New report highlights wide variation in managing the care of babies who are large for gestational age

Posted on February 04, 2021

Full term baby in NICU

Bliss responds to the latest HSIB National Report.

The Healthcare Safety Investigation Branch (HSIB) has published its latest report, which has made recommendations to improve safety during pregnancy and birth when babies are significantly larger than average. These babies can get stuck during birth due to shoulder dystocia, which can lead to serious outcomes including an increased risk of birth injury, brain damage or very rarely death.

When shoulder dystocia occurs, babies are at increased risk of Hypoxic-ischaemic encephalopathy (HIE), a condition which may be diagnosed if the baby’s brain does not receive enough oxygen and/or blood flow around the time of birth. They are also more likely to experience other birth injuries such as brachial plexus injuries (nerve injuries affecting the arm) and fractures.

The report has reviewed 31 individual cases to find key themes and identify opportunities for learning and improving safety. Findings from the report show:

  • There is wide variation in how different Trusts identify whether a baby is large for their gestational age, and similar variation in how mums and babies are monitored throughout pregnancy if a baby is expected to be bigger than average. There is no national guidance to identify and manage pregnancies with larger babies, which contributes to this variation.
  • There is variation in how the risk of shoulder dystocia, and what this may mean for labour and birth, is discussed with women, limiting their ability to make informed decisions. In 10 out of 14 cases where it was suspected that a baby was large for gestational age, there was no evidence of any discussion with the mother about what this may mean for her or her baby’s care.
  • In some cases there was a delay in recognising the signs of shoulder dystocia which meant additional help was not called for. In 4 out of 31 cases the neonatal team was not present for the birth.

The report recommends that Trusts adopt tools which will support informed decision making and discussions with pregnant women about their care and birth choices. It also recommends that the report findings are considered when guidance from the Royal College of Obstetricians and Gynaecologists on managing shoulder dystocia is updated.

Caroline Lee-Davey, Chief Executive of Bliss said: “Today’s findings highlight the need for NHS Trusts to improve care for larger babies who are at risk of experiencing harm from shoulder dystocia during birth, and reveal concerning levels of variation in practice. While the report includes examples of excellent care, its recommendations make clear the need for a consistent approach to be followed nationally to ensure every baby receives the care it needs.

“Bliss has long championed the importance of joint decision-making between parents and health professionals, which can only take place when parents are given accurate, timely information. It is therefore deeply disappointing to see that in many of the cases reviewed women were not given the information they needed to make informed decisions about their or their baby’s care.

“At the heart of every one of the 31 cases reviewed by HSIB is a baby and family whose lives have been changed, in some cases forever, by their birth experience. We call on Trusts to implement all of the recommendations of this report urgently.”

For more information about HIE, visit

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