Coroner's Finding: WILLMETT Laura Angela

Contributing factors

• maternal discharge from hospital on due date without continuous monitoring
• failure to return to hospital promptly after being advised labour had commenced
• poor handover/communication between referring doctor and receiving doctor
• delay in arranging emergency caesarean section despite early cardiotocographic abnormalities
• inappropriate instruction to mother to push when cervix incompletely dilated
• lack of continuous cardiotocographic monitoring during established labour
• lack of continuous midwifery support during labour
• obstructed labour not diagnosed
• possible early uterine rupture not communicated to receiving doctor

Coroner's recommendations

1. CHSALHN to inform health care providers involved in perinatal care in country SA of learnings, including increasing awareness of Regional Perinatal Network Committees, SA Health Perinatal Practice Guidelines for VBAC, South Australian GO Obstetric Shared Care Protocols, Standards for Maternal and Neonatal Services in South Australia, and CHSALHN procedures for emergency birthing and inter-hospital transfer
2. CHSALHN to provide access to SA Health and CHSALHN practice guidelines and protocols and perinatal support services
3. Health practitioners to consider ruptured uterus as part of differential diagnosis when pregnant woman presents with unexplained and severe abdominal pain, particularly with history of previous uterine surgery and/or abnormal fetal Doppler/CTG trace
4. CHSALHN Maternity Services Committee to facilitate review/development of procedures to guide health practitioners to routinely use a collaborative and well documented management plan in the SA Pregnancy record
5. CHSALHN to guide and support health practitioners when labouring woman presents to a non-birthing site
6. CHSALHN to guide health practitioners from non-birthing and birthing units to communicate before transfer commenced, during transit and upon arrival, including comprehensive handover verbally and in writing
7. Withdrawal of the option of VBAC at country hospitals such as Ceduna; referral of women electing VBAC to appropriate general practitioner obstetrician or tertiary centre
8. All women undertaking antenatal care at country hospitals and requesting VBAC must relocate to chosen VBAC birthing site no later than 36 weeks gestation
9. All midwives and general practitioner obstetricians employed within CHSALHN to complete RANZCOG Foetal Surveillance Education Program (FSEP) to provide minimum competency in reading and interpreting CTG
10. Transfer of obstetric women from non-birthing to birthing facilities must include communication and acceptance between medical officers, with comprehensive handover and photocopies of all documentation
11. VBAC deliveries in country hospitals should be rare occurrences; if allowed, women must be fully informed of limited resources, qualifications of practitioners, potential delays in emergency caesarean, and distance from home to hospital
12. Consideration should be given to whether VBAC deliveries should only be managed by consultant obstetricians, directed to Chief Executive of Department of Health and Wellbeing and Chief Executive of Royal Australian and New Zealand College of Obstetricians and Gynaecologists
13. Country Health South Australia to review VBAC policy for all country hospitals to ensure all risks are considered including hospital resources, local conditions such as distances from home, and difficulty of travelling to hospital expeditiously
14. When doubt exists as to whether a woman at 40 weeks presenting to country hospital with symptoms suggestive of labour is actually in labour, clinicians should seek advice from more qualified source in metropolitan area