In March 2020, we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity investigation programme.

These initial investigations were carried out between April 2018 and December 2019.

One of these themes was babies significantly larger than average who were at increased risk of a birth injury, brain damage or very rarely death because their shoulders get stuck during birth (known as shoulder dystocia).

This was identified as an area where further analysis could benefit system-wide learning.

Our national learning reports can be used by healthcare leaders, policymakers, and the public to:

  • Aid their knowledge of systemic patient safety risks
  • Understand the underlying contributing factors
  • Inform decision making to improve patient safety

The information in these reports is also used to inform future HSIB investigations or programmes of work.

Larger babies and shoulder dystocia

As defined by the Royal College of Obstetricians and Gynaecologists (RCOG), shoulder dystocia is where additional manoeuvres are required to complete the birth of a baby, after routine traction has failed to release the shoulders during a vaginal birth (Royal College of Obstetricians and Gynaecologists, 2012).

The majority of cases of shoulder dystocia occur when the uppermost shoulder of a baby impacts behind a mother’s pelvic bone after the birth of the head, preventing the birth of the body.

It is a time-critical obstetric emergency that can result in severe brain injury or death and other injuries such as brachial plexus injuries (nerve injuries affecting the arm) or fractures to the arm or collar bone of a baby.

Shoulder dystocia may also cause increased injury to the mother including bleeding and perineal trauma.

Safety recommendation

We examined the factors that increase the likelihood that shoulder dystocia will occur with larger babies, from pregnancy to labour and birth.

From the analysis of their reports, we have pinpointed that many of the challenges lie in how larger than average gestational age babies (LGA) are identified and the subsequent management of care of the mother during pregnancy.

The findings of the reviews suggested an opportunity for national change and we have set out one recommendation to the Royal College of Obstetricians and Gynaecologists (RCOG).

We expect a response to our safety recommendation within 90 days of publication of the investigation report. The response will be shared here when it's available.

Royal College of Obstetricians and Gynaecologists

It is recommended that the Royal College of Obstetricians and Gynaecologists (RCOG) takes into consideration the findings of this HSIB review when updating the RCOG Green Top shoulder dystocia guideline (No.42).

Feedback

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