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

0y · Male·hypoxia due to intrauterine pneumonia and haemorrhage with uterine rupture in a neonate with prolonged rupture of placental membranes

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.