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Hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to uterine rupture

The Coroner's office has communicated some recent findings to the AMA(SA) for the information and education of the medical profession.

In a finding of 8 July 2014, delivered by Anthony Ernest Schapel, Deputy State Coroner, into the death of Aurora Doreen Maureen Sleep, aged 4 days, the Coroner found that she died at the Women's and Children's Hospital, in November 2011 as a result of hypoxic-ischaemic encephalopathy attributed to intrapartum asphyxia secondary to uterine rupture and subsequent displacement of the placenta and baby into the maternal abdominal cavity.

The Deputy State Coroner made a number of recommendations, including for the education of the medical profession. The findings were:

1) That these findings be drawn to the attention of the Minister for Health and Ageing, the Chief Executive of the Department of Health, the Chair of the South Australian Maternal and Neonatal Clinical Network, the Editorial Board of MIMS Australia, the Chief Executive Officer of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and the President of the South Australian Branch of the Australian Medical Association for the education of its members;

2) That clinical guidelines be developed, including within the Australian College of Rural and Remote Medicine Rural Clinical Guidelines and the South Australian Perinatal Practice Guidelines – Induction of Labour Techniques, and the South Australian Perinatal Practice Guidelines – Uterine Rupture, relating to the risk of uterine rupture occasioned by the administration of prostaglandin gel in a woman who has had a previous uterine perforation whether surgically repaired or not. Such guidelines should include reference to:

a) the specific outcome in this case;
b) uncertainty in respect of the degree of healing of the uterine rupture;
c) the need to take into consideration the time that has elapsed between the uterine perforation and a subsequent labour;
d) the need to take into account any relationship between the size of the perforation and the incidence of rupture;
e) that there will be a risk of rupture, whether calculable or not, which is greater than nil;
f) the need to consider that the individual woman’s response to prostaglandin may not be predicted with certainty.

3) That members of the medical profession be advised that in the case of a uterine perforation that has not required surgical repair, there is a need to explain to the patient any risks associated with that rupture and any possible future consequences resulting from it;

4) That the medical profession be advised that in all cases where induction of labour is to be effected by way of prostaglandin gel, that consideration needs to be given to the matters described in subparagraph 2 herein and that those matters be explained to the particular woman in question with advice to the woman in each case that there is a risk involved in the administration of prostaglandin gel in cases where the woman has experienced a previous uterine perforation regardless of whether or not it has been the subject of surgical repair;

5) That general practitioners, including those with obstetric qualifications, be advised that in cases of doubt they should consult a consultant obstetrician about the use of prostaglandin gel in cases involving a previous uterine perforation;

6) That medical practitioners be advised that in cases involving induction of labour by way of the administration of prostaglandin gel where there has been a previous perforation of a uterus, that consideration is given as to whether in the event of a uterine rupture during labour the facilities within the relevant institution or hospital are capable of facilitating an emergency caesarean section without undue delay.

The full finding can be found on the Coroner's website here or here.