Department of Health Social Care
Central Government
Noted
The Department of Health and Social Care references NICE guidelines on intrapartum care and states NICE will log the coroner's concerns for future review but does not plan to update the guideline at this time. (AI summary)
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From Jackie Doyle-Price MP Parliamentary Under Secretary of State for Mental Health, Department Inequalities and Suicide Prevention of Health & Social Care 39 Victoria Street London SwIh OEU 020 7210 4850 PFD-1148325 Mr Andrew Walker HM Coroners Court 29 Wood Street Barnet ENS 4BE November 2018 De 4 A Jcll& Iam writing further to the Regulation 28 Prevention of Future Deaths Report issued on 10 September following the inquest into the death of baby Alba Pemberton: Iam replying as Minister with portfolio responsibility for maternity care. My officials have made enquiries with the National Institute for Health and Care Excellence (NICE) and NHS Improvement on the matters of concern in your report: In 2014, NICE published clinical guideline (CG190), Intrapartum care for healthy women and babies' , which sets out clear recommendations relating to risk assessment and place of birth. CG190 is evidence-based, using research results from a number of studies, including the Birthplace Study, 20112, which provides robust data on the risks and benefits of each birth setting that healthcare professionals and women can use to make informed choices on the place of birth: CG190 does not recommend an obstetric review or that obstetricians should be more involved in low risk births https: !LWwwnice Org uklguidance cgl9 https: www npel OX IC ukbinthplace May
Involving obstetricians in the midwifery-led care of women in a birth centre would undermine the woman's choice for low-risk care and the midwife' s role as the lead for a normal birth: Rather than obstetricians routinely involved in the care of women assessed as at low-risk of complications, CG190 sets out clear recommendations relating to risk assessment and place of birth: There should be protocols in place locally regarding risk assessment, consultation with, and escalation obstetric care: It appears, from the inforation given, that the failings in this case related to a lack of ongoing clinical assessment and escalation once there were signs and symptoms of fetal distress. You indicate in report that five-minute monitoring of the fetal heart rate was not followed by the healthcare professionals in the second stage f labour: As you will be aware, CG190, gives clear recommendations on the level of observations in the second stage of labour and the need to assess whether transfer of care may be needed: 'Observations during the second stage: 1.13.2: Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least minute, at least every 5 minutes With regard to meconium, CG190 defines the presence of meconium-stained liquor as either 'non-significant' or 'significant' : 'Non-significant meconium is_ green or yellow amniotic fluid that is thin and with no lumps of meconium present. It is sometimes referred to as 'light' or 'thin meconium: Significant meconium is dark green or black amniotic fluid that is thick or tenacious or any meconium-stained amniotic fluid containing of meconium. It is sometimes referred to as 'heavy or 'thick' meconium The NICE guideline includes the following recommendations regarding documenting the presence or absence of 'significant meconium:
1.5.2 As part of ongoing assessment; document the presence or absence of significant meconium. This is defined aS dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium being being to, your pale lumps
'1.5.3 If significant meconium is present, ensure that: healthcare professionals trained in fetal blood sampling are available during labour and healthcare professionals trained in advanced neonatal life support are readily available for the birth '1.5.4 If significant meconium is present, transfer the woman to obstetric-led care provided that it is safe to do sO and the birth is unlikely to occur before transfer is completed. Follow the general principles for transfer of care described in section
1.6 NICE has advised that it considers that CG190 appropriately reflects the available evidence and does not need to be at this time: Iam content to accept that position: You will wish to note that NICE will the concerns in your report against this guideline topic so that can be taken into consideration when NICE next comes to review the need for the guideline to be updated. JACKIE DOYLE-PRICE updated log they JJo
Involving obstetricians in the midwifery-led care of women in a birth centre would undermine the woman's choice for low-risk care and the midwife' s role as the lead for a normal birth: Rather than obstetricians routinely involved in the care of women assessed as at low-risk of complications, CG190 sets out clear recommendations relating to risk assessment and place of birth: There should be protocols in place locally regarding risk assessment, consultation with, and escalation obstetric care: It appears, from the inforation given, that the failings in this case related to a lack of ongoing clinical assessment and escalation once there were signs and symptoms of fetal distress. You indicate in report that five-minute monitoring of the fetal heart rate was not followed by the healthcare professionals in the second stage f labour: As you will be aware, CG190, gives clear recommendations on the level of observations in the second stage of labour and the need to assess whether transfer of care may be needed: 'Observations during the second stage: 1.13.2: Perform intermittent auscultation of the fetal heart rate immediately after a contraction for at least minute, at least every 5 minutes With regard to meconium, CG190 defines the presence of meconium-stained liquor as either 'non-significant' or 'significant' : 'Non-significant meconium is_ green or yellow amniotic fluid that is thin and with no lumps of meconium present. It is sometimes referred to as 'light' or 'thin meconium: Significant meconium is dark green or black amniotic fluid that is thick or tenacious or any meconium-stained amniotic fluid containing of meconium. It is sometimes referred to as 'heavy or 'thick' meconium The NICE guideline includes the following recommendations regarding documenting the presence or absence of 'significant meconium:
1.5.2 As part of ongoing assessment; document the presence or absence of significant meconium. This is defined aS dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium being being to, your pale lumps
'1.5.3 If significant meconium is present, ensure that: healthcare professionals trained in fetal blood sampling are available during labour and healthcare professionals trained in advanced neonatal life support are readily available for the birth '1.5.4 If significant meconium is present, transfer the woman to obstetric-led care provided that it is safe to do sO and the birth is unlikely to occur before transfer is completed. Follow the general principles for transfer of care described in section
1.6 NICE has advised that it considers that CG190 appropriately reflects the available evidence and does not need to be at this time: Iam content to accept that position: You will wish to note that NICE will the concerns in your report against this guideline topic so that can be taken into consideration when NICE next comes to review the need for the guideline to be updated. JACKIE DOYLE-PRICE updated log they JJo