SINGAPORE: KK Women’s and Children’s Hospital (KKH) is reviewing its procedures to consider continuous documentation of a newborn’s vital signs after a baby dies from some type of injury resulting from a decrease in oxygen or blood flow to the brain.
State Coroner Adam Nakhoda encouraged the hospital to adopt this practice after finding that the lack of continuous documentation of the baby’s vitals “was not ideal”. He made this note in a series of findings about the baby’s death made available this weekend.
The 11-day-old baby died of natural causes on April 12, 2021, and the case was referred to the coroner after the hospital alerted police to the baby’s death.
He was born by emergency cesarean section, with his mother under general anesthesia, after vaginal delivery with vacuum and forceps was unsuccessful and a slow fetal heartbeat was detected for eight minutes.
His mother was admitted to KKH at 39+1 weeks gestation and had gestational diabetes throughout her pregnancy and a history of Graves’ disease – an immune system disorder that affects the thyroid gland.
However, her thyroid function tests were normal throughout the pregnancy, as was her prenatal ultrasound.
The boy was born with three tight umbilical cord loops around his neck. The cord was cleared and it was noted that he had an “honest shriek” when delivered.
EVENTS AFTER BIRTH
The KKH neonatal resuscitation team attended to the baby immediately after birth and put him on a ventilator.
His initial heart rate was low and he was borderline oxygen saturation, so he was put on continuous positive airway pressure (CPAP) via nasal prongs until his condition improved.
The CPAP was discontinued six minutes after delivery, with the baby observed to be vigorous and “crying well”. The rest of the examination findings were normal.
At about 5 a.m., the doctors in the operating room were called away for a Code Blue activation, referring to a medical emergency.
The baby remained in the operating room under the care of a head nurse who was referred to only as SSN KJ in court documents. He would be transferred to the special care unit for observation.
SSN KJ weighed and measured the baby before putting him back on the resuscitator. According to her, measurements of the baby’s oxygen saturation and heart rate through a probe attached to his palm were normal. However, she noted that his crying was “rather weak” and contacted the Special Care Department for his transfer.
She then took him off the ventilator, placed him on a transport cot, and took him into the viewing room for his father to watch.
The baby’s father videotaped his child crying weakly, the coroner said. About four minutes into the video recording, the baby’s father noticed that the child was quiet, sleepy and slow to react.
He asked SSN KJ if the baby was still asleep. The nurse didn’t answer, but uncovered the baby’s swaddle and appeared to be watching him.
The baby appeared limp and showed no spontaneous limb movements. The nurse later said the baby was not breathing spontaneously and re-wrapped him in the wrap after 5 minutes and 19 seconds before returning him to the operating room.
In the operating room, the nurse put the baby back on the resuscitator and attached a probe to him. He didn’t appear to be breathing spontaneously, so the nurse administered intermittent positive pressure ventilation using a resuscitator before activating a neonatal code blue emergency at 5:22 a.m.
A team consisting of a consultant on duty, a senior resident on duty and two junior assistants on duty went to the baby.
At 5:25 a.m., he was unresponsive to stimulation, so he was intubated and manually ventilated before being transferred to the neonatal intensive care unit (NICU). His fraction of inspired oxygen had fallen to 21 percent.
He reached the NICU at 5:36 a.m. and was connected to a ventilator. At approximately 8:30 a.m., he began having clinical seizures, including breath holding followed by rapid breathing and movement of his upper extremities.
He was treated for the seizures and referred to the neurology team for co-management, but it was later found that he had large amounts of fresh blood in his mouth.
Between the second and fifth days of life, the infant’s condition remained largely unchanged, with no discernible change in neurological findings.
A magnetic resonance imaging (MRI) of the child’s brain revealed swelling and bleeding, among other things.
The infant remained on low ventilator settings, but showed no spontaneous movements or spontaneous breathing efforts, while his pupils remained fixed and dilated.
The findings were communicated to the baby’s parents, and after consideration on day six, they agreed to actively withdraw care, with provision for sedation and pain medication.
He was pronounced dead on April 12, 2021.
An autopsy determined the cause of death to be hypoxic ischemic encephalopathy (HIE). This is a form of brain dysfunction or injury that occurs when the brain experiences a decrease in oxygen or blood flow.
The HIE may have been related to Long QT syndrome — a heart signaling disorder that can cause fast, chaotic heartbeats or arrhythmias — with an abnormally low fetal heart rate. Forensic pathologists said the cause of death was likely due to a natural disease process.
THE FATHER’S QUESTION
During the coroner’s inquest, the baby’s father asked why the child was not put on a ventilator to support his breathing after he was diagnosed with breathing difficulties.
A consultant at KKH who wrote the medical report for the case said the baby was born limp with a slow heartbeat and the medical team had to go through the standard resuscitation process.
Six minutes after birth, he appeared to be breathing adequately and the CPAP was stopped. According to the protocol of the KKH, he would be transferred to the nursery for special care, because he had been resuscitated.
The baby was hooked up to a probe that would have recorded his oxygen saturation and heart rate, but there was no electronic record of these measurements because they were not recorded by KKH’s electronic medical record system.
The only vital signs recorded were those at the sixth and seventh minutes after birth. When he was placed in the transport cot and taken to the viewing room, the probe was disconnected.
There was no objective evidence to determine the baby’s condition before he was taken to the viewing room, the coroner said.
Another KKH medical report stated that there was no documentation of continuous monitoring of the baby’s vital signs given his initial stable status.
The KKH representative said that after reviewing this aspect, the hospital is working to ensure that documentation of a newborn’s vital signs is kept until the newborn is handed over to medical teams in the respective clinical areas.
The neonatology teams were advised to ensure that all newborn babies requiring oxygen supplementation were supervised by medical staff.
State coroner Adam Nakhoda found no foul play in the baby’s death and issued a finding of natural causes.
However, he noted that the baby’s vital signs were not recorded from the seventh minute after birth until he was returned to the operating room.
“I felt that the lack of continuous documentation of (the baby’s) vital signs was not ideal. I am encouraged by the fact that KKH is reviewing its procedures to consider continuous documentation of a newborn’s vital signs and I encourage it hospital to implement this,” he said.
However, he said the nurse’s actions were otherwise appropriate.
The coroner said it’s not known what caused the baby to stop breathing when he was in the viewing room, but tests later revealed he had a KNCQ1 missense variant and that mutations in the KNCQ1 gene are known to cause arrhythmias or chaotic heartbeats .
He accepted the forensic pathologist’s view that the HIE was not caused due to traumatic or unnatural circumstances, and instead held that his death was consistent as the result of a natural disease process.
The coroner said losing a child is always a devastating event, perhaps even more so if it is a newborn, and offered his condolences to the baby’s parents.