Tasmanian coroner discovers breech baby birth was mishandled by Launceston General Hospital before he died

A baby has died in a Tasmanian hospital after a ‘traumatic’ birth that was mishandled by healthcare staff who performed a caesarean section too late, a coroner has found.

CONTENT WARNING: This story contains details that may cause distress

Luke* was born at Launceston General Hospital (LGH) in upstate in October 2019.

In his findings into Luke’s death, Coroner Simon Cooper described the birth as a “traumatic labor process”.

The baby’s mother, Sandra*, had come to LGH for a scheduled appointment at an antenatal clinic and was found to be in the early stages of labour.

Her pregnancy was at 39 weeks and three days.

Mr Cooper said an examination by midwives showed the baby was in a breech position and Sandra was immediately admitted to hospital for an emergency C-section, also known as a caesarean section.

“LGH medical records indicate [Sandra] was ‘eager’ for a C-section,” he wrote.

A report to the coroner by an obstetrics specialist said there was a period of approximately 25 minutes when a “relatively simple caesarean section” could have been performed.

However, Mr Cooper said initial attempts were made by an obstetrician to deliver the baby vaginally, before another consultant obstetrician was called in to help.

Various maneuvers were tried without success before a caesarean section was undertaken to free the baby’s arms and head.

He said it turned out to be successful in the sense that Luke was able to be born vaginally soon after, but he was “seriously ill”.

“Unfortunately, his prognosis was poor due to hypoxic ischemia. [brain] injury he had suffered during childbirth.

The decision was made to place Luke in hospice care and he died on November 3, 2019.

“Poor clinical decision-making”

After positive identification of the baby’s body, Luke was transferred to the hospital morgue.

An autopsy the following day revealed the cause of death to be global hypoxic ischemic encephalopathy.

Obstetrics expert Dr Jonathan Nettle was asked to examine the circumstances of Luke’s short life.

He reported that Luke’s birth was a “difficult clinical situation which appears to have been compounded by poor clinical decision-making that did not adhere to relevant standard guidelines”.

Dr Nettle also found that a “clear clinical assessment of fitness to attempt vaginal breech delivery has not been performed”.

He said anytime between 3.03pm – when Sandra’s membranes ruptured – and 3.29pm it would have been possible to perform a relatively simple cesarean section.

Coroner Cooper concluded that Luke’s birth was “mishandled at LGH”.

“On the other hand, the care and treatment he received after his birth, both at the LGH and at the RHH, was of an appropriate standard,” he said.

The LGH told the coroner it was investing in a simple ultrasound unit that midwives and medical staff would be trained to use for confirmation of fetal presentation.

The hospital has been contacted for comment.

*Names have been changed.

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