Vacuum delivery 'most likely' led to death of baby Livia
An inquest jury has returned a verdict of medical misadventure after a baby girl died following an attempt to perform a vacuum delivery.
Baby Livia Angel Urkova-Marini was the only daughter of Ludmila Ukova and Aldo Marini, from Carlow town.
She was born in St Luke's Hospital, Kilkenny, at 12.04pm on May 18, 2014 and died at 7pm that same day.
The 11-member jury at Kilkenny Coroner's Court made four recommendations, including that there is good communications between medical staff in maternity care and particularly with parents.
The jury also found that good, timely and appropriate care for both public and private patients should be given.
They further found that the HSE should provide training about vasa previa.
This is a rare condition that involves the baby's head pressing down on the umbilical cord and which is dangerous for the child if a tear occurs in the cord and its blood vessels.
The inquest was previously told by Dr Peter Boylan, chairman of the Institute of Obstetricians and Gynaecologists, who reviewed the hospital records, that an attempt at vacuum delivery of baby Livia by the registrar on call after labour had slowed "should not have been done".
This was due to the mother's cervix not being fully dilated.
Coroner Tim Kiely put it to Dr Boylan that there was evidence that a bleed occurred during the first attempt by registrar Dr Ali Gewash at a vacuum delivery.
Dr Boylan explained that a vacuum cup is attached to the baby's head, but if there are blood vessels running across the head, the pulling of the vacuum cup when it is detached can cause a bleed.
The coroner asked him: "Are you saying the performance of the suction ultimately led to the bleed that led to the death?"
"More than likely, yes," Dr Boylan said.
He added that the mother "more than likely" had a case of vasa previa.
Under questioning from Paul McGinn SC, for the hospital, Dr Boylan agreed that vasa previa was "undiagnosed" before delivery.
"It's an extremely difficult diagnosis to make."
The cause of death was given as birth asphyxia, haemorrhagic shock secondary to vasa previa.