Editor's Note to Sentinel Event Alert Issue #  30

Please note that the Sentinel Event statistics have changed since the Sentinel Event Alert Issue #30 was drafted. As of December 31, 2005, there are a total of 109 cases of perinatal death or permanent disability that have been reported to the Joint Commission for review under the Sentinel Event Policy. Of those 109 cases, 93 resulted in infant death and 16 cases involved major permanent disability.

While a healthy and safe birth for the mother and infant is the goal for all labor and delivery units—regardless of the level of services available—in some instances, what should be a joyous, celebratory event turns to tragedy when the newborn dies. The rate of perinatal mortality in the U.S. has steadily declined to a rate of 6.9 deaths per 1,000 live births in 2001. (1)  Nevertheless, since 1996, a total of 47 cases of perinatal death or permanent disability have been reported to the Joint Commission for review under the Sentinel Event Policy. Cases considered reviewable under the Sentinel Event Policy are "any perinatal death or major permanent loss of function unrelated to a congenital condition in an infant having a birth weight greater than 2,500 grams." Forty of the cases resulted in infant death and seven cases involved permanent disability. The mothers ranged in age from 13 to 41, with the average and median age being 27 years, and in just over one-half of the cases, it was the first child. The average gestation was 39 weeks.

While the absence of early and regular prenatal care is a leading contributor to the risk of infant death, review of the JCAHO's 47 cases reveals that lack of prenatal care was an identified maternal risk factor in just 4 percent of cases. Other identified maternal risk factors included age (13 percent), previous C-section (11 percent), diabetes (4 percent), and substance abuse (4 percent). Identified complications during the birth included:  non-reassuring fetal status (77 percent), placental abruption (8 percent), ruptured uterus (8 percent), and breech presentation (6 percent). Forty-nine percent of the cases were emergency C-section; 46 percent vaginal deliveries; and 4 percent delays in C-section decision. Of the vaginal deliveries, 21 percent were vacuum extraction delivery or attempted; 13 percent mid forceps delivery or attempted; 11 percent failure to do indicated C-section; and 8 percent vaginal birth after C-section (VBAC).