0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
…40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision-making around assi…
0y · Female·Intrapartum hypoxia due to breech delivery with head entrapment and associated c…
…tation. Her mother, Ms Wood, went into spontaneous labour at home but did not reach hospital in time. The delivery involved head entrapment and cord compression leading to intrapartum hypoxia and death. The coroner found…
7y · Male·Hypoxic ischaemic encephalopathy in the setting of a breech delivery
…d died at 7 days old. The mother had been counselled by hospital obstetricians about risks of home breech delivery and advised to present to hospital if labour commenced. Despite these clear recommendations and a planned…
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 sever…
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 w…
0y · Female·Perinatal asphyxia
Summer Elizabeth Rose Niehoff died from perinatal asphyxia hours after vaginal birth following a prolonged labour in hospital. The coroner found multiple clinically preventable failure…
30y · Female·respiratory failure related to bronchopneumonia following cerebral anoxia due to…
A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM without prior cervical assessment and epidural …
0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a …
…rine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother attended hospital with ruptured membranes at 38+6 weeks gestatio…
0y · Female·respiratory failure due to congenital pneumonia with hyaline membrane disease ca…
…from respiratory failure due to congenial pneumonia caused by streptococcus pneumoniae. The maternal high vaginal swab taken one week before delivery was positive for streptococcus pneumoniae but this critical result wa…
36y · Female·Global ischaemic injury following cardiorespiratory arrest in the immediate post…
…e third stage in PPH-risk cases, maintain continuous vital signs monitoring post-birth, perform immediate vaginal examination to detect tears, remove patient from pool immediately if PPH suspected, and respond urgently …
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell…
0y · Female·Severe hypoxic ischemic encephalopathy due to brain injury from complicated assi…
…ll died eight days after birth from severe hypoxic ischemic encephalopathy following complicated assisted vaginal birth at Ingham Hospital. Her mother had a low-risk pregnancy complicated by spontaneous rupture of membr…
2y · Male·Hypoxic ischaemic encephalopathy and intracranial haemorrhage complicating obstr…
…foetal tachycardia and reduced variability on CTG monitoring. After failed attempts at vacuum and forceps delivery in the birthing room, an urgent category-one caesarean section was performed. The infant was born in poor…
Unknown·Subgaleal Haemorrhage caused by position of forceps on baby's head together with…
…12 December 2008 from a subgaleal haemorrhage. The coroner found the death was directly caused by forceps delivery — specifically the position of the forceps on the baby's head combined with excessive traction and compre…
Female·Head injury in the setting of an obstructed labour
A term-destined baby (35 weeks gestation) died from head injuries sustained during delivery. She presented to hospital with suspected preterm labour, was managed conservatively initially, and progr…
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
… concerns to senior obstetric review until too late, and an apparent 'tunnel vision' focused on achieving vaginal delivery despite slow labour progress and deteriorating fetal condition. The patient herself requested a …
0y · Female·Hypoxic episode, probably caused by cord entanglement during delivery
…in ~20% of births but is lethal in <1% in hospital settings where continuous fetal monitoring and skilled delivery can detect complications. Without antenatal assessment, cord entanglement went undetected and unmanaged. …
0y · Male·Global cerebral hypoxic injury and perinatal asphyxia secondary to uterine ruptu…
…The death was preventable. His mother, Ms Thurgood, had two prior caesarean sections and refused hospital delivery despite clear medical advice from obstetricians about the 2% rupture risk and need for continuous CTG mon…
0y · Male·acute hypoxic damage caused by shoulder dystocia during delivery
Declan Brian McConville was born with shoulder dystocia (impacted shoulders) after vacuum-assisted delivery at Royal Darwin Hospital on 31 August 2007. He was stuck in the birth canal for approximately 15 minutes …
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
…y. The coroner found the death was preventable if foetal heart rate abnormalities had been recognised and delivery expedited earlier, likely between 11:56 PM and 12:06 AM. Key clinical lessons: (1) CTG monitoring must be…
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