SINGAPORE - 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 bra...