Inquest into the Death of Baby AM

0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture

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.