Finding into death of Baby M

0y · Female·Perinatal asphyxia

Baby M was born at 38+4 weeks gestation in poor condition at The Royal Women's Hospital on 10 November 2022 and died at 24 minutes of age from perinatal asphyxia. Autopsy findings suggested cord compression occurring 4-6 hours before delivery had compromised foetal wellbeing, though no compromise was detected during labour or antenatally. The neonatal resuscitation encountered multiple technical difficulties: failed intubation by the junior registrar, then successful intubation by the consultant at 15 minutes of life but without effective ventilation achievement. Clinical lessons include: escalation to senior staff could have been marginally earlier (called at 6 minutes rather than potentially at 1 minute); higher ventilation pressures could have been considered earlier; laryngeal mask airway should be considered after failed intubations; umbilical catheter securement technique requires careful attention to prevent blockage. However, expert review concluded Baby M had very low survivorship likelihood given the severity of her pre-birth compromise and unrelenting ventilation difficulties. Comprehensive neonatal resuscitation training including simulation and video laryngoscopy may help in future similar situations.