Finding into death of Cara Grace Zambelli
Deceased
Cara Grace Zambelli
Demographics
0y, female
Coroner
Coroner Audrey Jamieson
Date of death
2006-08-08
Finding date
2011-07-11
Cause of death
Hypoxic ischaemic encephalopathy due to true knot in umbilical cord
AI-generated summary
A term infant died from hypoxic ischaemic encephalopathy caused by a true knot in the umbilical cord. The mother presented in labour with spontaneous rupture of membranes and had a prolonged second stage. Foetal heart rate monitoring showed intermittent decelerations and bradycardia from 0300 hours onwards. The locum obstetrician contacted the on-call registrar at 0410 hours regarding maternal exhaustion; the registrar was off-site, 30 minutes away. At 0418 hours a significant bradycardia to 60 bpm prompted assisted vacuum delivery at 0431 hours. The infant required extensive resuscitation and died 2 days later. The coroner found the resuscitation timely and rigorous, but identified the Maternity Handbook notification guidelines were not followed (should have notified at 30 minutes of pushing, not 1 hour), and the off-site rostering of the registrar influenced the delivery plan. The coroner did not make adverse findings against clinicians, noting the outcome was not predictable with hindsight.
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Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- True knot in umbilical cord became progressively tighter during labour and descent through birth canal
- Prolonged second stage of labour lasting 1 hour 31 minutes
- Foetal heart rate monitoring by intermittent auscultation rather than continuous electronic monitoring
- Failure to notify obstetric registrar at 30 minutes of pushing as per Maternity Handbook guidelines
- Off-site rostering of on-call obstetric registrar (30 minutes travel time)
- Delay in senior registrar arrival to hospital
Coroner's recommendations
- Box Hill Hospital should continue efforts to secure 24 hour per day, 7 days per week on-site obstetric registrar cover and report on steps taken and future strategic plans
- The Maternity Handbook should be reviewed and amended to provide specific direction about care, retention, and documentation of the placenta and cord in adverse outcome situations where pathology and histopathology is warranted
- Instructions in the Maternity Handbook should emphasise the importance of maintaining the placenta and cord intact
- Photography of the placenta and cord should be included as routine in all obstetric adverse outcomes
Full text
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