KKH looking into monitoring newborns’ vital signs until handover after baby's death
KK Women’s and Children’s Hospital (KKH) is looking into monitoring a newborn’s vital signs until it is handed over to other teams in the hospital, after an 11-day-old baby died from a brain injury in April 2021.
State Coroner Adam Nakhoda noted in a report released recently that for a period of time after the baby’s birth, his vital signs were not recorded. He described this lack of continuous documentation as not ideal.
He said in the report that the baby’s mother, who was delivering her first child, underwent an emergency caesarean section, following an unsuccessful vaginal delivery attempt.
After he was born at about 4.30am, the baby was found to have three tight loops of the umbilical cord around his neck. The cord was removed immediately and he was placed on a resuscitator.
As his vital signs were noted to be less than optimal, he was given assisted ventilation for two minutes which helped his heart rate and oxygen saturation improve.
However, at three minutes after birth, his oxygen saturation was noted to be borderline and he was then given continuous positive airway pressure til his vital signs improved.
The baby was observed to be vigorously moving and had a good cry, and State Coroner Nakhoda noted that nothing amiss was observed.
However, when the baby was taken to the viewing room so that his father could see him, the coroner said it was apparent that his condition had begun to deteriorate.
The father and a nurse noticed that he was giving weak cries and appeared limp.
When this became more pronounced and the baby did not show spontaneous limb movements and was not breathing spontaneously, the nurse took him back into the operating theatre.
His vital signs were not recorded from the seventh minute after birth until he was taken back into the operating theatre at about 5.20am.
The nurse put him back on the resuscitator, reattached a probe that allowed for measurement of his oxygen saturation and heart rate, resumed the assisted ventilation and then activated a Code Blue emergency, which is used when a patient is in cardiac or respiratory arrest.
The baby was transferred to the Neonatal Intensive Care Unit and was connected to a ventilator.
But his condition continued to deteriorate. An ultrasound found indications of swelling of the brain while there was also suggestion of severe brain disease.
By the fifth day after the baby was born, his condition had worsened further and his parents agreed to withdraw care after discussion with the medical staff and careful consideration. The baby was pronounced dead on April 12, 2021, at about 12.30 pm.
State Coroner Nakhoda ruled out foul play and said the baby had died of natural causes. He also noted that the cause of death was certified to be a brain injury that occurs when the organ experiences a decrease in oxygen or blood flow.
He added that that it was unlikely that the wrapped umbilical cord had played a part as there was period where the baby was well and breathing independently.
A senior consultant at KKH’s department of neonatology stated in a medical report that there was no documentation of continuous monitoring of the baby’s vital signs considering his initial stable status.
The consultant added that on review of this aspect, the hospital was working to ensure documentation of a newborn’s vital signs are kept until the newborn is handed over to other teams in the hospital.
State Coroner Nakhoda said he was heartened by the fact that KKH is reviewing its procedures to consider continuous documentation of a newborn’s vital signs.
“Losing a child is always a devastating event, perhaps more so when the child is a newborn,” he added.