Coronial
VIChospital

Finding into death of BABY FF

Deceased

Baby FF

Demographics

2y, male

Coroner

Coroner Audrey Jamieson

Date of death

2017-05-21

Finding date

2020-10-19

Cause of death

Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstructed labour

AI-generated summary

A term infant died on day 2 of life from hypoxic-ischaemic encephalopathy and intracranial haemorrhage following obstructed labour requiring emergency caesarean section. The mother presented in spontaneous labour at 39 weeks and experienced prolonged labour with foetal tachycardia and reduced variability on CTG monitoring. After failed attempts at vacuum and forceps delivery in the birthing room, an urgent category-one caesarean section was performed. The infant was born in poor condition with APGAR scores of 1, 2, 2 and required resuscitation and intubation. Significant birth injuries including subgaleal haemorrhage and intracranial bleeding were noted. While expert review found antenatal care and labour management were generally appropriate, the coroner identified inadequate FHR monitoring during transfer to theatre and lack of continuous CTG during the operative delivery attempt. The finding emphasises the importance of continuous foetal monitoring, appropriate escalation in obstructed labour, and multidisciplinary training for managing impacted foetal heads at caesarean section.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsneonatologyanaesthesiamidwifery

Error types

monitoringcommunicationprocedural

Drugs involved

oxytocinepidural narcoticsinotropic infusion

Clinical conditions

hypoxic ischaemic encephalopathyintracranial haemorrhageobstructed labourfoetal tachycardiasevere metabolic acidosissubgaleal haemorrhagebirth asphyxia

Procedures

vacuum extractionforceps deliverycaesarean sectionfoetal head disimpactionintubationumbilical vein catheter insertionarterial line insertionblood transfusiontherapeutic hypothermia

Contributing factors

  • Obstructed labour with prolonged second stage
  • Foetal tachycardia and reduced CTG variability
  • Failed instrumental delivery attempts with vacuum and forceps
  • Foetal head disimpaction prior to caesarean section
  • Birth trauma from operative delivery
  • Inadequate foetal heart rate monitoring during transfer to theatre
  • Poor quality CTG trace during operative delivery attempt

Coroner's recommendations

  1. RANZCOG to emphasise continuous foetal heart rate monitoring during transfer to theatre and up until caesarean delivery
  2. Multidisciplinary scenario-based training (such as PROMPT) to include techniques for safe delivery when foetal head is deeply impacted in pelvis
  3. Emphasis on early identification and escalation of obstructed labour and potentially difficult foetal head extractions during caesareans
  4. Theatre teams to be aware of manoeuvres and techniques required for safe disimpaction of foetal head
  5. Senior obstetric doctor to perform vaginal examination immediately before caesarean section when impacted foetal head suspected
  6. Experienced clinicians trained in neonatal resuscitation to be in attendance where technically difficult delivery anticipated
  7. Incorporation of difficult caesarean section scenarios into obstetric emergency training with maternity and theatre teams
Full text
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