Neonatal collapse alongside skin-to-skin contact

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

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 the themes highlighted was neonatal collapse alongside skin-to-skin contact.

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.

Skin-to-skin contact is where a baby is dried and laid directly on their mother’s bare chest after birth. Skin-to-skin contact has physiological and psychological benefits for both the mother and baby.

It is recommended by the World Health Organization, National Institute for Health and Care Excellence, Public Health England and Unicef UK. It has become established practice in England, with most mothers having skin-to-skin contact with their babies after birth.

A review of the reports completed between April 2018 and August 2019 as part of our maternity investigation programme was carried out. The review identified 12 cases of sudden unexpected postnatal collapse (SUPC). SUPC is a rare but potentially fatal collapse in babies that appear otherwise healthy. In 6 of these cases, the positioning of the baby during skin-to-skin contact may have contributed to SUPC.

In the SUPC cases that we looked at, contributing factors included:

• Sepsis
• Stroke
• Persistent pulmonary hypertension
• Respiratory issues due to opiates given to the mother in the antenatal or intrapartum period

This national learning report has a focus on the importance of clinical monitoring to ensure that babies are as safe as possible during skin-to-skin contact following birth. 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.

We have worked with Unicef, who administer the UK Baby Friendly Initiative Standards, to ensure that this report is a key learning document. It advocates for skin-to-skin contact whilst providing support for the healthcare system to safely provide this evidence-based practice.