Coronial
WAhome

Inquest into the Death of Baby AM

Deceased

Baby AM

Demographics

0y, male

Date of death

2017-09-14

Cause of death

severe hypoxic ischaemic encephalopathy secondary to uterine rupture

AI-generated summary

Baby AM died from severe hypoxic ischaemic encephalopathy secondary to uterine rupture during a planned home vaginal birth after caesarean (VBAC). The mother, Ms M, was 40 weeks and 5 days pregnant, attended by a private midwife (Ms Mansfield) with GP Obstetrician backup. After informal early labour at home, Ms Mansfield returned at approximately 1.50pm and detected signs of possible uterine rupture: abnormally low blood pressure and low fetal heart rate. Emergency transfer to Busselton Hospital occurred; emergency caesarean section revealed complete uterine rupture with baby in abdominal cavity. Baby AM was severely hypoxic at birth and died 3 days later. Key issues: Ms M had risk factors including previous failed induction and untried pelvis; limited documentation of informed consent discussions; no continuous fetal monitoring occurred at home; delayed medical assessment in early labour (midwife absent 7.45am-1.50pm); CTG and specialist obstetric review not obtained despite being recommended. The coroner found the death was potentially preventable if Ms M had planned hospital birth with early assessment, timely CTG monitoring, or earlier specialised review at Bunbury Hospital High-Risk Clinic.

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Specialties

obstetricsmidwiferyemergency medicinepaediatricsanaesthesia

Error types

diagnosticcommunicationdelay

Clinical conditions

uterine rupturehypoxic ischaemic encephalopathyvaginal birth after caesarean failurefetal distressmaternal haemorrhage

Procedures

emergency caesarean section

Contributing factors

  • home birth setting without continuous fetal monitoring
  • previous caesarean section (uterine scar)
  • previous failed induction of labour
  • untried pelvis
  • delayed midwife assessment during early labour
  • absence of CTG monitoring
  • lack of early specialist obstetric review
  • documentation deficiencies regarding informed consent
  • distance from hospital (20+ minutes)

Coroner's recommendations

  1. WACHS should work to improve communication and documentation between midwives, GP Obstetricians, and specialist obstetricians
  2. WACHS should expand community midwifery services and birthing centre options beyond Bunbury into greater south-west region to provide safer options within public health system
  3. For planned VBAC at home, midwife, GP Obstetrician, and pregnant woman should ideally all participate in joint discussion, whether in person or via technology, to ensure robust conversation and fully informed consent
  4. Written documentation of all discussions regarding benefits and risks of VBAC should be maintained in clinical records
  5. Referral to specialist high-risk clinic should be documented in writing when recommended
  6. For VBAC clients, provision of written information including RANZCOG materials and hospital pamphlets should be documented
  7. Pregnant women planning VBAC at home should have assessment by GP Obstetrician with documented communication with midwife
  8. Better planning needed for management of post-term pregnancy (40+ weeks) in VBAC home birth setting, including consultation with GP Obstetrician
  9. Medical profession should reduce unnecessary primary caesarean section rate to address increasing demand for VBAC
Full text
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