New HSIB report confirms importance of close monitoring of babies in immediate postnatal period

August 2020

We welcome this latest maternity report by The Healthcare Safety Investigation Branch (HSIB) and the valuable insight it provides for the close monitoring of babies in the immediate postnatal period.

Unicef UK Baby Friendly Initiative Programme Director Sue Ashmore 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 this way we can maintain safety, whilst still ensuring that all mothers and babies benefit from the many advantages of early postnatal skin-to-skin contact. 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 skin-to-skin contact.”

The report comes after six cases were identified out of a total of 335 (1.8%) where positioning of the baby during skin-to-skin, alongside other causative factors, may have contributed to sudden unexpected postnatal collapse (SUPC). SUPC is a rare but potentially fatal collapse in babies that appear otherwise healthy. 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.

Over the last 20 years, a large body of evidence has been built around the impact of skin-to-skin contact on infant and maternal health. Skin-to-skin contact helps babies adjust to life outside the womb and supports mothers to initiate breastfeeding and to develop a close and loving relationship with their baby. Skin-to-skin promotes many other benefits, including improving oxygen saturation, reducing cortisol (stress) levels and enabling the colonisation of the baby’s skin with the mother’s friendly bacteria to provide protection against infection.

To reduce risk of SUPC, vigilant observation of the mother and baby should continue, including that of the baby’s temperature, breathing, colour, positioning and tone, with prompt removal of the baby if the health of either give concern. Additional factors that can increase risk of SUPC while the baby is in skin-to-skin contact can include antenatal use of opiate medication, sedation, staff’s focus on other tasks and more. Staff should have a conversation with the mother and family about recognising any changes in the baby’s condition.

The Unicef UK Baby Friendly Initiative recommend that:

• maternity services update their own policies to ensure that these adhere to the recommendations
• the recommendations are disseminated to staff as soon as possible and are included in future staff updates
• all staff are enabled to implement the findings effectively.

For more information on safety considerations for skin-to-skin, visit the Unicef UK Baby Friendly website.