Baby Kylie Hamilton, a 3-day-old neonate, died from perinatal asphyxia following emergency Caesarean delivery during her mother's induced labour. The mother had gestational diabetes and the fetus showed concerning CTG abnormalities from early in labour. Clinical staff appropriately managed most of the labour, but a critical decision point occurred at 2.15pm when syntocinon was recommenced despite inadequate labour progress and concerning fetal heart rate patterns. The coroner found a reasonable clinical basis existed for Caesarean delivery at 2.15pm or 2.45pm. Autopsy revealed the baby had suffered chronic intrauterine hypoxia (weeks to months prior to delivery) due to placental compromise, followed by acute hypoxia during labour. While earlier delivery by Caesarean at 2.45pm might have resulted in a less compromised infant, the coroner could not determine with certainty whether this would have changed the ultimate outcome given the extensive chronic hypoxia.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
fetal compromise with poor reserves evident on CTG from early labour
inadequate labour progress despite syntocinon augmentation
clinical decision to continue labour augmentation at 2.15pm despite non-reassuring features
Coroner's recommendations
That Monash Health consider the significance of a gradual reduction in baseline foetal heart rate in post-maturity pregnancies and how this should be incorporated into clinical assessment and decision-making
That Monash Health consider the value and timing of repeat foetal blood sample testing during labour, particularly in cases with non-reassuring features and prolonged labour
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