Poor fetal monitoring is one of the leading causes of death in babies in England, a review finds

NHS staff fail to properly monitor a baby’s heartbeat during labor in almost half of cases where serious deficiencies lead to tragedy, a maternity care investigation has found.

The Care Quality Commission found that in 45 of 92 cases (49%) where a baby died or suffered severe brain damage, there was inadequate fetal monitoring during birth in a midwife-led unit in England.

The findings show that correct monitoring is “vital” to ensure care is safe in all maternity units, said Sandy Lewis, director of the CQC’s safety investigations program (MNSI).

It analyzed four common shortcomings in the 92 births in a report aimed at helping midwives and doctors improve the quality and safety of care.

In one case, the research team found that “there were likely abnormalities in the infant’s heart rate that persisted over an extended period of time and were not identified during intermittent auscultation (monitoring).”

In another case, midwives were so busy dealing with a separate emergency on the ward that they failed to check the baby at the appropriate recommended times and the woman was left unattended.

The 92 incidents involved 62 cases in which the newborn suffered severe brain injury, 19 in which the newborn was alive at the onset of labor but was stillborn, and 11 in which the newborn died within the first six days of life.

Lewis said: “In the 92 cases analyzed in this report, difficulties in carrying out or interpreting the results of fetal monitoring were a factor in 45 cases.

“We understand that reading this may be concerning for women who are currently pregnant, for those planning a pregnancy, or for their families.

“It is important to recognize that during the period covered by the report, thousands of pregnant women experienced a safe pregnancy, labor and birth.”

The MNSI also identified short staffing levels and high workloads in maternity wards as another major factor that could cause things to go wrong. The Royal College of Midwives and the Commons Health Select Committee have called on the NHS to recruit 2,500 extra midwives to help improve care.

The NCT parenting organization said midwives not having enough time to properly monitor a baby’s heart rate contributes to what are too often “dangerous” maternity wards.

“This report is extremely worrying as all too often we see women and their babies at risk of dangerous levels of care due to an overworked and understaffed maternity workforce,” said Maxine Palmer, head of development at the NCT .

“If midwives have to compromise on routine one-on-one care during labor, often requiring them to listen to a baby’s heartbeat, then they are not in a position to provide safe care.”

Women should receive the same standard of care whether they decide to give birth in a hospital, a midwife-led unit or at home, Palmer added.