as part of their Baby Friendly Initiative. Skin-to-skin contact has been proven to trigger instinctive behaviours between mother and baby, allowing them to bond and the baby to naturally feed and promoting the baby to adapt to life outside of the mother’s womb.

Key findings from the HSIB report are:

- Observations from the HSIB report indicate that a baby with good Apgar scores who appears to be well can safely have skin-to-skin contact with the mother, however the baby still requires close observations. An instance has been recorded during the investigation where a baby has not been correctly placed to enable observation. In this case, the mother was unable to see the baby’s face and was unable to reposition him. This is not good practice as the baby being laid face down on the mother can cause obstruction to the airways.

- A mother who is in pain may not be able to hold her baby safely, particularly as pain relief may affect her ability to observe and care for the baby with sound judgment. There have been instances where a mother has been engaged in skin-to-skin contact with the baby while also having perineal sutures done by a midwife. While this can be safe, it has been recommended that in these instances the risks should be discussed. The mother should be in a semi reclining position and advised of the correct position for the baby to keep the airways clear and how to recognise any changes in condition of the baby. Further risks of skin-to-skin contact leading to SUPC may include staff not being focused on observation of the baby, mothers with a high BMI and in circumstances where the mother has had antenatal opiate analgesia (this can sometime cause a period of alertness followed by short term respiratory decline in the baby). Skin-to-skin contact should not happen in instances where the mother is on strong pain relief; it is recommended that the baby either has contact with a birth partner such as the father or is placed in a warm resuscitaire in the mother’s view.

- The assessment of the baby’s Apgar score should not be from a distance. The Apgar score should be assessed at 1 minute, 5 minutes and 10 minutes of life to ensure that the baby is in a good condition continuously. Not all checks can be performed visually (for example checking the baby’s heart rate) and it has therefore been considered that the formal process requires the checks to be reviewed to minimise the individual nature of each assessment.

- The need for vigilance in observing the newborn to prevent SUPC has been noted. Factors such as postnatal midwifery tasks (e.g., placenta delivery, cleaning the mother and completing documentation) can have an impact on the ability of the midwife to effectively monitor the newborn when in skin-to-skin contact with the mother. During the investigation, it was noted that in 5 of the 12 cases, neonatal collapse occurred while the midwife was performing other duties. The ability to detect SUPC decreases under a high task load, and it is therefore recommended in the report that midwives stay vigilant as best they can and advise mothers of what to look for to reduce instances of SUPC.

- HSIB have noted that not having the correct tools and technology in the delivery suite is a systematic failure that can put the baby at risk of unobserved SUPC. Instances where the midwife has had to leave the room to collect the correct tools for suturing or keys for the drug cupboard have been recorded. Additionally, physical environment such as bad lighting in the room and organisational issues such as not enough beds in the delivery suite and staffing issues are factors that are hindering midwives’ ability to effectively observe and monitor newborn babies. A reluctance to call in community midwives due to the fact it takes resources from community care has also been observed. It has been recommended that trusts take more care with their workforce planning to ensure that where possible this is not an issue.

- Following the HSIB investigations, UNICEF have updated their guidance with safety considerations and recommended that all maternity services update their policies in line with the new guidance to continue to meet the Baby Friendly standards and improve patient safety. In reference to then baby, it is important that the airway is maintained in the correct position, and that both mother and medical professional continuously listen for breathing irregularities, changes in colour, floppiness or the baby going cold as these are all symptoms of SUPC.

We are pleased to see that recommendations are being made regarding the safety of both mother and child during maternity care, particularly as we see regularly cases involving such risk factors. We at RWK Goodman warmly welcome any changes that can be made to improve patient safety and hope that all maternity services take these recommendations into account to ensure cases of SUPC are recognised as early as possible to protect infants.

RWK Goodman’s clinical negligence team has specialism in birth injuries. If you would like further information on the HSIB reports and birth injury claims, you can click here to read our HSIB guide or please do contact us for further, personalised legal advice.

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