Coroner's Finding: SLEEP Aurora Doreen Maureen

4y · Female·hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to uterine rupture and subsequent displacement of the placenta and baby into the maternal abdominal cavity

Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner found the original obstetrician failed to communicate risks to the mother or her treating doctors. The induction team did not consider the perforation a material risk despite guidelines suggesting previous uterine surgery is contraindicated with prostaglandins. Aurora's death was preventable via elective caesarean section. Key lessons: practitioners must communicate previous uterine injuries to patients and subsequent carers; guidelines require clarification regarding perforations not requiring surgical repair; risks of prostaglandin use with previous perforation must be explicitly discussed with patients to enable informed consent.