Each Baby Counts: Key Messages from 2015.

London, UK: Royal College of Obstetricians and Gynaecologists; 2016.

This report highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm.

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