Finding into death of Malakai Cross-De Jesus

0y · Male·Complications following forceps delivery

A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex forceps deliveries with red flags (malposition, failed initial application, fetal bradycardia) should be escalated to operating theatre with consultant supervision rather than attempted in birthing suite; (2) subgaleal haemorrhage risk was high (APGAR <7 at 5 min, prolonged labour, multiple pulls) yet scalp observations were delayed due to CPAP bonnet obscuring assessment; (3) early recognition of SGH would have allowed earlier tailored resuscitation and optimized chances of survival; (4) confirmation bias led clinicians to focus on sepsis rather than haemorrhagic shock. Key preventive measures: transfer to theatre when red flags appear, implement robust scalp monitoring protocols post-instrumental delivery, improve situational awareness in neonatal resuscitation, and develop statewide guidelines for massive transfusion in neonates.