Coronial
WAhospital

Inquest into the Death of Baby CJ (Subject to Suppression Order)

Deceased

Baby CJ

Demographics

0y, male

Coroner

Coroner Linton

Date of death

2014-03-16

Finding date

2017-08-22

Cause of death

hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a neonate with prolonged rupture of placental membranes

AI-generated summary

A neonate died shortly after birth from hypoxia due to intrauterine pneumonia, haemorrhage and uterine rupture following prolonged rupture of membranes during a planned vaginal birth after caesarean (VBAC). The mother attended hospital with ruptured membranes at 38+6 weeks gestation but discharged herself against medical advice before receiving antibiotics. She returned 33 hours later in labour. During labour, signs of possible uterine rupture emerged around 6:00pm, and emergency caesarean section was recommended. However, the parents declined, influenced by their successful previous vaginal births. After further deterioration and instrumental delivery complications, forceps were eventually applied at 9:11pm. The baby was born in severe distress with cord around neck and died despite resuscitation. Key clinical lessons: early recognition of uterine rupture warning signs (pain at scar, CTG changes, foetal distress); importance of clear, urgent communication of serious risks to parents during labour; risk of VBAC with Syntocinon; and the challenge of parental refusal of necessary intervention despite medical advice.

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

Specialties

obstetricsneonatologyanaesthesiamidwifery

Error types

communicationdelay

Drugs involved

oxytocinbenzylpenicillinepidural anesthesianitrous oxide

Clinical conditions

premature rupture of membranesintrauterine pneumoniachorioamnionitisuterine rupturevaginal birth after caesarean (vbac)foetal distressfoetal hypoxiacord around neckintrauterine infection

Procedures

vaginal deliveryepidural insertionlabour induction with syntocinonvacuum delivery attemptforceps deliveryneonatal resuscitationintubationemergency exploratory laparotomy

Contributing factors

  • prolonged rupture of membranes (33 hours before return to hospital)
  • maternal discharge against medical advice before receiving prophylactic antibiotics
  • delayed return to hospital for antibiotics (15 hours late)
  • uterine rupture during labour in context of VBAC and Syntocinon use
  • intrauterine infection/chorioamnionitis from prolonged PROM
  • foetal hypoxia from both uterine rupture and infection
  • parental refusal of emergency caesarean section at 6:00pm when rupture suspected
  • parental preference for vaginal delivery based on previous successful VBAC
  • communication failure regarding severity of situation and urgency of intervention
  • delayed instrumental delivery (occurred 9:11pm when rupture likely occurred 4:45-6:30pm)

Coroner's recommendations

  1. Need for better communication processes with parents during labour when complications arise and events are not going to plan, ensuring parents fully understand the seriousness and urgency of situations
  2. Emphasis on clear, urgent communication regarding risks specific to VBAC with induction and the high-risk nature of such cases
  3. Hospital review changes including clarification of procedures, strict adherence to cervimetric progress in labour, and guidance for CTG concerns warranting intervention (as implemented by Kaleeya Hospital)
  4. Importance of ensuring parents understand that uterine rupture risk is not reduced by previous successful VBAC and risk doubles with Syntocinon use
  5. Consider documentation (e.g., signing forms) when parents refuse recommended emergency intervention to ensure they understand seriousness
  6. Development of frameworks to better communicate with parents who prefer minimal medical intervention while ensuring understanding of actual clinical risks
Full text
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