Finding into death of Lucia Grace Sefton (Bowlen)
Deceased
Lucia Grace Sefton (Bowlen)
Demographics
female
Date of death
2015-08-06
Finding date
2019-09-18
Cause of death
Head injury in the setting of an obstructed labour
AI-generated summary
A term-destined baby (35 weeks gestation) died from head injuries sustained during delivery. She presented to hospital with suspected preterm labour, was managed conservatively initially, and progressed to spontaneous labour. After arrest of descent at full dilation, caesarean section was appropriately arranged. During delivery, the fetal head was found to be deeply impacted in the maternal pelvis (occipito-posterior position), requiring significant disimpaction manoeuvres by midwifery staff. The baby was born severely compromised and died shortly after unsuccessful resuscitation. The pathologist concluded head injuries caused death, likely from the disimpaction process. Clinical learning points include: (1) careful assessment immediately pre-operatively to identify impacted heads; (2) ensuring senior experienced obstetricians and anaesthetists are present and prepared; (3) proper technique using cupped hand for upward pressure rather than two fingers; (4) consideration of alternative techniques including breech extraction or uterine incision extension; (5) multi-disciplinary training in management of impacted fetal heads.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- occipito-posterior fetal position
- deeply impacted fetal head in maternal pelvis
- caput succedaneum impairing assessment of fetal head position
- prematurity (35 weeks gestation)
- interval between final vaginal examination in birth room and caesarean section allowing further head descent
- lack of clear guidance and experience in managing disimpaction of impacted premature fetal head
- limited documentation of disimpaction manoeuvres employed
- lack of re-examination in theatre prior to caesarean section
Coroner's recommendations
- Safer Care Victoria to support RANZCOG to ensure ongoing Practical Obstetric Multi-Professional Training (PROMPT) includes techniques for safe delivery of the baby where the head is deeply impacted in the pelvis
- Clinical Director of Obstetrics and Gynaecology and Senior Manager of Women's and Children's Services to ensure training for clinical staff in measures to assist with delivery of deeply impacted foetal head
- Implementation of Bendigo Health policy for requirements of Consultant Paediatricians to achieve competency in neonatal and paediatric resuscitation
- Inclusion of scenario of difficult delivery of foetal head at caesarean section and subsequent subgaleal haemorrhage in local PROMPT courses
- Scheduled repetitive audit of all Resuscitaires to ensure Guidelines and Flowcharts are present on all cots
- Review of handover process in Obstetric Department
Full text
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