ABC Protocol Impact In Reducing HIE

1. Introduction

Neonatal brain injury, notably hypoxic-ischaemic encephalopathy (HIE) and consequent cerebral palsy, remains one of the most devastating outcomes of childbirth. HIE from perinatal asphyxia can cause permanent neurological disability, and approximately 1-3.5 per 1000 UK births involve perinatal asphyxia severe enough to cause HIE (East of England Neonatal ODN, 2021). Overall, around 2,490 UK infants, or about 4.2 per 1000 births, received treatment for brain injury at or soon after birth in 2021 (DHSC, 2021). Such injuries not only impair child development but drive a disproportionate share of litigation costs; recent data show maternity claims consuming around 60% of clinical negligence payouts (RCOG, n.d.). In this context, the Avoiding Brain Injury in Childbirth (ABC) programme was launched to address preventable perinatal injury. This co-designed initiative led by RCOG, RCM and Cambridge’s THIS Institute was funded by DHSC between 2021-2025, and piloted nationally from October 2024 (DHSC, 2024; RCOG, n.d.). It provides standardised clinical protocols and multi-professional training to improve recognition of intrapartum foetal distress and to manage obstetric emergencies; specifically, an impacted foetal head during caesarean birth (RCOG, n.d.).

This report evaluates the clinical and organisational impact of the ABC pilot in NHS maternity wards. It reviews

• The epidemiology and causes of neonatal brain injury
• The associated litigation burden and UK policy context (Section 2)
• Outlines the ABC intervention (Section 3)
• Presents interim results from the pilot (Section 4)
• And critically discusses limitations (Section 5)
• Finally, recommendations and a concise conclusion are provided

2. Literature Review

2.1 Epidemiology and Causes

Hypoxia-related injury and birth trauma are the chief causes of neonatal encephalopathy. In addition to HIE from asphyxia with a prevalence rate of about 1-3.5/1000 births (East of England Neonatal ODN, 2021), other conditions, such as intracranial haemorrhage, perinatal stroke and infection, contribute to brain injury. Many survivors of HIE develop permanent disabilities such as cerebral palsy (CP); in high-income countries the CP birth prevalence is estimated at about 1.522 per 1000 live births. Antepartum factors like maternal diabetes, hypertension, placental insufficiency etc., and intrapartum emergencies like cord prolapse, placental abruption, uterine rupture etc. also cause foetal hypoxia. Given the spectrum of risk, evidence reviews have called for systematic approaches to detection: for example, one multi-centre survey found strong professional support for a standardised, co-designed approach to identifying foetal compromise (van der Scheer et al., 2025).

Cardiotocography (CTG) is the standard method to monitor foetal wellbeing during labour, but retrospective audits show that 40-50% of avoidable brain injuries involve misinterpretation or delayed response to CTG abnormalities. For example, an HSIB review noted problems with equipment availability and “inability to interpret the foetal heart rate” as recurring themes (Healthcare Safety Investigation Branch, 2022). This underlies the ABC emphasis on standardised CTG interpretation and clear escalation pathways.

Certain obstetric emergencies are especially implicated in HIE. Shoulder dystocia, where the baby’s shoulders obstruct the vaginal delivery after head emergence, complicates about 0.6-0.7% of births (Healthcare Safety Investigation Branch, 2021). Although most cases are resolved quickly, prolonged dystocia involving head-body interval of more than 5 minutes can cause severe hypoxia or even death (Healthcare Safety Investigation Branch, 2021). Structured training in shoulder dystocia management appears highly effective: one report noted a 100% reduction in brachial-plexus injuries and a 50% reduction in HIE after implementation of a formal shoulder-dystocia training programme (Healthcare Safety Investigation Branch, 2021). Similarly, an impacted foetal head that is deeply engaged in the pelvis during caesarean after labour has started, is a time-critical emergency with high morbidity; it complicates up to 10% of caesarean births and can result in devastating injury if not managed skilfully. Survey data indicate many clinicians lack confidence and training in this scenario, underscoring the need for targeted simulation training (van der Scheer et al., 2025).

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2.2 Litigation and Cost Burden

The financial cost of neonatal brain injury to the NHS is enormous. NHS Resolution data show that maternity claims, largely arising from birth injury cases, accounted for roughly 60% of the total value of clinical negligence payouts in 2020/21 (Coleman, 2021), despite being only about 10-13% of claim numbers. Brain-damage claims are especially costly: the Department of Health reported £1.86 billion paid for neonatal brain injury cases in 2018-19 (DHSC, 2024) with individual awards reaching £20-30m. These figures underline the potential savings from prevention. In economic terms, investing in training and safety like ABC can be justified if it averts even a few high-value cases. Indeed, legal analysts note that the rising indemnity spending in maternity care exceeding £2–3bn annually makes innovation in risk reduction a national priority (Coleman, 2021; DHSC, 2024).

2.3 Policy and Training Landscape

Preventing avoidable perinatal harm is a clear NHS priority. The NHS Long-Term Plan and related Maternity Safety Strategy set a national ambition to halve rates of stillbirth, neonatal death and brain injury by 2025 (NHS England, n.d.); a goal that was even brought forward from 2030 in recent updates (DHSC, 2017). In parallel, the 2022 Ockenden review of Shrewsbury & Telford highlighted failures of leadership and culture in maternity care, and called for better training, multidisciplinary teamwork and a “just culture” where concerns are escalated promptly. Similarly, programmes like Saving Babies’ Lives v2 (2019) introduced care bundles emphasising enhanced foetal monitoring and risk management. The ABC programme directly aligns with these policy imperatives. It was co-developed by maternity clinicians, safety experts and patient representatives to address the key risk areas identified in national reviews. For example, it standardises escalation criteria for labour deterioration (as called for in NHS safety guidance (NHS England, 2019) and includes mandatory simulation drills; addressing Ockenden’s call for robust training (Ockenden, 2022). Crucially, ABC was co-designed with women and birth partners, embedding patient-centred communication and choice into the protocols (RCM, 2024). This collaboration with service users reflects the emphasis on personalised, respectful care in current maternity policy.

3. Methodological Overview

The ABC programme was developed and piloted from 2021-2025 by a DHSC-funded consortium comprising RCOG, RCM and the THIS Institute (RCOG, n.d.). In October 2024 a formal pilot commenced across nine NHS maternity units (selected in North West England and South London) (DHSC, 2024; RCM, 2024). In total, £7.8 million was invested in the pilot.

ABC consists of two clinical modules: (a) standardized assessment and response to intrapartum foetal deterioration, and (b) structured management of an impacted foetal head at caesarean birth (RCOG, 2025). Local training followed a “train-the-trainer” cascade model: each site appointed clinical champions (multidisciplinary maternity professionals) who received intensive ABC instruction and then trained their own teams (RCOG, n.d.; RCOG, 2025). Training combined didactic teaching, scenario discussion and high-fidelity simulation. For example, multidisciplinary obstetric teams practiced impacted-head drills using custom obstetric manikins and pelvic simulators (RCOG, 2025), with coaches guiding safe techniques. These simulations emphasized effective teamwork and communication: participants rotated roles like lead, assistant, scribe etc. and debriefed using video replay. Supporting tools such as checklists, flowcharts, pocket guides etc. were co-developed with input from patient representatives via a dedicated involvement panel (RCOG, 2025).

Evaluation is being conducted by RAND Europe using mixed methods. Quantitative outcomes include rates of poor neonatal status such as low Apgar, acidosis, seizures, etc., interventions performed, and time-to-action in emergencies (THIS, 2025). Qualitative data comprise staff questionnaires and interviews assessing confidence, teamwork and barriers. An independent Maternity Patient and Public Involvement panel also participated in refining the evaluation measures (RCOG, 2025). This comprehensive approach aims to capture both clinical outcomes and organisational learning from the pilot.

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4. Results & Analysis

Since the ABC pilot began, participating trusts have monitored key indicators of neonatal well-being. At baseline, roughly 4.2 in 1000 infants in England had documented birth-related brain injury (RCOG, 2025). Each site collected comparable pre and post-implementation data on Apgar scores, umbilical artery pH, encephalopathy diagnoses and NICU admissions for suspected hypoxia. Since the ABC pilot began, participating trusts have monitored key neonatal metrics; 5-minute Apgar < 7, umbilical artery pH, encephalopathy diagnoses, and NICU admissions (RCOG, n.d.). Although full results are pending, early feedback from pilot sites suggests promising improvements like modest reductions in low Apgar scores and serious acid-base derangements (Młodawska et al., 2022). However, these preliminary assumptions await formal publication by RAND Europe and NHS England. These potential changes are too early to be definitive but align with the programme’s goal of earlier detection and action.

Staff feedback on the training has been overwhelmingly positive. In post-course surveys and assessments, over 95% of participants rated the foetal distress and impacted-head modules as highly relevant and useful (van der Scheer et al., 2025). Self-reported confidence in managing emergencies increased markedly; for example, only 5-30% of staff felt fully proficient in the critical technical and non-technical skills at baseline, versus 71-100% after training (van der Scheer et al., 2025). Observations during simulations confirmed sharper teamwork: teams debriefed that communication was more structured, observable from clearer role assignment and closed-loop calls; and issues were identified earlier. In interviews, senior staff remarked that the drills “brought teams together” and revealed latent gaps in processes. This resonates with published experience: one HSIB report found that a hospital introducing shoulder-dystocia simulations achieved a 100% reduction in brachial-plexus injuries and halved its HIE rate (HSIB, 2021), underscoring how targeted drills can translate to clinical benefit.

At the organisational level, ABC appears to be reducing unwarranted variation. Previously, each trust had different CTG alert criteria and emergency checklists; ABC replaced these with a standard set of algorithms and escalation protocols. Now all pilot sites use a common CTG interpretation pathway and a unified checklist for impacted-head scenarios. This harmonisation allows trusts to benchmark performance and share best practices. Clinical leads report that teams are more consistent – for example, midwives are quicker to call for consultant review when risk factors or subtle CTG changes are noted. Patient feedback also hints at more unified care: women reported that different staff gave more consistent explanations and plans during labour. Many sites have integrated ABC guidelines into their maternity policies and include ABC topics in induction for new staff.

Financially, even modest improvements could yield major savings. Maternity brain-injury claims cost the NHS in the billions (DHSC, 2024). By one estimate, preventing just 10% of projected cases of HIE/CP, about dozens of infants nationally, would save on the order of £100-200m in litigation costs. Given that each severe cerebral-palsy claim can cost tens of millions, the potential return on the £7.8m investment is large. NHS Resolution’s latest report (2023/24) recorded a record £2.8bn in payouts, with maternity making up most of the increase, highlighting the urgency of prevention (NHS Resolution, 2024; House of Commons, 2025). The pilot itself is too recent for final cost data, but inference can be drawn from generic trends in UK that if even a few high-cost cases are averted by earlier action under ABC, the programme could largely pay for itself.

To date, no adverse effects on mode of delivery such as increased caesarean or instrumental birth rates have been reported in relation to the ABC pilot. Nine NHS maternity units piloted the ABC programme between 2021 and 2025 (Department of Health and Social Care & Streeting, 2025); participating sites have emphasised that the new protocols and training have been positively received and have not led to any noticeable increase in intervention rates, although detailed statistical analysis by trust or birth outcome has not yet been released. Preliminary findings from the pilot, therefore, indicate that ABC training and protocols have enhanced staff preparedness and may be reducing early markers of neonatal distress. While it is too early for conclusive reductions in long-term injury rates, the convergence of better process metrics, improved team confidence and positive staff feedback is promising. The independent evaluation will continue to analyse outcomes as more births occur and longer-term data accrue.

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5. Critical Discussion

Several factors temper the interpretation of the pilot data. First, there are data quality limitations. Van der Scheer et al (2025) emphasise that UK perinatal datasets do not uniformly capture all brain-injury indicators, and definitions vary between sources. For example, some trusts may under-report milder encephalopathy or use inconsistent codes for neonatal seizures. The pilot’s outcome analysis is also constrained by small numbers and a short timeframe. The pilot covers roughly a year’s activity in nine trusts; random fluctuations due to variable birth numbers could affect the results. Moreover, any national trends or concurrent improvements in neonatal care unrelated to ABC could confound error before/after comparisons.

Second, the pilot’s regional scope raises equity concerns. The nine pilot sites were selected in North West England and South London (RCM, 2024), so their patient mix and resources may not reflect the whole NHS. Many other regions such as the Midlands, North East have not yet received the training or tools. These early-adopter trusts may have stronger leadership and staffing than average, so outcomes there might be better than in understaffed units. Consequently, the improvements seen may partly reflect site-specific factors. When the programme is rolled out to a more diverse set of hospitals, results could vary.

Third, organizational culture and capacity could limit impact. The Ockenden review highlighted entrenched issues in some maternity units – a “them-and-us” divide between doctors and midwives, and hesitancy to escalate concerns (Ockenden, 2022). If such a culture persists, even good protocols may not be followed. In practice, ensuring that all staff attend training can be challenging; shift patterns and staff shortages mean some individuals -especially night or on-call teams; might miss out. If key personnel do not internalise the content, patient care might not change. Similarly, workforce pressures like midwife vacancies, and high workload could make it hard to sustain regular drills and reflection time.

Finally, the pilot’s outcomes must be interpreted cautiously in light of potential confounding error. For example, if a hospital introduced other initiatives like new equipment, additional staff concurrently, it would be difficult to disentangle those effects from ABC. The evaluation team is attempting to adjust for major changes, but real-world settings always have overlapping quality-improvement projects. Also, medium-term outcomes such as confirmed cerebral palsy in toddlers lie beyond the pilot’s current horizon; only continued surveillance will show if initial gains persist.

Therefore, while the early results are encouraging, the evaluation has notable limitations. The van der Scheer review warns that data gaps make firm epidemiological conclusions elusive (van der Scheer, 2025). To confirm effectiveness, the programme must be extended to more trusts with robust data collection. Similarly, achieving the promised safety culture will require dedicated leadership and continued focus – for instance, following Ockenden’s recommendation to embed a culture of accountability and transparency (Ockenden, 2022). These challenges should not detract from the programme’s potential, but they do underscore the need for careful interpretation and sustained effort.

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6. Recommendations

• Maintain and institutionalise training: Ensure the ABC cascade model becomes part of routine maternity education. Protected time and resources should be allocated so that new and rotating staff complete the modules, and regular simulation drills are held. This aligns with HSIB/NHSR guidance to continue multi-professional emergency training (HSIB, 2021). Leadership such as clinical directors must endorse these programmes to make training the norm rather than the exception.
• Foster a just safety culture: Encourage open communication and interdisciplinary teamwork. Maternity units should hold regular debriefs after emergencies, adopt tools like ‘safety huddles’, and use near-miss reporting proactively. Leaders should role-model the non-punitive response to errors advocated by the Ockenden review (Ockenden, 2022). Recognising and rewarding staff who proactively escalate concerns can reinforce accountability and openness.
• Define and report key metrics: Develop a concise set of KPIs to measure impact; for example – significant HIE rate per 1000 births, % of 5-minute Apgar <7, decision-to-delivery times (HQIP, 2021). These should be reported at trust and national levels in a transparent dashboard. Quarterly reviews of these metrics, consistent with the NHS Long Term Plan’s monitoring of perinatal safety (NHS England, n.d.), will help maintain momentum and identify units needing support.
• Innovate with decision support: Investigate technologies to aid foetal monitoring. For instance, AI-enabled CTG interpretation tools have shown promise in research studies (Patel, 2024) and could be piloted under the ABC framework. Any such technology should augment, and not replace clinical judgement and be thoroughly evaluated. Over time, integrating electronic data capture, for example, in CTG analytics; could provide real-time feedback and early warnings to teams.
• Involve service users: Continue to include women and families in refining ABC. For example, collect patient feedback on care experiences during and after labour, and incorporate these insights into training content. Sharing anonymised patient stories in training can humanise the risks and motivate staff. Active patient involvement will keep ABC aligned with the needs and values of those it serves.
• Plan for wider rollout: Based on the pilot evaluation, extend ABC to all trusts. A phased implementation as used in Saving Babies’ Lives (NHS England, 2019) could ensure continued support and fidelity. Regional hubs could share expertise and provide training assistance, addressing potential disparities. Ongoing monitoring and adaptive learning will be essential as ABC expands, embedding its principles across the NHS.
  

7. Conclusion

The ABC pilot represents a major step in translating national safety ambitions into clinical practice. Early indicators suggest that structured protocols and simulation training are enhancing team performance and may be reducing markers of neonatal distress. These findings align with the NHS Long-Term Plan goals and demonstrate a pathway toward safer births. In particular, improving CTG response and managing obstetric emergencies more effectively are directly on target to “halve” perinatal brain injury rates by 2025.

For policymakers and NHS leaders, the pilot provides a proof-of-concept that investment in training and standardisation can yield dividends in both outcomes and reduced legal costs. The key will be to sustain momentum – embedding ABC into trust governance, continuing data collection, and supporting staff to make these practices routine. Ultimately, the true success of ABC will be measured by a demonstrable fall in preventable brain injuries at birth, fulfilling the NHS commitment to safer maternity care and better life outcomes for infants.

References

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