Laura Brockman's baby died after she suffered a uterine rupture. Laura had a previous caesarean section, and she planned a hospital birth for this baby. Her labour was induced with Prostin, which has been linked to ruptured uterus in women with caesarean scars. Laura tells her story below; my comments in italics include notes from the hospital's report on Stephen's birth, which Laura has shown to me.
I lost my precious son Stephen on the 26th of April 2000. He was my fourth son. I have had two normal deliveries, but my third son was born by cesarean after I failed to progress past 6cm; he also had fetal distress. I was refused a caesarean with my fourth baby. They said there was no need as I had already given birth naturally.
I saw my consultant at 40 weeks gestation and he decided to induce me with Prostin gel (prostaglandin gel).
There was no real reason for inducing me. The consultant said I had a fairly large baby and would send me in. He swept my membranes, and commented that my cervix was not favourable, but we should get things started. I think he had had a busy day, I was the twentieth lady he had seen, and I think he just wanted to go home; no real care was taken over me.
I did request a section after my examination. All he said was "You're not scared are you?" I replied "Yes, as I don't want a repeat of my last labour". He never commented on this. He has now admitted negligence, saying that if he had read my notes he would never have induced me, a section would have been booked immediately.
Before the induction process was started, the baby's heart was monitored with a CTG and was found to be satisfactory. The Prostin gel was inserted at 7.10 pm on 25 April.
My contractions started 15 mins after the first dose of Prostin; they were extremely painful, but not considered to be (true) labour.
Laura's notes say that she 'responded rapidly' to the Prostin and started contracting every 2-3 minutes. The first deceleration of Stephen's heart was noted at 8.05 pm, but by 9.17 no further decelerations had been noted. The monitor was taken off to allow Laura to move around for half an hour, and recommenced at 9.45.
By 11pm it was noted that the baby's heart tracings were 'flat' and 'not very reactive', although his heart rate itself was fairly normal at 142 beats per minute. However, although Laura was having regular contractions, labour did not appear to be progressing well - her cervix was still only 2-3 cms dilated.
I did not have anyone with me (well, no-one to one care) after the prostin had been inserted on the antenatal ward. I was really left to it - they popped in now and again, they took my blood pressure and I was examined. They wanted to break my waters but I refused to let them. I was so scared at the time I didn't know what I wanted. I just wished they had given me the caesarean, but it is no good looking back now.
After three hours I was taken to the Labour ward to receive some pain relief (Pethidine - 100 mgs - and Stemetil, 12.5 mgs). It helped regulate the contractions and make me feel more comfortable, I felt fine. I had asked for an epidural but was not classed as being in labour, so this was refused. I had a midwife with me constantly after I had been transferred to the labour ward.
I was monitored continuously - I was only taken off the machine to be transferred upstairs to the labour ward, where I was immediately put back on it.
The baby's heart rate appeared normal, and reactive, at this point. It remained normal until 1.00am on 26 April when it dropped to 100 bpm, then recovered. At 1.10 am it dropped again, but recovered. Laura's abdomen was examined and there was no tenderness over her caesarean scar.
I got up to go to the toilet and my waters broke. Within 10 minutes of this happening my son Stephen's heart rate was fluctuating. I had no unusual pain, no bleeding and no shock, just three very large jolts in my belly.
The liquor was clear, and Laura was given an examination to check for cord prolapse - none was found. After this, the baby's heart dropped to 100 bpm again, and recovery was slow. Laura was given oxygen from a face mask. A registrar examined Laura's abdomen again, and noted that there was still no tenderness, and the abdomen was soft. The baby's head was 2cm above the ischial spines. His heart rate returned to 141 bpm with 'good variability'. The doctor's plan at this point was to continue monitoring.
AT 1.45 am the baby's heart rate decelerated to 90-100 bpm with slow recovery, and contractions were irregular. His heart continued to decelerate to 90-68 bpm. The midwives started to prepare for a caesarean section, and attempted to locate a surgeon and anaesthetist - but the doctors they contacted were not available. One consultant refused to perform the caesarean as he was not on-call at the time, although he was coming into the hospital.
I was made to wait approximately one hour before they could get Stephen out as there was no anesthetist available. When the surgery finally took place, on opening me up they found Stephen in the abdominal cavity; the placenta was completely detached, and my uterus was in total shreds. It was not a classic rupture. My son never took a breath.
By 2 am the midwives were seriously worried about the baby's heart rate and called for a second surgeon and anaesthetist. The baby's heart rate was around 61 bpm by the time a surgeon was located. However, the anaesthetist did not arrive until 2.30 am. The baby's heart rate had fallen to 41 bpm by 2.34 am. The caesarean commenced at 2.39 am and Stephen was delivered at 2.41 am, showing no signs of life. He was resuscitated, but died at 6.30 am.
My husband and I had a meeting with the hospital involved to discuss the findings of their internal inquiry. I am pleased to tell you that they have discontinued the use of Prostin Gel, for ladies with a previous c-section, throughout the hospital. They are also informing and advising other hospitals in the area to stop its use. This I think is great news.
The hospital has put on an extra anaesthetist, at night, who can be called specifically for that part of the hospital, in case of any other emergencies, so we can rest assured that there is adequate cover in the future.
They are also looking in to the induction policy. The hospital is inducing far too many ladies when they are not ripe for labour, and they hope to bring down the numbers significantly.
They accepted that my consultant was negligent, by not reading my notes before my induction took place; if he had done so I would never have been induced. They are also going to make important information with high risk births more prominent on the ladies' notes, so the consultant can see any underlying problems at a glance.
An independent inquiry has made two further recommendations, which the hospital has implemented immediately. Firstly, all staff are to attend a course on CTGs, which will involve learning how to read and decipher them, and will have to have to take the course every single year. Secondly, any consultant on the premises, whether they are off-duty or not, must immediately respond to any emergency, or face disciplinary action.
I feel much better knowing that some good has come from Stephen's death. I just hope to God it never happens again. I know it should never happen at this hospital again, after all their changes.
Laura Brockman
Laura has since had a beautiful daughter, Mollie, who was born safe and well after a planned caesarean section.
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