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Showing results for tags 'Baby'.
Found 565 results
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Content ArticleThe national Perinatal Mortality Review Tool (PMRT) was developed with clinicians and bereaved parents in 2017 and launched in England, Wales and Scotland in early 2018; it was subsequently adopted in Northern Ireland in autumn 2019. The aim of the PMRT programme is introduce the PMRT to support standardised perinatal mortality reviews across NHS maternity and neonatal units Unlike other review or investigation processes, the PMRT makes it possible to review every baby death, after 22 weeks’ gestation, and not just a subset of deaths. This report presents data from the 3,693 reviews which were completed between March 2019 and February 2020.
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Content Article
Sodium Valproate: The Fetal Valproate Syndrome Tragedy
Patient-Safety-Learning posted an article in Women's health
In this article, Sodium Valproate: The Fetal Valproate Syndrome Tragedy, Sharon Hartles, member of the Open University’s Harm and Evidence Research Collaborative, reflects upon the use of Sodium Valporate, marketed as Epilim, to treat patients at risk of epilepsy and the subsequent harms in fetal development and birth defects that arose from its use. -
Content ArticleIn addition to older individuals and those with underlying chronic health conditions, maternal and newborn populations have been identified as being at greater risk from COVID-19. It became critical for hospitals and clinicians to maintain the safety of individuals in the facility and minimise the transmission of COVID-19 while continuing to strive for optimised outcomes by providing family-centered care. Rapid change during the pandemic made it appropriate to use the plan–do–study–act (PDSA) cycle to continually evaluate proposed and standard practices. Patrick and Johnson describe how their team established an obstetric COVID-19 unit for women and newborns, developed guidelines for visitation and for the use of personal protective equipment, initiated universal COVID-19 testing, and provided health education to emphasize shared decision making.
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Content ArticleAuthors of this study conclude that among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care (continuous skin-to-skin contact) had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilisation. Follow the link below to access the paper in full via The New England Journal of Medicine.
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Content ArticleThe aim of this study from Gurol-Urganci et al. was to determine the association between COVID-19 infection at the time of birth and maternal and perinatal outcomes. Covid infection at the time of birth is associated with higher rates of fetal death, preterm birth, preeclampsia and emergency Caesarean delivery. There were no additional adverse neonatal outcomes, other than those related to preterm delivery. Pregnant women should be counseled regarding risks of covid infection and should be considered a priority for vaccination.
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Content ArticleThis report, published by the National Child Mortality Database, is based on data for children who died between April 2019 and March 2020 in England, and finds a clear association between the risk of child death and the level of deprivation (for all categories of death except cancer). More specifically, Child Mortality and Social Deprivation states that over a fifth of all child deaths might be avoided if children living in the most deprived areas had the same mortality risk as those living in the least deprived – which translates to over 700 fewer children dying per year in England. The report’s authors are now calling on policy makers and those involved in planning and commissioning public health services as well as health and social care professionals to use the data in this report to develop, implement and monitor the impact of strategies and initiatives to reduce social deprivation and inequalities.
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Content ArticleMollie Daisy Dimmock died from perinatal asphyxia due to hypoxia 34 minutes after being delivered. This was caused by umbilical cord compression from shoulder dystocia which lasted for five minutes before Mollie was fully delivered. In his report, the Coroner Crispin Butler raises concerns about the NICE guidance in relation to intrapartum care for women with existing medical conditions or obstetric complications and their babies.
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Content ArticleIn this podcast, Gill Phillips speaks to Nadia Leake and Rachel Collum, parents of premature babies who had long stays in neonatal care after birth, about the importance of Family Integrated Care. Gill developed Whose Shoes?® as a tool to allow people to 'walk in other people's shoes'. Through a wide range of scenarios and topics, Whose Shoes?® helps groups explore many of the concerns, challenges and opportunities facing the different groups affected by the transformation of health and social care.
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Content ArticleThis report looks at how the inaccurate use of the skin cleaning agent chlorhexidine in neonatal care caused severe chemical burns to a baby.
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Content ArticleThis report looks at an incident where a neonate suffered an oesophageal perforation following endotracheal and nasogastric tube insertion.
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Content ArticleThis report looks at how when face-to-face midwife visits were replaced by virtual appointments during the Covid-19 pandemic, the health of the some babies deteriorated. Guidance has been amended to state that initial visits should be face-to-face.
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Content ArticleThis case study looks at the issue of using ethyl chloride spray during fetal blood sampling procedures, which leaves a plastic residue on the babies scalp.
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Content ArticleThis case study looks at how plastic cord clamps used in caesarean sections are not visible on x-ray, which could be a patient safety issue.
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Content Article
This joint letter calls on Maria Caulfield MP, Parliamentary Under Secretary of State for Patient Safety and Primary Care, to implement in full the recommendations of the Independent Medicines and Medical Devices Safety (IMMDS) Review on behalf of those harmed by the side effects of Primodos, Mesh and Sodium Valproate. It is signed by Marie Lyon from the Association for Children Damaged by Hormone Pregnancy Tests, Kath Sansom from Sling The Mesh and Emma Murphy and Janet Williams from In-Fact. -
Content ArticleA midwife in England shares their experiences of working in the NHS in 2021. They describe the mental and physical impact of having to work beyond capacity on a daily basis, a situation caused by a staffing crisis in the midwifery workforce. The impact of this is that more midwives are leaving the NHS as they are unable to cope with these pressures, which makes the workload for remaining staff even heavier.
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Content Article
RCM - Midwife number slumps (7 February 2022)
Patient-Safety-Learning posted an article in Maternity
In this blog, Stuart Bonar, Public Affairs Advisor at the Royal College of Midwives, looks at the growing midwifery workforce crisis in the UK. For the first time since records began, the number of midwives is falling year-on-year. The impact on those midwives who remain in the NHS is bigger workloads and decreasing wellbeing. The author calls on the government to pay attention to the situation, and suggests that an adequate pay rise for midwives and midwifery assistants should be part of the solution to falling staff numbers. -
Content ArticleThis study in Patient Education and Counseling aimed to systematically review parental perceptions of shared decision-making (SDM) in neonatology, and identify barriers and facilitators to implementing SDM. The study identified the following key barriers to SDM: Emotional crises experienced in the NICU setting Lack of medical information provided to parents to inform decision-making Inadequate communication of information Poor relationships with caregivers Lack of continuity in care Perceived power imbalances between HCPs and parents. It also identified the following key facilitators for SDM: Clear, honest and compassionate communication of medical information Caring and empathetic caregivers Continuity in care Tailored approaches that reflected parent’s desired level of involvement.
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Content ArticleThis guidance will help Local Maternity Systems align their Equality and Equality Action Plans with Integrated Care Systems health inequalities work. The guidance includes an analysis of the evidence, interventions to improve equity and equality, resources, indicators and metrics.
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Content ArticleThis index of medications provides evidence-based patient leaflets about the use of different medicines in pregnancy. The leaflets are produced by the UK Teratology Information Service (UKTIS). Women can look up medications to understand their impact on pregnancy and how they may affect the chances of miscarriage and birth defects, and provide information on their own pregnancy to add to the knowledge base around medicines in pregnancy.
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Content ArticleThis campaign from Kit Tarka Foundation aims to remind anyone coming into contact with a young baby to remember their T-H-A-N-K-S: Think Hands And No Kisses. Young babies are particularly susceptible to infections, but many people are unaware of the risks and what they can do to reduce them.
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EventuntilLearn from Dr Bill Kirkup and other key speakers about recent National Maternity Service Reviews and how they are changing practice. Register
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EventBaby Lifeline has announced that their fourth annual National Maternity Safety Conference will take place on Thursday 21st September 2023 at the Hilton Metropole Hotel in Birmingham. Once again it will be focussing on learning together for a safer maternity future, building on the overwhelming success of the previous three conferences. Baby Lifeline is always keen to showcase best practice in healthcare and are pleased to welcome poster presentation abstracts again this year. They are particularly keen to hear about maternity service quality improvement measures which speak to one or more of the following themes: Listening to families and staff Promoting safety culture Teamworking Reducing mortality & morbidity. Register
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Community Post
'Drug scandal that damaged 20,000 babies'
Patient Safety Learning posted a topic in Adverse interactions
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An investigation by The Sunday Times has found that the drug sodium valproate is still being handed out to women in plain packets with the information leaflets missing, or with stickers over the warnings. Sodium valproate, has been given to women with epilepsy for decades without proper warnings, and has caused autism, learning difficulties and physical deformities in up to 20,000 babies in Britain. The government is refusing to offer any compensation to those affected by sodium valproate, despite an independent review by Baroness Cumberlege concluding in 2020 that families should be given financial redress. Read the Twitter thread from Rebecca Bromley who has been working with families who have suffered:- Posted
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Content ArticleThis is the first report of a national confidential enquiry specifically focussed on child deaths. Confidential enquiries have already contributed to major improvements in obstetrics, neonatal, and perioperative care in the UK. However they are time consuming and require extensive collaboration between various professional groups as well as the attention of a dedicated full-time research team. Hence, when planning a confidential enquiry in a new patient group, it is pertinent to investigate both feasibility and utility at its outset. The aim of this enquiry was to evaluate the feasibility of using this methodology to reduce the number of child deaths and make a significant contribution to child health in the UK. The basic functions of a confidential enquiry are: To develop and maintain a register of the cases under scrutiny. To subject cases in the register (or a specific sample of them) to review by a panel of experts with a focus on identifying avoidable factors where there have been adverse outcomes. Subsequent recommendations are then derived from both the analysis of the register and the conclusions of the expert review panels. This report presents the findings of a feasibility study “The Child Death Review” in which confidential enquiry methodology was applied to child deaths (28 days to 17 years 364 days) occurring in three regions of England, all of Wales and Northern Ireland in the calendar year 2006. A surveillance programme was mounted in order to determine where and when deaths occurred. A comprehensive core dataset was developed and then collected on all deaths. A sample, designed to have an even spread across age groups and the geographical areas involved, was then subjected to more detailed enquiry. This involved scrutiny of the available records by a multidisciplinary panel in each case.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency (MHRA) are providing an update on a retrospective observational study on the risk to children born to men who took valproate in the 3 months before conception and on the need for the re-analysis of the data from this study before conclusions can be drawn. No action is needed from patients. For female patients, healthcare professionals should continue to follow the existing strict precautions related to preventing the use of valproate in pregnancy (Valproate Pregnancy Prevention Programme).
