New report confirms importance of clinical vigilance in the immediate postnatal period for safe care of babies

by Communications team

The latest maternity learning report from the Healthcare Safety Investigation Branch focuses on the importance of clinical monitoring to ensure that babies are as safe as possible during crucial skin to skin contact following birth.

Advocating skin to skin

We have worked with Unicef, who administer the UK Baby Friendly Initiative standards, to ensure that the report is a key learning document, advocating skin to skin whilst providing support for the healthcare system to safely provide the evidence-based practice, which was used in 82% of all births in England in 2018/ 2019.

Sudden unexpected postnatal collapse

The report comes after HSIB identified 6 out of a total of 335 reviewed cases where positioning of the baby during skin to skin may have contributed to sudden unexpected postnatal collapse (SUPC). SUPC is a rare but potentially fatal collapse in babies that appear otherwise healthy.

The 6 cases were drawn from an overall 12 cases reviewed as part of our maternity investigations between April 2018 and August 2019. In the SUPC cases that we looked at, contributing factors were conditions such as sepsis, stroke, persistent pulmonary hypertension, and respiratory issues due to opiates given to the mother in the antenatal or intrapartum period. In 3 of the 12 cases, the babies sadly died, and the 9 surviving babies received treatment in the neonatal intensive care unit.

Effective monitoring during skin to skin

The overarching theme from the learning report is that effective monitoring during skin to skin straight after birth is key, along with continued vigilance and prompt removal of the baby if there are any health concerns.

With this in place, a baby born well and assessed with a good Apgar score (used to assess wellbeing immediately after birth, then 5 and 10 minutes after) can benefit from being in skin to skin contact with their mother or parent. Continued observation of the Apgar score can also be done with little or no interruption to the skin to skin.

Monitoring is especially important when there are additional risk factors that could increase the chance of SUPC, for example antenatal or intrapartum use of opiate medication, sedation and increased maternal body mass index.

Communication with parents

The report also observes that lack of communication to parents and poor positioning can also contribute to this. Staff should always speak to parents about correct positioning of the baby, the difference pain relief or other medications given to the mother could make, and also how they can recognise changes in the baby’s condition.

Systemic risk factors

HSIB maternity investigations also pointed to a number of systemic risk factors that may also reduce staff ability to ensure effective clinical monitoring. This includes the amount of tasks needing to be done straight after the baby’s birth, leaving the maternity suite to find essential equipment, the physical environment and also staff issues overall affecting flow and workload.

Sandy Lewis, Programme Director of Maternity Investigations, said: “Whilst occurrence of SUPC during skin to skin is rare, the impact can be sudden and devastating. We felt it was important to produce this learning report to highlight that minimal interventions can make all the difference in reducing the risk of harm.

“Skin to skin is really important for the mother baby bond, helping the baby to adjust to life outside the womb and supporting breastfeeding. A key part of our remit as a national body is to ensure that any learning can be shared widely across the NHS. We have worked closely with Unicef to ensure that the small number of cases we identified can contribute to safer care, whilst emphasising the benefits of skin to skin contact for parents and babies.”


Sue Ashmore, Director of Unicef UK Baby Friendly Initiative, said: “The impact of sudden unexplained postnatal collapse (SUPC) for the families involved can be devastating and lifelong so we must do everything we can to learn from this investigation.

“Close and ongoing observation and careful positioning of the baby and mother or partner while in skin-to-skin contact is critical for the baby’s short- and long-term health and wellbeing. Any concerns, including and particularly those raised by the parents, should be responded to immediately. In the past two decades, research has shown that skin-to-skin contact helps babies adjust to life outside the womb and supports mothers to initiate breastfeeding and develop an emotional bond with their baby.

“Every incidence of SUPC is one too many. Working together we can ensure that all babies are kept safe, while still enabling babies, their mothers and families to benefit from the many advantages of skin-to-skin contact.”

Read the report

For more information, download and read the skin to skin national learning report.

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