Coronial
VIChospital

Finding into death of Tyler Reading-Adams

Deceased

Tyler Reading-Adams

Demographics

0y, male

Date of death

2007-11-07

Finding date

2013-05-09

Cause of death

Intrapartum hypoxia due to true knot in umbilical cord with cord wrapped three times around neck causing vascular occlusion

AI-generated summary

Tyler Reading-Adams died at 95 minutes old from intrapartum hypoxia caused by a true knot in his umbilical cord wrapped three times around his neck. The mother presented at 40 weeks 6 days gestation with spontaneous rupture of membranes and clear liquor. CTG monitoring in ED showed some variable decelerations but no persistent concerning features. Labour progressed normally with intermittent fetal heart rate monitoring in the birthing suite. During the 12-minute second stage, the baby's heart rate declined from 122 to 70 bpm, but this was not considered concerning as delivery was thought imminent. The midwives performed their duties appropriately given the absence of prior diagnosis of cord complications. The coroner found the death was due to an undetectable anatomical anomaly rather than clinical mismanagement, and made recommendations for improved data collection on umbilical cord abnormalities and future antepartum ultrasound screening capabilities.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

obstetricsmidwiferyneonatologypaediatrics

Drugs involved

nitrous oxideoxygenadrenaline

Clinical conditions

intrapartum hypoxiatrue knot in umbilical cordumbilical cord encirclementneonatal asphyxiacardiac arrest

Procedures

resuscitationCPAPintubationcardiac massage

Contributing factors

  • True knot in umbilical cord
  • Umbilical cord wrapped tightly three times around baby's neck
  • Inability to diagnose cord complications prenatally with available ultrasound technology in 2007
  • Rapid deterioration during second stage of labour
  • Undetectable anatomical anomaly not apparent on routine antenatal monitoring

Coroner's recommendations

  1. The Department of Health recommend revision of the Victorian and Australian Perinatal Data Collections for births from 1 January 2014 to include information about the status of the umbilical cord including whether it is round the neck or has a true knot and providing for free text to clarify any other abnormalities
  2. The Consultative Council on Obstetric and Paediatric Mortality and Morbidity of its own initiative arrange for the three Level 6 Maternity Services in Victoria to commence use of their current reporting procedures to include information about the status of the umbilical cord including whether it is round the neck and/or has a true knot and to clarify any other abnormalities
  3. The Secretary of the Department of Health provide the Consultative Council on Obstetric and Paediatric Mortality and Morbidity with the funding required to implement these changes in the Victorian Perinatal Data Collections for births from 1 January 2014
  4. The Department of Health monitor the data produced by the new data collection to inform it about the priority it should give to procuring new radiology equipment which can identify true knots and cord around the foetus' neck so that clinical responses can be informed by the knowledge of potential cord vascular occlusion
  5. The Consultative Council on Obstetric and Paediatric Mortality and Morbidity and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists publish the statistical information that becomes available from the Victorian Perinatal Data Collection as a way of encouraging obstetricians and midwives to consider how they can minimise the risks associated with true knots and other umbilical cord complications in otherwise non-concerning births
Full text
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This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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