Table 4

Nature of the episodes of suboptimal care identified for the CESDI stillbirths and neonatal deaths and the cases of neonatal encephalopathy

CESDI deaths (n = 59)Neonatal encephalopathy cases (n = 49)
Nature of the suboptimal caren%n%
*2/30 neonatal deaths.
CESDI, Confidential Enquiries into Stillbirths and Deaths in Infancy.
Failure to recognise a problem during labour:
    Abnormal CTG or meconium21351225
    Poor progress in labour2 30
Failure to act appropriately during labour:
    No CTG performed despite indications4 70
    Poor quality CTG7120
    Uterine stimulation despite fetal heart rate effects3536
    Delays in communication13222041
Failure to communicate during labour:
    Abnormal CTG3 512
    Call/inform more senior staff712510
    Paediatrican not called for delivery5 9510
Failure to act appropriately after delivery:
    Delayed/inappropriate resuscitation19321225
    Poor/inappropriate surveillance2 7*1225