Coronial
VIChospital

Finding into death of Lucia Grace Sefton (Bowlen)

Deceased

Lucia Grace Sefton (Bowlen)

Demographics

female

Coroner

Coroner Caitlin English

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. Report an inaccuracy.

Specialties

obstetricspaediatricsneonatologyanaesthesia

Error types

proceduralsystem

Drugs involved

celestoneparacetamol/codeinenifedipinemetoclopramidebenzylpenicillinadrenaline

Clinical conditions

preterm labourobstructed labouroccipito-posterior presentationcephalic impactionhead injuryskull fractureintracranial haemorrhagemetabolic acidosisasphyxia

Procedures

caesarean sectiondisimpaction manoeuvresfoetal head extractioncardiopulmonary resuscitationintubationepidural insertion

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

  1. 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
  2. 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
  3. Implementation of Bendigo Health policy for requirements of Consultant Paediatricians to achieve competency in neonatal and paediatric resuscitation
  4. Inclusion of scenario of difficult delivery of foetal head at caesarean section and subsequent subgaleal haemorrhage in local PROMPT courses
  5. Scheduled repetitive audit of all Resuscitaires to ensure Guidelines and Flowcharts are present on all cots
  6. Review of handover process in Obstetric Department
Full text
Official source Archived copy

Related cases from VIC

VIChospital2025-09-29

Finding into death of Baby M

0y · Female·Perinatal asphyxia

Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6…

obstetricsneonatologyproceduralcommunicationadrenaline
VIChospital2025-05-13

Finding into death of Baby W

0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour

Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…

obstetricsneonatologydiagnosticproceduralclindamycin
VIChospital2025-02-20

Finding into death of Mia Rose Iskander

0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…

Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…

obstetricsneonatologydiagnosticdelayamoxicillin

Source and disclaimer

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.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.