HSIB learning report says better care is needed to avoid harm to newborn babies from unsafe skin-to-skin contact

The Healthcare Safety Investigation Branch’s (HSIB) latest national learning report has highlighted the need for better care to avoid harm to newborn babies from unsafe skin-to-skin contact immediately after birth. The report follows HSIB’s review of 12 cases in which newborn babies suffered sudden unexpected postnatal collapse (SUPC) during skin-to-skin contact. Three babies died. Others needed ‘cooling’ to reduce damage to the brain from lack of oxygen. Most needed neonatal intensive care treatment after suffering cardiorespiratory (heart and lungs) collapse. 

Lack of midwife observation, incorrect positioning and leaving the baby in the care of a sedated or heavily medicated mother were amongst the failings which led to unsafe care. 

What is skin-to-skin contact?

Skin-to-skin contact is a common practise in which a newborn baby is placed on their mother’s chest immediately after birth. It is recommended by healthcare organisations, including the World Health Organization (WHO), NICE, Public Health England and Unicef UK as it has been found to have physiological and psychological benefits for both the mother and baby. Skin-to-skin contact in the first hour after birth has been found to:

• relax mother and baby; 
• help the baby adapt to their new environment by regulating their temperature, heart rate and breathing;
• protect the baby against infection by their skin coming into contact with the mother’s friendly bacteria;
• stimulate hormones to help with bonding and breastfeeding.  

HSIB’s national learning report reminds maternity teams that skin-to-skin contact takes place during a critical time in which the baby and mother need high levels of observation and postnatal care. It is essential that in all the activity which follows a birth, the baby is continually and properly observed. A mother who is exhausted, affected by sedation, in pain, undergoing perineal suturing or unable to see the baby that she is trying to hold on her chest, cannot keep her baby safe. That depends on careful monitoring and observation via safe systems and midwifery care. 

What is HSIB? 

The Healthcare Safety Investigation Branch, or HSIB, is responsible for investigating all NHS maternity patient safety incidents which meet the RCOG’s Each Baby Counts criteria. This includes intrapartum (during labour) stillbirths, neonatal (newborn) deaths and hypoxic brain injury to babies born at 37 or more weeks of pregnancy. In addition to their investigation of individual incidents, HSIB collect and publish the lessons to be learned by the NHS from these tragedies, in the hope of improving maternity services. All HSIB maternity investigations are reviewed by a clinical panel of obstetricians, midwives, neonatologists and anaesthetists.

In March, HSIB identified sudden unexpected postnatal collapse (SUPC) as one of the safety themes arising from its maternity investigations. Its August 2020 report, National Learning Report: Neonatal Collapse Alongside Skin-to-skin Contact sets out the lessons to be learned by NHS maternity services from patient safety incidents involving  neonatal collapse during skin-to-skin contact.

What is sudden unexpected postnatal collapse (SUPC)?

Sudden unexpected postnatal collapse or SUPC is a rare but sometimes fatal cardiorespiratory collapse of an apparently healthy term newborn baby soon after birth. SUPC can happen any time within the first week of life but is most common within two hours of birth. The British Association of Perinatal Medicine defines SUPC as any term or near-term (born at 37+ weeks of pregnancy) infant who: 

• Is well at birth, with an APGAR score at 5 minutes of 7 or more, and suitable for routine (not intensive) care; 
• Has a severe unexpected cardiorespiratory collapse (involving heart and lungs);
• Needs resuscitation with intermittent positive-pressure ventilation (IPPV); 
• Collapses within the first 7 days of life and dies.
• Goes on to need intensive care or develops encephalopathy (brain damage or disease).

A diagnosis of SUPC assumes that other medical causes for the collapse have been ruled out, such as heart disease or sepsis. 

What did HSIB’s learning report say about neonatal collapse during skin-to-skin contact?

Out of 335 maternity investigations carried out by HSIB between April 2018 and August 2019, excluding cases involving stillbirths and maternal deaths, 12 babies (3.6%) met the criteria for SUPC.  Of these 12 babies: 

• Three babies died, two from hypoxic brain injury (lack of oxygen) and one from pulmonary haemorrhage (bleeding into the lungs).
• The remaining nine babies were all treated in neonatal intensive care.
• Seven babies received ‘cooling’ treatment to reduce hypoxic brain damage, some also received oxygen. MRI scans later showed no evidence of harm.
• Two babies were diagnosed with persistent pulmonary hypertension of the newborn (PPHN) after the collapse. PPHN means the blood vessels in the baby’s lungs don’t open properly after birth, leading to reduced oxygen in the baby’s blood. 
• Three babies were treated for an unconfirmed diagnosis of sepsis. 
• One baby had choanal stenosis (narrowed nostrils) and a floppy larynx, which would not be easily visible at birth but increased the risk of airway obstruction if incorrectly positioned during skin-to skin contact. 
• Three mothers had been prescribed opiate drugs before and during labour, which can cause drowsiness and affect the baby’s breathing immediately or soon after birth.  
• One baby was later found to have suffered a possible stroke late in the pregnancy, which could have affected the baby’s breathing or caused seizures, resulting in cardiorespiratory compromise.

HSIB’s report focussed on the way in which skin-to-skin contact contributed to the collapse of these babies, aside from any other potential causes. In doing so they identified the following lessons. 

• A baby who appears well at birth with good APGAR scores can be safely laid skin-to-skin with the mother (or parent)  and needs close observation in the first minutes after birth.
• The APGAR score, which gives a score of 0,1 or 2 to the baby’s heartrate, colour, tone, reflex and respiratory effort, at one, five and 10 minutes, with a maximum score of 10, is an essential part of postnatal care. These assessments can take place during skin-to-skin contact but may need to interrupt skin-to-skin contact briefly to allow correct, close observation of the baby. HSIB found that APGAR observations at five or ten minutes were sometimes only carried out visually, without using a stethoscope to check the baby’s heartrate or feeling the baby’s muscle tone. This may give a misleading assessment of the baby’s condition. HSIB recommends that the formal process of Apgar checks should be reviewed to avoid subjective assessments and to inform guidance.
• Vigilant observation of the mother and baby must take place during skin-to-skin contact, and the baby removed if concerns arise over either’s health. Whilst midwives handled essential postnatal tasks, such as managing the mother’s postnatal care, checking observations, communicating with the family, and completing documentation, they were not always able to see the baby during skin-to-skin contact. At times mother and baby (or father and baby) were left unattended. In five cases, the baby collapsed whilst the midwife was busy with other tasks, including repairing a mother’s perineal tear. In one case the baby collapsed whilst left with the father whilst the midwife attended to the mother who was vomiting. In two cases the midwife left the room to use essential equipment which was located elsewhere. System failures, such as excessive workload with competing tasks, lack of correct equipment in the delivery room, and low staffing levels all make it harder for the midwife to watch the baby in the hours after birth. In the cases reviewed, the collapse of the babies was spotted between eight and 45 minutes after birth. 
• Mothers must be in a position to hold and feed their baby safely. They should be able to see their baby’s face.  
• The baby must be positioned carefully with their head supported to keep their airway clear. The mother should be made aware of the importance of the baby’s position. In one case the baby was found to be pale and floppy after having been left face down on the mother’s chest for 37 minutes whilst the mother’s perineal tear was repaired.  In another case the mother had been left to breast feed the baby whilst on gas and air for pain relief whilst her perineum was being sutured. HSIB pointed out that a mother who is in pain may not be able to hold her baby safely. In 6 of the 12 cases, the position of the baby for skin-to-skin contact may have contributed to the sudden unexpected postnatal collapse. 
• Staff should talk with the mother and her partner as soon as possible after birth about the importance of recognising changes in the baby’s colour or tone, and the need to alert staff immediately if they are concerned. 
• Staff should always listen to parents and respond immediately to any concerns that they raise.  
• Pain relief, opiates and sedation can affect a mother’s ability to watch and care for her baby. Skin-to-skin contact should not take place with mothers who are receiving gas and air or other painkillers which affect their consciousness and awareness of their baby’s position. If the mother has been prescribed opiate medication in labour, this can cause drowsiness, nausea, and vomiting in the mother, and slow breathing and drowsiness in the newborn baby. 
• Skin-to-skin contact with mothers with high body mass index (BMI) may increase the risk of neonatal collapse. 

The Unicef UK Baby Friendly Initiative which supports neonatal skin-to-skin contact has updated its maternity policy statement and is now encouraging maternity services to learn from HSIB’s recommendations.  

If you are caring for a child with severe disability arising from negligent maternity or neonatal care and would like to find out more about making a claim, contact us by email on cerebralpalsy@boyesturner.com.