28 results for “cardiotocography monitoring”
0y · Female·Intra-uterine hypoxia
…ham Hospital at term following spontaneous labour. Labour was augmented with IV Syntocinon after ARM. Cardiotocography (CTG) monitoring was difficult to interpret due to poor detection of uterine contractions. From appro…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
…ependent midwife Stephanie Geyer. When labour did not progress normally, the mother was transferred to a monitoring suite for continuous cardiotocography (CTG). Critically, the CTG recorded the mother's heart rate instea…
0y · Male·hypoxic-ischaemic encephalopathy due to prolonged fetal bradycardia
…ctively observed by staff. Registered Midwife Scobie, as Shift Coordinator, undertook responsibility for monitoring but failed to check the trace or arrange for someone else to do so. When a student midwife (RN Baker) re…
0y · Female·Perinatal asphyxia
…iagnosed, the mother would have received different antenatal care including diabetes management, glucose monitoring, possible additional ultrasound, and continuous CTG monitoring during labour, likely changing labour man…
0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…
…as delivered at 9.55 pm on 9 July 2000 at Naracoorte Health Service with no signs of life (Apgar 0). CTG monitoring during labour showed concerning fetal bradycardia episodes around 6.55 pm with recovery, followed by tot…
Male·Hypoxic-ischaemic encephalopathy due to meconium aspiration syndrome
… weeks died from hypoxic-ischaemic encephalopathy due to meconium aspiration. Critical failures in fetal monitoring were identified: the admission CTG was abnormal but not recognised as such by the midwife; continuous CT…
Male·Global hypoxic-ischaemic encephalopathy
Preston Paudel, born at 37 weeks gestation after meconium-stained labour with syntocinon augmentation, was delivered severely compromised with Apgar scores of 1-1-1 and died of hypoxic-ischaemic encephalopathy. Multiple …
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
0y · Female·Perinatal asphyxia
…clinically preventable failures: escalation of oxytocin augmentation to 60ml/hour without adequate fetal monitoring for hyperstimulation; inadequate maternal pain relief that prevented proper monitoring reliability; poor…
Tate Spencer-Koch: intrapartum hypoxia due to shoulder dystocia; Jahli Hobbs: in…
…li Hobbs (breech presentation) died from placental abruption during a breech delivery without continuous monitoring; CTG would likely have enabled timely intervention. Tully Kavanagh (second twin) died from hypoxic-ischa…
0y · Female·Birth asphyxia due to tight umbilical cord around neck with meconium aspiration
… meconium aspiration. The coroner identified multiple systemic failures in care. Crucially, admission cardiotocography (CTG) monitoring was inadequate (less than 5 minutes, policy required 10+ minutes). During labour, fo…
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
…regnancy complicated by spontaneous rupture of membranes and underwent labor induction. During labor, cardiotocography traces deteriorated from 2100 hours but medical staff were not escalated to review until after 0138 h…
0y · Female·Hypoxic brain injury in the setting of meconium aspiration syndrome and chorioam…
…thick meconium present and required resuscitation. Critical clinical lessons include: (1) inadequate CTG monitoring before induction—the abnormal trace was not reviewed for 35 minutes despite appearing pathological from …
Female·meconium aspiration
Talisha Hildebrandt was stillborn at Ayr Hospital on 7 January 2007 due to meconium aspiration. The pregnancy was low-risk and managed appropriately. A CTG monitor showed concerning fetal heart rate changes, prompting ur…
6y · Male·Global cerebral ischaemia secondary to perinatal asphyxia
…arean section for obstructed labour and fetal distress. Key clinical lessons include: (1) continuous CTG monitoring should have been initiated immediately on arrival given documented decreased fetal movements in the week…
0y · Male·Perinatal hypoxia
…dwives failed to adequately monitor fetal heart rate and did not recommend hospital transfer. Continuous monitoring was unavailable at home. Transfer occurred at 8:05pm with severely abnormal fetal heart rate. The corone…
0y · Female·perinatal asphyxia
Baby Kylie Hamilton, a 3-day-old neonate, died from perinatal asphyxia following emergency Caesarean delivery during her mother's induced labour. The mother had gestational diabetes and the fetus showed concerning CTG ab…
0y · Male·Perinatal hypoxia
An 8-day-old neonate died of perinatal hypoxia on 14 December 2019, 8 days after emergency caesarean section. The infant presented with seizures, hypotonia, and severe encephalopathy. Autopsy revealed severe global cereb…
Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…
…cinon commenced (standard practice but contrary to manufacturer recommendations); delayed continuous CTG monitoring until abnormal fetal heart rate detected at 3:45pm by auscultation; 20-minute delay to obstetric review …
0y · Female·Congenital Streptococcus agalactiae (Group B) pneumonia in the setting of compli…
Baby Mabel Windmill was born in a moribund state following emergency caesarean section after complicated labour and died from congenital Group B streptococcal pneumonia. The inquest identified several suboptimal clinical…
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