Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery
HSIB Legacy
Published
Maternity
Neonatal
his investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood transfusion emerged as a safety risk from investigations carried out under our maternity investigation programme.
2 recommendations
2 of 2 responded
Safety Recommendations (2)
NHS Resolution
R/2022/183
HSIB recommends that NHS Resolution, working with relevant specialities through the clinical advisory group, amends the maternity incentive scheme guidance for year five to include the neonatal team as one of the professions required to attend multi-professional training.
NHS Resolution committed to including the neonatal team as a required profession for multi-professional training in year five of the maternity incentive scheme, with a plan to finalize by December 2022.
Thank you for the recommendation, NHS Resolution will work with the maternity incentive scheme safety action leads and include the neonatal team as one of the professions required to attend multidisciplinary training. This will be discussed at a workshop where the safety actions for year five of the maternity incentive scheme will be developed and agreed. Actions planned to deliver safety recommendation: Make recommendation inclusions to the training safety action (or equivalent title) within year five of the maternity incentive scheme safety actions, by 31 December 2022. Resources in place to deliver action: clinical advisory group meeting with maternity incentive scheme clinical leads. Other dependencies identified: Endorsement/Agreement with the Royal College Of Paediatrics And Child Health (RCPCH). Response received on 9 May 2022.
Resuscitation Council
R/2022/184
HSIB recommends that the Resuscitation Council (UK)’s Newborn Life Support training course highlights that neonatal resuscitation teams should consider fetal blood loss in the event of neonatal resuscitation that includes chest compressions. In addition, this consideration should be included in the guidance to support the newborn life support algorithm.
The Resuscitation Council UK updated Newborn Life Support course lecture notes and a simulation to include considering O-ve blood for fetal blood loss during neonatal resuscitation. All centers have been informed.
Resuscitation Council UK (RCUK) was happy to work with HSIB to improve the safe care of babies at birth. As RCUK is the expert organisation for guidelines for resuscitation of the newborn infant, we were able to share expertise with HSIB on emergency blood transfusion at birth. We worked with HSIB to agree a common ground for the report and the information contained in our newborn resuscitation courses. As a result, we have updated the lecture notes used on our newborn resuscitation courses to include the need to consider the need for O-ve blood as part of the assessment at birth lecture. We also include acute blood loss at birth and the need for O-ve blood in one of the simulations that can be used in the RCUK Newborn Life Support course. All centres delivering our courses have been informed about the updates and there has been a positive response to the changes from our Instructor base. Our UK resuscitation guidelines are written using scientific evidence taken from international guidelines and updated on a five year cycle. All evidence will be reviewed for the next update and further revisions made where needed. Response received on 29 April 2022. Updated response received on 10 October 2022.