We identified the safety risk through the maternity investigation programme as 22 reports (from the period 2018 to 2021) highlighted concerns about the recognition of the need for, or the initiation of, emergency neonatal blood transfusion.
A national investigation was launched to examine the safety issue and found that whilst it is rare, and there is a gap in data on incidences of neonatal blood transfusion delays, the impact can be significant. 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 result in brain injury caused by lack of oxygen to the baby’s brain.
Baby Aria’s story
This impact was seen in the case HSIB examined to illustrate the safety issues. Baby Aria’s story was shared with the investigation team by her parents Alex and Robert.
Alex had experienced sudden unexpected blood loss whilst at hospital and when Aria’s heartbeat could not be found, Alex was transferred for an emergency caesarean. When Aria was born she required resuscitation and was given a blood transfusion before being transferred to the neonatal unit.
Baby Aria sadly died when she was two days old.
The investigation explored what influences the timely administration of blood transfusion to newborn babies following acute blood loss during labour and/or delivery.
Our key findings relate to communication between different clinical teams and earlier consideration of the need for a blood transfusion.
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.
The report concludes with two safety recommendations focused on implementing scenario based multidisciplinary training between maternity and neonatal teams and facilitating earlier consideration of fetal blood loss by neonatal resuscitation teams through the Newborn Life Support training course.
Melanie Ottewill, National Investigator at HSIB, says: “The need for blood transfusions during resuscitation is rare, but the impact of a delay can be devastating as we heard from Alex and Robert, Aria’s parents.
“Our report forms an important piece of literature in an area with limited research and can support any future work that explores safety issues relating to neonatal blood transfusions.
“The aim is that our safety recommendations can raise awareness of the issue and prompt clinicians to consider the option of a blood transfusion in the early stages of resuscitation.”