A woman in labour at Cavan General Hospital (CGH) continued to be given a drug to increase her contractions despite evidence her uterus was overstimulated and her baby was in distress, an inquest heard.
Fiona Watters subsequently gave birth to baby Jamie Flynn, of Tara Court Square, Navan, Co Meath, who died in his mother's arms at the Rotunda Hospital on November 24th, 2012. He had been born two days earlier at the consultant-lead unit in CGH suffering from a severe brain injury as a result of oxygen deprivation (hypoxia).
Returning a verdict of medical misadventure, coroner Dr Brian Farrell said hyper-stimulation of the uterus was the principal risk factor identified in the baby's death.
The inquest previously heard that CGH consultant obstetrician Dr Salah Aziz delayed doing an emergency Caesarean section because there were no nursing staff available to man the operating theatre.
Ms Watters was initially induced on November 20th. She was first seen by Dr Aziz on the morning of November 22nd and he broke her waters. The baby’s heart rate was monitored over the course of the day. Dr Aziz was subsequently contacted by a midwife at 10.30pm because Ms Watters had been pushing for an hour with no head visible. Another Caesarean section was being carried out in theatre at the time.
Dr Aziz told the inquest he was “left with no choice” but to try delivery using a vacuum or forceps in the labour ward. This failed and Ms Watters was transferred to theatre for Caesarean section. The baby was born in poor condition.
Giving evidence Dr Aziz said that there had been an abnormal reading on the baby’s cardio-tachograph (CTG) earlier when Ms Watters was being given induction hormone Prostiglandin that should have been brought to a registrar’s attention.
The final day of the inquest heard from the coroner's expert that there was evidence of hyper-stimulaton on the CTG as early as 4pm that afternoon, with the baby doing well up to that point. Prof Richard Greene, consultant obstetrician at Cork University Maternity Hospital, said that it appears that Ms Watters continued to receive incrementally increased doses of oxytocin, a drug used to increase contractions, over the following hours until after 9pm when it is then reduced.
Hypoxia in babies
“It appears from the documentation on the CTG that the oxytocin infusion was progressed upwards throughout the labour from 4pm onwards, during a period when the uterus appears to be hyper-stimulated and the patient making progress in labour. Both hyper-stimulation and the progress would question a need to reduce the oxytocin rather than increase it at this time,” he said.
Prof Greene said hyper-stimulation in the uterus can lead to hypoxia in babies because it reduces recovery time for blood flow to the placenta and oxygen recovery to the foetus. As this persisted in Ms Watters’ labour, he said, there is evidence on the CTG that the baby was showing signs of distress “likely to evolve from hypoxia due to the hyper-stimulation of the uterus”.
“There were changes suggesting that the baby was not happy physiologically and showing signs of that in its own heartbeat,” he said.
The oxygen deprivation did not happen “suddenly”, he told the court.
Commenting on the delay in the Caesarean section, he said it was “difficult to be certain that an earlier delivery, had a second theatre been available, would have altered the outcome”.
The inquest earlier heard the cause of death was extensive meconium aspiration into the airways as a result of hypoxic brain injury. Returning his verdict, Dr Farrell said he was accepting this and that the principal risk factor identified is the evidence of hyper-stimulation.
He recommended that Cavan General Hospital review the situation regarding a second out-of-hours theatre. The inquest also heard the placenta was not retained and Dr Farrell said this should be done in all cases where babies are born in poor condition.
In September, the High Court quashed a HSE report into baby Jamie Flynn's death on foot of a challenge by Dr Aziz.