Brain Injury in Term Infants: The ‘Each Baby Counts’ Programme
The RCOG1 has recently in June ’17 published the findings of the ‘Each Baby Counts’ programme for 2015. It is a 5 year project. In the foreword, David Drummond RCOG President, states that while most mothers take home a healthy baby there are a small number of babies who die or suffer severe complications during labour. Frequently the root cause is difficult to ascertain. Things go wrong very quickly and the sequence of events is often difficult to follow. A common problem is the inability to time the onset and duration of the exact insult that causes the neurological problem. The neurological sequelae suffered by the child place a major burden on affected families. These difficult cases adversely affect hospitals and their staff. There are years of uncertainty caused by possible litigation. Neonatal Encephalopathy has emerged as the preferred terminology as it describes a syndrome of disturbed neurologic function after birth in infants born at or beyond 35 weeks gestation2.
Neonatal Encephalopathy is one of the greatest challenges facing perinatal medicine. Globally there are 700,000 cases of death or disability from birth asphyxia annually. The RCOG estimates that there are between 500 and 800 cases of severe brain injury in term infants in the UK annually. The aspiration is to reduce this figure by 50% by 2020. This calculation is based on the assumption that a substantial number of cases are preventable. It is a matter of some debate. Some commentators maintain that antecedent factors before the onset of labour play a role in many cases. It is frequently unknown whether the ultimate brain injury took place around the time of delivery or following cumulative events during the pregnancy. A case-control study undertaken by the Rotunda group found that in a series of 237 infants with encephalopathy and 489 controls there were a combination of antenatal and intrapartum risk factors3.
Since January 2015 the Each Baby Counts’ programme has been collecting and pooling the results of local risk management reviews. It is an attempt to ascertain a national picture. Until now there has been no central source to collate perinatal events. Without the overall picture it is difficult to identify common risk factors and to learn from lessons learned. The value of a large data collection set is that it offers the potential to learn from hospitals that are doing particularly well. By capturing data at a central level it is hoped that long-lasting cultural changes can be made. It is dependent on the co-operation of all hospitals. This is feasible as long as the process remains a learning opportunity and not a punishment. There is much about birth asphyxia that is ill understood. The clinical details of a cohort of cases is one way of contributing to the knowledge base.
During 2015 there were 800,000 births in the UK. Among this cohort there were 921 term infants who suffered from asphyxia during labour. Among the 921 affected infants there were 119 (13%) intrapartum deaths, 147 (16%) early neonatal deaths, 655 (71%) severe brain injuries. If this data was extrapolated for Ireland with its 65,000 births annually the calculation would be a total of 74 term infants with asphyxia made up of 9 intrapartum deaths, 12 early neonatal deaths, and 52 with severe brain injury. There is clear variability both in the fetal reserve and in the duration and degree of the insult in case by case.
The Programme places an emphasis on the in-hospital, local review of birth asphyxia cases. The construction of the review varies widely, 52% being specific and 48% non-specific. The format of the specific reviews was mostly root cause analysis. In the UK the review groups consist of a midwife 96%, obstetrician 94%, neonatologist 62%. The focus should be on systemic factors rather than individual actions. The outcome of local reviews was as follows, 21% no action recommended, 18% further training of staff members, 53% recommended systemic changes. The report does not outline what factors other than the clinical details are considered in the local reviews. In particular whether the brain MRI findings, placental histology, and metabolic investigations are taken into account.
Previous Reports have highlighted that the same mistakes are made repeatedly. Guidelines are not the only answer to the problem because they are not always followed. Quality improvement is an important tool because it concentrates on bringing about improvement. It has ability to tackle an adverse event and bring in an effective change that works for patients. This change should encompass patient safety, patient experience and efficacy. It is planned to develop care bundles and other tools to drive local quality improvement.
Human factors are the ways in which staff members interact with each other. Situation awareness is the ability to take note of all clinical activity around one and being able to anticipate potential complications. There should be a key person to oversee what is happening on the unit. There should be structured briefings when patient care needs urgent escalation. Another issue is staff stress and fatigue. Decision-making is more difficult when staff is tired.
Everybody should clearly understand his role and responsibilities within the service. The importance of in-service trainers is emphasised by a number commentators. Mandy Forrester midwife made the important point that good staffing levels are important in the delivery of perinatal care. In England alone there is a 3,500 midwifes shortage. She added that too often the focus is on individual actions. A related factor is the experience and seniority of the perinatal staff. Staff retention due to the stressful nature of the work is a constant concern. Health care professionals frequently work in environments that do not support best practice.
The Each Baby Counts programme will over time help to build up a better understanding of the clinical circumstances around Neonatal Encephalopathy.
- Each Baby Counts: Key messages from 2015. Royal College of Obstetricians & Gynaecologists. 2017
- Tan S, Wu Y. Etiology and pathogenesis of neonatal encephalopathy. uptodate
- Hayes BC, McGarvey C, Mulvany S et al. A case-control study of hypoxic-ischaemic encephalopathy in newborn infants at >36 weeks gestation. Am J Obstet Gynecol 2013;209:29.e1