Finding into death of Finn Moser

Contributing factors

• Miscalculation of fetal weight discordancy (calculated 20% instead of 14.1%)
• Deep impaction of fetal head in maternal pelvis not recognised preoperatively
• Occipito-posterior fetal head position not communicated to surgical team
• Absence of pre-operative vaginal examination by most senior clinician to assess head position
• Discontinuation of fetal heart rate monitoring during transfer to theatre
• Continuation of Syntocinon infusion after decision to proceed to caesarean section
• Absence of consultant obstetrician from commencement of caesarean section despite multiple pregnancy
• Difficult disimpaction and extraction manoeuvres resulting in skull fracture

Coroner's recommendations

1. RWH ensure guidelines and practices are aligned with College's Delivery of the fetus at caesarean section guideline; final vaginal examination prior to emergency caesarean should be conducted by most experienced obstetrician present
2. RWH and College refresh education resources covering: early identification and escalation of obstructed labour or difficult fetal head extractions; multi-disciplinary scenario-based training (PROMPT) including techniques for safe delivery of deeply impacted heads; risk of head injuries (particularly skull fractures and significant bleeding) in obstructed labour; continuous fetal monitoring especially in theatre
3. Safer Care Victoria support training targeted to midwives assisting in vaginal disimpaction during caesarean sections
4. College review Delivery of the fetus at caesarean section guideline to: specify vaginal examinations immediately prior to caesarean should be performed by most senior obstetrician; include recommendations in mandatory surgical safety timeout checklist specifying need for vaginal examination prior to caesarean and identification of obstructed labour or difficult head extraction
5. RWH ensure compliance with College's November 2017 RANZCOG Training Registrar Supervision Guideline