Finding into death of Baby Paula Victoria OShea
Deceased
Paula Victoria O'Shea
Demographics
0y, female
Date of death
2008-02-20
Finding date
2014-08-12
Cause of death
Intra-uterine hypoxia
AI-generated summary
Baby Paula O'Shea was born at Sandringham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detection of uterine contractions. From approximately 1300 hours, the CTG showed concerning features including rising baseline fetal heart rate and decelerations. The attending midwife attempted to contact the obstetrician; a Caesarean section was performed at 1425 hours (approximately 85 minutes later) for failure to progress. Baby Paula was severely asphyxiated at birth with Apgar scores of 1, 0, 0, 0 at successive time intervals, and died despite resuscitation. The coroner found no breach of clinical care, concluding that while earlier CTG interpretation might have enabled earlier intervention, survival could not have been anticipated. Baby Paula's death resulted from intra-uterine hypoxia, likely multifactorial including severe head impaction during delivery, which was unforeseeable and extremely difficult to manage despite appropriate clinical manoeuvres.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Difficult CTG trace interpretation due to poor uterine contraction detection
- Right occipital posterior fetal position
- Failure to progress in labour
- Severe fetal head impaction during delivery
- Possible cord compression, cord around neck, or birth trauma
Coroner's recommendations
- Consideration of improved CTG monitoring devices or alternative methods to detect uterine contractions, such as intrauterine pressure catheters, to overcome technical limitations in labour management
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