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  • National Learning Report: Neonatal collapse alongside skin-to-skin contact (13 August 2020)

    Article information
    • UK
    • Reports and articles
    • Pre-existing
    • Original author
    • No
    • HSIB
    • 13/08/20
    • Everyone


    National Learning Reports offer insight and learning about recurrent patient safety risks in NHS healthcare that have been identified through HSIB investigations. They present a digest of relevant, previously investigated events, highlight recurring themes and, where appropriate, make safety recommendations. National learning reports can be used by healthcare leaders, policymakers and the public to aid their knowledge of systemic patient safety risks and the underlying contributory factors, and to inform decision making to improve patient safety.

    The Healthcare Safety Investigation Branch (HSIB) Summary of themes arising from HSIB maternity investigation programme report (March 2020) describes eight themes arising from the maternity investigations. Sudden unexpected postnatal collapse (SUPC) was identified as a theme for further exploration in order to highlight areas of system-wide learning.

    SUPC is a rare but potentially fatal event in otherwise healthy appearing term (born after 37 completed weeks) newborn babies at birth. Between April 2018 and August 2019 HSIB completed 335 maternity investigations. Of the 12 identified SUPC cases, there were 6 cases where positioning of the baby to achieve skin-to-skin contact may have contributed to SUPC. While the number of incidents found was small compared to the number of term babies who had skin-to-skin contact at birth these incidents may in future be avoided and so learning is essential.


    Unicef UK Baby Friendly Initiative has updated its policy guidance in the light of these investigations and some organisations are using posters and checklists to help staff understand and carry out their responsibilities. HSIB has also observed the impact of high task load, environment and staffing levels on the ability of staff to detect SUPC.


    Maternity services should consider the following learning observations to ensure safe delivery of skin-to-skin care.

    • Based on the evidence, a baby who is born apparently well, with good Apgar scores, can be safely laid skin-to-skin with the mother or parent and requires close observation in the first minutes after birth.
    • Apgar scores must be attributed using close clinical observation of the baby. This can be achieved with the baby remaining in skin-to-skin contact. There may be a need to interrupt skin-to-skin contact briefly to ensure Apgar scoring is assessed accurately.
    • Vigilant observation of the mother and baby should continue, with prompt removal of the baby if the health of either gives concern.
    • Mothers should be encouraged to be in a semi recumbent (half lying, half sitting) position to hold and feed their baby, ensuring the mother can see the baby’s face.
    • Care should be taken to ensure that the baby’s position is such that their airway remains clear and does not become obstructed.
    • Staff should have a conversation with the mother and her companion about recognising any changes in the baby’s condition.
    • Always listen to parents and respond immediately to any concerns raised.
    • Medicines given to the mother should be considered when discussing skin-to-skin contact. Pain relief given to mothers can affect their ability to observe and care for their baby.
    • Additional risk factors should also be considered. The level of risk for SUPC when a baby is in skin-to-skin contact can increase with, for example, increased maternal body mass index, antenatal use of opiate medication, sedation, and staff’s focus on other tasks.
    National Learning Report: Neonatal collapse alongside skin-to-skin contact (13 August 2020) https://www.hsib.org.uk/investigations-cases/neonatal-collapse-alongside-skin-skin-contact/national-learning-report/
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