Severe Fetal Trauma during a Caesarean Section – Blog series – The case of baby Nixon - What happened?
In July 2017 the Coroners Court of Queensland reported findings of an inquest (click for link) into the death of Baby Nixon who died shortly after birth at 38 weeks. A Caesarean Section (CS) was performed for failure to progress. During the CS the Obstetric Registrar encountered difficulty delivering the fetal head. A midwife was asked to assist and pushed vaginally to help dis-impact the head.
The autopsy identified Nixon suffered significant injuries including skull fractures, subdural & subarachnoid haemorrhages and brain swelling. The fractures most likely occurred when the two fingers were pushing on the head via the vagina in an attempt to disimpact the head from the pelvis.
In an earlier Coroner’s report (click for link) from 2007 in another Queensland Hospital, sadly a very similar incident occurred,
“During the caesarean section it was identified that Benjamin’s head had become stuck in the pelvis and a procedure to disimpact his head was performed by the obstetrician and a midwife. At autopsy multiple skull fractures were found and severe brain injury was identified. According to the treating doctors, pathologists and independent specialist obstetricians, these injuries were very unusual, if not, unprecedented.”
These stories highlight that the situation is not unique, we are aware of many similar tragedies that have occurred in a number of hospitals throughout the UK, as highlighted in our earlier blog post: Medicolegal issues in a second stage Caesarean Section
Have you had a similar experience? How would you manage this situation? Please share your experiences and thoughts in the comments section below.
Read the advice and recommendations from the coroner’s report in the blog post here.
Dr Varma is a consultant Obstetrician & Gynaecologist with 35 years experience in the field of O&G. He is the inventor of Fetal Pillow and a part time Medical Director of Safe Obstetric Systems. He is still in active clinical practice mainly in the field of Urogynaecology.