Finding into death of Lucia Grace Sefton (Bowlen)

Female·Head injury in the setting of an obstructed labour

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.