Demographics
0y, male
Coroner
Deputy State Coroner Caitlin English
Date of death
2017-09-30
Finding date
2021-11-08
Cause of death
Hypoxic ischaemic encephalopathy complicating peri partum asphyxia
AI-generated summary
A term neonate died at 3 days of age from hypoxic ischaemic encephalopathy due to perinatal asphyxia. The mother presented in early labour, was initially discharged, then readmitted when labour progressed. Labour progressed slowly; cervical dilation remained at 8cm for 2.5 hours despite mild-moderate contractions. Fetal bradycardia developed at 7:30pm and emergency caesarean section was performed 22 minutes later. The baby was born severely compromised (Apgar 0/1/2/3 at 1/5/10/20 minutes) with profound acidosis indicating prolonged hypoxia. Post-mortem revealed hypercoiled umbilical cord with suspected vascular obstruction and thrombus. Key learning: proper partograph documentation is essential for assessing labour progress and preventing investigative delays. While management was ultimately deemed reasonable, anaesthetic availability for emergency procedures was addressed through system improvements implemented post-incident.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
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