Coroner's Finding: KN - deidentified

0y · Male·global hypoxic ischaemic encephalopathy

A term breech baby was born at Launceston General Hospital following a traumatic vaginal delivery with instrumental assistance after failed initial extraction attempts. The infant suffered severe hypoxic-ischaemic encephalopathy and died at 13 days old. Expert review identified that no formal assessment of suitability for vaginal breech birth was conducted, and multiple opportunities existed between membrane rupture and the second obstetrician's arrival to perform a straightforward caesarean section. The coroner found the birth was mismanaged due to poor clinical decision-making not adhering to standard guidelines. Post-natal care at both hospitals was appropriate. Key clinical lesson: breech presentation at term requires careful assessment and timely surgical intervention; delayed decision-making in this context led to preventable severe neonatal hypoxic injury.