A coroner says a rare umbilical cord condition that led to the "deeply sad" death of a baby just after birth was missed on successive occasions.
By Rachel Moore of RNZ
Sage William Mana Lewis was born on November 14, 2019 and died on November 16.
A coroner has found that a rare pregnancy complication was missed on successive occasion and that at no point were the risks associated with the condition remaining unresolved discussed with the baby's mother.
"This is a deeply sad case, in which two parents and their family have suffered the devastating loss of their baby boy almost immediately after his birth," coroner Ian Telford said.
"Although Sage lived for only a short time, it is apparent that he was cherished for every second of the one day, 15 hours and 42 minutes that he was with those who loved him."
Telford said he had met Sage's mother and maternal grandmother and was struck by their "dignified calm in the face of such profound and enduring grief".
"Most particularly I was struck by their focus on what could be learned from what had happened to them, and how those lessons might help to prevent a similar tragedy from occurring in the future."
Hannah Nicholson's labour was induced at Rotorua Hospital on the evening of November 14, 2019 at 38 weeks plus one day gestation.
In his findings, Telford said labour progressed normally until there was a sudden drop in Sage's heart rate.
The decision was made for an emergency caesarean section and Nicholson was transferred to theatre for the operation. Sage's heartbeat was still low, and he was delivered "in poor condition and was not breathing".
Resuscitation started immediately and the baby was transferred to the Special Care Baby Unit before being transferred to Waikato Hospital.
"Sage's condition continued to deteriorate. Ultimately, it was assessed that he was unlikely to survive, and a decision was made to cease active treatment," Telford said.
His death was formally recorded at 12.15pm on November 16, 2019.
Specialist perinatal pathologist Dr K Bartlett said Sage suffered significant blood loss, with a lack of oxygen to his organs.
Examination of the placenta showed the umbilical cord was abnormally attached to the membranes surrounding the placenta, instead of directly to the placenta.
This is known as a velamentous cord insertion, which Bartlett said was a very rare condition that occurred in about 1% of placentas.
It meant umbilical blood vessels travelled through the membranes for some distance without the usual protective tissue, making them vulnerable to being compressed or torn during labour.
Bartlett found that in Sage's case, one of these unprotected blood vessels, the umbilical vein, was torn.
"The tear caused significant bleeding, and this was the likely source of the severe blood loss that left Sage in such poor condition at birth."
Telford said as was usual in these circumstances, Health New Zealand Lakes conducted a learning review to consider what happened, how, and why.
The review noted that, at 20 weeks and two days' gestation, an ultrasound identified an additional section of placenta, together with blood vessels running close to and overlying the cervix (vasa praevia).
It was planned that if this persisted, an elective caesarean section at 36 weeks would be recommended.
Then, during week 25 of pregnancy, Nicholson was admitted to Rotorua Hospital with a small antepartum haemorrhage.
"Scanning reported succenturiate placenta (as before) but no signs of vasa praevia. The review states that this was assessed to still meet some guidelines for diagnosis of the condition, concluding that this scan showed evidence of vasa praevia, but it was not recognised."
Transabdominal and transvaginal scans were performed at 30 weeks' gestation, with that report again saying no placenta praevia.
However, the review said measurements obtained in the scan indicated that a vasa praevia was still present according to some guidelines, but this was not explicitly stated.
At 30 weeks and one day of gestation, Nicholson was then referred to hospital with high blood pressure, where the 30-week scan report was noted but not commented on again during visits by medical staff on two consecutive days.
The review of the scan showed Nicholson's condition still met the definition of vasa praevia under some guidelines.
"The presence of a vasa praevia at 30 weeks does not appear to have been recognised by the medical staff during this admission," Telford said.
Nicholson was discharged and admitted to Rotorua Hospital again at 32 weeks and one day.
Telford said the doctor recorded, in relation to the 30-week scan, that it showed "no vasa praevia". Nicholson was discharged the next day.
At 33 weeks and five days gestation, an ultrasound scan report stated, "vasa praevia identified at 20 weeks, not present at 25 and 30 weeks".
Nicholson was not seen again before going into labour.
He said the review report made a large number of recommendations which should help minimise the risk of similar events occurring in the future.
"I particularly note that HNZ Lakes has now developed and implemented a care pathway for prenatally diagnosed vasa praevia and socialised this with staff. This condition has also been added to the list of conditions that are now referred to the High-Risk Clinic."
Updated guidelines had also been published that provided greater clarity of the diagnostic criteria.
Telford encouraged Health New Zealand Lakes to share this with other centres so that its benefits extended more broadly across the health system.
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