Table 3 Failures or delays identified in 15 avoidable perinatal deaths, as evaluated through Confidential Enquiries^a

Failure to recognise a problem at admission/before labour

20

41.7

 Delayed/inappropriate diagnosis

5

 Poor/inappropriate surveillance

7

 Abnormal CTG

5

 Delays in communication among health professionals

3

Failure to recognise a problem during labour

1

2.1

 Abnormal CTG or meconium

1

Failure to act appropriately during labour

7

14.6

 No CTG performed despite indications

1

 Poor quality CTG

2

 Uterine stimulation despite adverse effects on fetal heart rate

3

 Delays in communication among health professionals

1

Failure to act appropriately after labour

10

20.8

 Delayed/inappropriate neonatal resuscitation

4

 Poor/inappropriate neonatal surveillance

6

Failure to act appropriately during Cesarean Section

3

6.3

 Incorrect type of anestesia

2

 Delay in fetal extraction/improper extraction

1

Failure in healthcare organization

7

14.6

 Inadequate hospital level of care

1

 Delay in organizing Cesarean section (operating room unavailability)

2

 Delay in organizing Cesarean section (difficulty in calling the second surgeon)

1

 Delay in organizing Cesarean section (difficulty in calling the anesthetist)

1

 Delay in organizing Cesarean section (unavailability of neonatologist)

2

Total instances of failures or delays

48

100.0