Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Investigation summary

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.

Reference event

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.

Findings

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.

Safety recommendations

NHS Resolution

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.

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 (UK)

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.

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.

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