We have identified a safety risk in maternity care relating to delays to intrapartum intervention once fetal compromise is suspected.

The term intrapartum refers to the period of time spanning the commencement of labour, the birth of the baby and the delivery of the placenta and membranes.

For the wellbeing of a baby and/or a mother, clinicians may advise one or more interventions as labour progresses. A clinical intervention is any intentional action designed to improve a situation or prevent it from getting worse. Intrapartum interventions can range from medications (for example, to progress labour) and operations (for example, caesarean section) to performing manoeuvres during an emergency.

Reference event

We started this investigation after reviewing the maternity investigations HSIB has carried out to date at NHS trusts across England, as part of our maternity investigation programme.

Our review indicated that delays to intrapartum intervention once fetal compromise is suspected is a contributing factor to stillbirths, neonatal deaths and babies born with suspected brain injury.

Investigation summary

This national investigation considers the safety risk of delays in interventions during labour (intrapartum) once there have been signs indicating that a baby may not be well (fetal compromise). This was identified as a theme from a review of hundreds of HSIB’s maternity investigations. Evidence from national reports confirms that such delays are a safety issue.

There has been a national focus on improving safety in maternity care over the last five years. This has resulted in the publication of multiple national reports, with multiple recommendations and multiple programmes of safety improvement work being initiated.

This investigation draws together the key reports and initiatives and the common focus areas of attention. Both the national reports and HSIB’s maternity reports have identified recurring themes such as inadequate staffing, poor infrastructure and high workload to be contributory factors in the delays.

Rather than taking a traditional approach of concentrating on why things go wrong, the investigation looked instead at what helps things go right. Grounded in safety science, the investigation looked at factors within a maternity unit that can promote consistent safe performance despite the fluctuating demands of circumstances. The investigation’s findings were informed by observation and conversations with staff and national stakeholders in the maternity field along with existing research on how to foster safety in maternity units.

The investigation makes one safety recommendation and presents considerations for trusts that may increase organisational resilience and therefore reduce the potential for harm.

Download and read the full Delays to Intrapartum Intervention report.

Safety recommendation

We made one safety recommendation to the Care Quality Commission (CQC) as a result of this investigation. The response is now available and shared below.

Care Quality Commission

It is recommended that the Care Quality Commission, together with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary teamwork and psychological safety in its regulation of maternity units.


Towards the end of 2020, CQC implemented plans for a programme of Focused Maternity inspections with an emphasis on safety.

This programme will inspect approximately 20 services. The CQC’s framework for these Focused Maternity inspections closely aligns with HSIB’s recommendation for the CQC.

Our approach focuses on the safety of the service, encompassing the way teams work together, train together, what the culture of the service is telling us, how the service is managed at all levels, risk management, reporting and learning.

We will also look at how well staff are supported by senior members of the service and their teams.

The themes gathered from this series of inspections will be published as an Independent Voice publication in the summer of 2021.

We are also in the process of developing the CQC strategy for the period 2021-26 which will include the topic of multidisciplinary team working and safety culture.

Response received 1 February 2021


You can tell us what you think about our healthcare safety investigations and your experience of HSIB by filling out our online feedback form.