Summary
Each Baby Counts is a national quality improvement programme led by the Royal College of Obstetricians and Gynaecologists (RCOG) to reduce the number of babies who die, or are left severely disabled, as a result of incidents occurring during term labour.
The Each Baby Counts programme brings together the results of local investigations into stillbirths, neonatal deaths and brain injuries occurring during term labour to understand the bigger picture, share the lessons learned and prevent babies from dying or suffering brain injuries in the future.
This report presents key findings and recommendations based on the analysis of data relating to the care given to mothers and babies throughout the UK, to ensure each baby receives the safest possible care during labour.
Content
Recommendations
Human factors and behaviour:
- Each Baby Counts has demonstrated that human factors are recurrent themes that need to be urgently addressed at a systemic level.
- Research is required to establish how to operationalise learning from this report into practice with improved clinical outcomes.
Workload and workforce challenges:
- Develop and fund an appropriate tool to record current workload and anticipate the obstetric care required for the population.
- This tool should complement the midwifery acuity tools currently implemented nationally.
- Research is required to identify safe obstetric staffing standards for the workload and acuity, to guide policy-level changes for the workforce.
Communication:
- All staff must be familiar with using their unit emergency communication and escalation protocols, in particular where emergency buzzers are located and how to activate a switchboard emergency call.
- This should be mandatory in departmental induction and included in simulated escalation calls during local multidisciplinary team training.
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