NHS staff do not correctly monitor a baby’s heart rate during labour in almost half of cases where serious failings lead to tragedy, a review of maternity care has found.
The Care Quality Commission identified that inadequate foetal monitoring occurred in 45 of 92 cases (49%) in which a baby died or suffered serious brain damage while being born in a midwife-led unit in England.
The findings show that correct monitoring is “critically important” to ensure care is safe in all maternity units, said Sandy Lewis, the director of the CQC’s maternity and newborn safety investigations (MNSI) programme. It analysed four common failings in the 92 births in a report that is intended to help midwives and doctors improve the quality and safety of care.
In one case the investigation team found that “there were likely to have been abnormalities in the baby’s heart rate which were ongoing for a prolonged period of time, which were not identified during intermittent auscultation [monitoring]”.
In another, midwives were so busy dealing with a separate emergency on the unit that they failed to monitor the baby at the correct recommended intervals and the woman was left unattended.
The 92 incidents involved 62 cases in which the newborn suffered a severe brain injury, 19 in which it was alive at the start of labour but was stillborn and 11 when it died within its first six days of life.
Source: Guardian, 8 May 2024
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