The national investigation
This 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.
If a baby has lost blood before or during birth, efforts to resuscitate them may be less effective because they may not have enough blood to carry the oxygen their body needs. Delays in the administration of a blood transfusion in this scenario can therefore result in brain injury caused by lack of oxygen to the baby’s brain.
This investigation explores the issues that influence the timely administration of blood transfusion to newborn babies following acute blood loss during labour and/or delivery.
Specifically, it explores:
- communication between the different medical teams involved in the care of women/pregnant people and their babies during labour and birth
- national guidance for medical staff on when to consider the option of a blood transfusion for a newborn baby
As an example, which is referred to as ‘the reference event’, the investigation examined the experience of Alex and Robert, whose baby Aria was born by emergency caesarean section following an acute blood loss.
The administration of a blood transfusion as part of resuscitation requires a number of preparatory steps, including collecting the blood and undertaking various checks before using it. Inclusion in resuscitation training of a prompt for clinicians to consider the need for a transfusion, and to prepare for it if appropriate, may help reduce any delay.
Involving members of neonatal teams (staff who specialise in the care of newborn babies) in multidisciplinary training in maternity units is not routine. Standardising their inclusion in such training would promote a shared understanding of relevant clinical information and ways of working.
Alex and Robert went to the hospital where they were booked for maternity care after Alex’s waters broke at home.
While at the hospital Alex experienced sudden unexpected blood loss and was transferred to the labour ward.
Baby Aria’s heartbeat could not be found on a cardiotocograph (a machine that monitors a baby’s heartbeat and a woman’s or pregnant person’s contractions during labour), but an ultrasound scan identified a slow heartbeat.
Alex was transferred to an operating theatre for an emergency caesarean section and baby Aria was delivered soon after. Baby Aria required resuscitation and was given a blood transfusion before being transferred to the neonatal (newborn baby) unit.
Baby Aria sadly died when she was 2 days old.