In the birthing suite at Melbourne’s Royal Women’s Hospital, four hours after her labour started, Krystal Reading thought something was wrong.
It was just after 6am on November 7, 2007. This was the 23-year-old Reservoir mother’s second baby.
Within the hour, her fears were confirmed. Her son, Tyler Reading-Adams, was born at 6.52am with his knotted umbilical cord wrapped tightly around his neck.
The baby’s heart rate rapidly dropped and, three minutes after birth, medical staff started resuscitation. More oxygen was administered as they found he had no pulse and was gasping intermittently.
Tyler’s heart rate continued to drop and by 7.40am, the resuscitation efforts had failed. At 8.30am, Tyler died.
Doctors later concluded that the tight knots in Tyler’s 54 centimetre umbilical cord had caused his death. The diagnosis of “true knots”, which causes a constriction of the blood vessels, was not made.
But in Australia and Victoria, authorities lack reliable information about umbilical cords and links between true knots, or the cord being wrapped around a baby’s neck, and its chance at life.
Now, a coroner wants the state government to put more money into research that could save the lives of babies like Tyler.
In her finding into Tyler’s death earlier this month, published this week, coroner Dr Jane Hendtlass said the Health Department should add to funding for the state Consultative Council on Obstetric and Paediatric Mortality and Morbidity so it could monitor data submitted about umbilical cords.
The information could only be obtained through changes to the existing computer programs that collect data on every baby born in Victoria.
This information would then allow hospitals to buy more advanced radiology equipment that would be able to detect true knots in umbilical cords.
The head of the consultative council, Professor Jeremy Oats, told the coroner that true knots and umbilical cords being wrapped around babies’ necks is common, and it is rare for there to be clear evidence that those instances caused death.
Dr Hendtlass said in the absence of a diagnosis of true knots, the midwives performed duties appropriately.
Dr Hendtlass recommended that the Royal Women’s, the Mercy Hospital for Women and the Monash Medical Centre work together to collect data about umbilical cords in an effort to maintain information about them in Victoria.
Dr Christine Bessell, executive medical adviser at the Royal Women’s Hospital, told the coroner that the research and information “could result in a reduction in adverse pregnancy outcomes”.
Research from Norway, Israel and Finland, cited by Dr Hendtlass in her finding, concluded that for babies born with true knots in their umbilical cord, there was a greater chance of death. According to the Norwegian study, that risk was as much as 10 times greater than that of other babies.
Dr Hendtlass said if the overseas research was applied to Victoria, 890 of the 71,444 babies born in 2011 would be expected to be born with true knots. Of those 890, 13 could be expected to die.
She warned that without any data, there could be no firm predictions made about Victorian mortality rates.