An NHS Resolution report has found that the number of babies born with avoidable birth injuries could be significantly reduced with improved foetal heart monitoring.
The investigation found the midwives failing to check babies’ heart rates during labour is the biggest cause of avoidable birth injuries in the NHS, accounting for seven out of ten cases.
Another common cause was delays in giving birth, including delays in transferring to a labour ward, admission to theatre delays and delays around vaginal breech births.
The report analysed 96 serious cases of babies born with avoidable brain injuries, out of 197 that were investigated for liability in England.
The NHS Resolution has been studying cases since April 2017 and covers all 129 acute maternity trusts in England and is part of a government scheme to have rates of stillbirths, neonatal/maternal deaths and brain injuries by 2025.
The investigation calls for urgent changes to ensure babies are properly monitored during labour. Their recommendations included urgent research to develop a standardised approach to monitoring foetal heartbeat rates, better transparency and more support for NHS staff.
The report also called for more research to examine how better to protect babies during caesarean sections.
Following concerns over the failure to properly monitor women expecting twins and triplets, the National Institute of Heath and Care Excellence (NICE) recently urged all trusts to follow their advice and label foetuses during scans so that each is properly checked.
Nadine Dorries, Health Minister for maternity and patient safety, said: “In the rare but devastating cases of brain injury in new-borns, we’re determined to continually improve how we support affected families and ensure the NHS can learn immediate lessons to avoid future harm.”
Prof Lesley Regan, president of the Royal College of Obstetricians and Gynaecologists, said: “Every incident of avoidable harm is a tragedy for the family and distressing for the maternity staff involved.
“Alongside the need to provide families with prompt interventions and more post-incident support for staff, this report has highlighted the need to develop more clinical interventions to prevent these incidents from happening in the first place.
“The RCOG is committed to working closely with the NHS, Royal College of Midwives and other partners to provide further national guidance and training for maternity teams to reduce the risk of avoidable harm.”
