Finding into death of Finn Moser

1y · Male·Head injury in the setting of labour

Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to presumed growth discordancy (subsequently recalculated as concordant). Labour progressed slowly, and caesarean section was undertaken. During extraction, Finn's head was deeply impacted in the maternal pelvis requiring difficult disimpaction and extraction, resulting in bilateral subdural haematomas, subarachnoid haemorrhages and skull fracture. Multiple clinical management issues were identified: miscalculation of fetal weight discordancy, discontinuation of fetal monitoring during transfer to theatre, failure to perform pre-operative vaginal examination to assess fetal head position, and absence of consultant obstetrician supervision during a potentially difficult delivery. The RWH and the College were recommended to review guidelines and educational practices regarding detection and management of impacted fetal heads.