Sentinel events#
No executive summary as currently short
Definition of a sentinel event#
A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Specific acute clinical events which occur close to the time of delivery or are the primary reason for delivery are called perinatal sentinel events (PSE).[Shankaran et al. 2017] Sentinel events associated with HIE are those that interrupt oxygen flow or blod flow to the infant.[Ellenberg and Nelson 2012]:
As explained by Steve Thronton, “they are usually clinical findings such as bleeding with abruption abruption, or the identification of a cord prolapse”.
Possible sentinel events for HIE#
Uterine rupture - uterus tears and baby slips into abdomen
Umbilical cord mishap
Cord prolapse - umbilical cord slips down in front of baby through the open cervix after the waters have broken
Knotted cord - knots that form naturally from the fetus moving around
Ruptured cord - cord breaks or bursts
Compressed cord - cord flattened by pressure
Tight nuchal cord - umbilical cord tightly wrapped around baby’s neck
Placental abruption - placenta comes away from uterus wall prematurely
Shoulder dystocia - babies head is born but one of the shoulders becomes stuck behind the mother’s pubic bone
Severe maternal haemorrhage - blood loss
Maternal cardiac arrest
Trauma
Seizures
Amniotic fluid embolism - aminotic fluid enters maternal bloodstream
References for these being sentinel events:
Incidence of sentinel events in HIE cases#
Sentinel events account for 10-36% of cases of HIE - with the majority of HIE cases having no obvious cause.[Leith et al. 2024]