Coroner's Finding: GALEA Lesley Anne

30y · Female·respiratory failure related to bronchopneumonia following cerebral anoxia due to amniotic fluid embolism following uterine rupture during labour

A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM without prior cervical assessment and epidural analgesia at 7:35 AM. No vaginal examinations were performed between 1:00 AM and 9:30 AM despite these interventions. Continuous electronic fetal monitoring was delayed until 8:00 AM. She collapsed at 9:30 AM with amniotic fluid embolism following uterine rupture, suffering catastrophic cerebral hypoxia, cardiac arrest, coagulopathy, and eventual death from bronchopneumonia 4 months later. The coroner found inadequate labor progress assessment, insufficient fetal heart monitoring given multiple risk factors (trial of scar, Syntocinon, epidural), and poor communication between midwifery and medical staff. While the amniotic fluid embolism itself was unpredictable, earlier delivery through appropriate fetal monitoring and labor assessment might have prevented uterine rupture.