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A pregnant woman writhing in pain collapsed with a ruptured uterus after 17 hours in the hospital.
Her baby died about a month later.
Waikato DHB’s care for “Ms. C” did not meet her obligations, Deputy Commissioner for Health and Disability Rose Wall said in a report released Monday.
However, a uterine rupture in this situation is “extremely rare.”
The woman, known as Ms. C, was 28 weeks pregnant when she arrived at a Waikato hospital with abdominal pain.
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Medical staff considered causes such as a blocked intestine, but still did not know what was wrong when it collapsed 17 hours later.
A rupture in her uterus was discovered when her baby was born by emergency cesarean section.
Baby C initially survived, but died a month later due to hypoxia at birth, that is, he did not receive enough oxygen.
“This whole experience has left me completely emotionally and physically drained and distrustful of the medical profession,” Ms. C told the commission.
Waikato DHB has since increased the midwifery staffing, according to the report, with more registrars, midwives and senior medical officers.
He also conducted a didactic session on uterine rupture.
Mrs C told her midwife “I … thought I was dying” while returning from an ultrasound.
He collapsed shortly after, around 6.42pm, and his daughter was born by emergency cesarean section.
Then the rupture in her uterus was discovered.
Baby C spent 25 days in the neonatal intensive care unit (NICU), before her death.
Natanael Melchor / Unsplash
Baby C was born by emergency cesarean section, but died after 25 days in the hospital.
Earlier on the day of Ms C’s collapse, around 10 am, she described excruciating pain.
“All I could do was sob,” he said.
A recorder described her writhing in pain, and later notes describe her tight sheets.
Ms. C was in her 30s and had a history of severe endometriosis and surgery.
Taking more than 12 hours for a surgical review and scan “does not seem to reflect the urgency that pain symptoms would suggest,” said expert counselor and obstetrician Professor Peter Stone.
“[Mrs C’s] the symptoms were disproportionate to the signs and actually quite large or almost excessive amounts of pain relief were given for an undiagnosed situation and yet there was no treatment plan.
The “rare and catastrophic” case was traumatic, said Dr. A, an obstetric consultant.
“However, we were able to save [Mrs C] and we think [Baby C]. His death was very sad for everyone involved ”.
It was so rare for a woman’s scarless uterus to rupture when she was not in labor that a DHB like Waikato would only expect to see it once in 20-25 years, said Dr. A.
Wall agreed that few doctors would have considered or made the rare diagnosis of a ruptured uterus before Ms C. collapsed.
Many aspects of her care were well managed, but DHB violated the Health and Disability Services Consumer Rights Code.
Failures included not getting more senior staff to review the case and a lack of effective communication between the OB and general surgery teams.
Dr. A, an obstetric consultant, also received an adverse comment.
Ms. C had seven medical checkups, but none for obstetrics between 12:50 pm and her collapse, according to the commission’s report.
Ms. C took too long to get the ultrasound, an important diagnostic step.
And neither obstetrics nor general surgery “assumed full responsibility for management nor did they have the necessary sense of urgency.”
Wall made a number of recommendations to Waikato DHB, all now in place, including reporting the results of their review, showing evidence of recent staff training, and apologizing to Ms. C and her family.
