MBRRACE-UK Perinatal Confidential Enquiry 2017 Report published today

Front cover of the report

“Term, singleton, intrapartum stillbirth and intrapartum-related neonatal death”

The third Perinatal Confidential Enquiry report issued by the MBRRACE-UK collaboration is published today 28th November 2017: You can read it on the reports page.

The rate of term, singleton, intrapartum stillbirth and intrapartum-related neonatal death has more than halved since these deaths were last reviewed nationally in 1993. This represents a reduction of about 220 intrapartum deaths per year.

Despite the fall in the mortality rate these deaths remain an important group for concern not least because, in the vast majority, the mother was directly receiving maternity care when the baby died or when the event in labour or birth occurred which led to the baby’s death.

Led by the MBRRACE-UK collaborators based in the Department of Health Sciences at the University of Leicester, the MBRRACE-UK report focuses on the quality of care for stillbirths and neonatal deaths of singleton babies born at term who were alive at the start of care in labour, and who were not affected by a major congenital anomaly.  This type of death occurred in 225 pregnancies in the UK in 2015 and represents about 5% of perinatal deaths overall.

A representative sample of 78 of eligible deaths of babies born in 2015 were selected for the confidential enquiry process. The care provided for these mothers and babies was reviewed in detail against national guidelines and standards by a panel of clinicians, including midwives, bereavement midwives, obstetricians, neonatologists, neonatal nurses and pathologists who considered every aspect of care. In the panels’ view for 80% of the deaths different care may have resulted in a different outcome for the baby.

The main findings from the panel enquiries were that:

  • in at least a quarter of the deaths there were problems with inadequate staffing and resources to provide safe care; 
  • heavy workload contributed to delays in induction in one third of women being induced;
  • not all women who had had a caesarean section in a previous pregnancy had had a clear discussion about their birth plan;
  • there were problems recognising when women moved from early to established labour and appropriate monitoring wasn’t instituted as a consequence;
  • guidelines weren’t followed when monitoring the baby’s heart rate leading to delays when babies needed to be delivered urgently;
  • for most babies where resuscitation was attempted it was delivered effectively by clinical staff present at the delivery based on the Neonatal Life Support programme;
  • overall the quality of bereavement care was variable, with a lack of joint midwifery, obstetric and neonatal input;
  • one in three neonatal deaths did not have a post-mortem examination or placental histology carried out;
  • the majority (95%) of intrapartum-related deaths were reviewed, however, nine in ten of the reviews were of poor quality and didn’t follow guidance for serious incident reviews.

To read more you can download the full report, executive summary and the lay report on the reports page.