Coronial
SAhospital

Coroner's Finding: SLEEP Aurora Doreen Maureen

Deceased

Aurora Doreen Maureen Sleep

Demographics

4y, female

Date of death

2011-11-21

Finding date

2014-07-08

Cause of death

hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to uterine rupture and subsequent displacement of the placenta and baby into the maternal abdominal cavity

AI-generated summary

Aurora Sleep died from hypoxic-ischaemic encephalopathy caused by uterine rupture during labour induction with prostaglandin gel. Her mother had a perforated uterus from a D&C procedure 9 months earlier. The coroner found the original obstetrician failed to communicate risks to the mother or her treating doctors. The induction team did not consider the perforation a material risk despite guidelines suggesting previous uterine surgery is contraindicated with prostaglandins. Aurora's death was preventable via elective caesarean section. Key lessons: practitioners must communicate previous uterine injuries to patients and subsequent carers; guidelines require clarification regarding perforations not requiring surgical repair; risks of prostaglandin use with previous perforation must be explicitly discussed with patients to enable informed consent.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

obstetricsmidwiferypaediatrics

Error types

communicationdiagnosticsystem

Drugs involved

prostaglandin geloxytocin

Clinical conditions

uterine perforationuterine rupturehypoxic ischaemic encephalopathyintrapartum asphyxiagestational hypertensionhypertonic uterusfoetal bradycardia

Procedures

prostaglandin gel applicationlabour inductionemergency caesarean sectionsubtotal hysterectomyd&c (dilatation and curettage)laparoscopy

Contributing factors

  • uterine perforation from prior D&C procedure (February 2011) with incomplete communication of risks
  • administration of prostaglandin gel to induce labour in setting of previous uterine perforation at fundus
  • hypertonic uterine contractions caused by prostaglandin gel
  • failure of original obstetrician to communicate risk to patient or subsequent treating physicians
  • lack of explicit guideline clarity regarding perforations not requiring surgical repair
  • failure to provide informed consent discussion regarding risks of prostaglandin use
  • absence of consultation with senior obstetrician despite novel clinical scenario
  • lack of consideration of elective caesarean section as alternative delivery method

Coroner's recommendations

  1. Draw findings to attention of Minister for Health and Ageing, Chief Executive of Department of Health, Chair of South Australian Maternal and Neonatal Clinical Network, Editorial Board of MIMS Australia, Royal Australian and New Zealand College of Obstetricians and Gynaecologists, and South Australian Branch of Australian Medical Association
  2. Develop clinical guidelines within Australian College of Rural and Remote Medicine Rural Clinical Guidelines and South Australian Perinatal Practice Guidelines addressing risk of uterine rupture from prostaglandin gel in women with previous uterine perforation (whether surgically repaired or not), including reference to: the specific outcome in this case; uncertainty regarding degree of healing; time elapsed between perforation and subsequent labour; relationship between perforation size and rupture incidence; that rupture risk exists and is greater than nil; unpredictability of individual response to prostaglandin
  3. Advise medical profession that uterine perforations not requiring surgical repair require explanation to patients of associated risks and future consequences
  4. Advise that when induction of labour is effected by prostaglandin gel, consideration must be given to perforation-related factors and these must be explained to the woman with advice regarding risk
  5. Advise general practitioners with obstetric qualifications to consult a consultant obstetrician in cases of doubt regarding prostaglandin use in previous uterine perforation
  6. Advise medical practitioners to consider whether institutional facilities are capable of performing emergency caesarean section without undue delay before proceeding with prostaglandin-induced labour in setting of previous uterine perforation
Full text
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