Leacked! KATH Report on five still born babies.

REPORT ON FIVE STILL BORN BABIES DELIVERED ON 5^TH FEBRUARY, 2014 AT THE LABOUR WARD OF KATH.

1.0 INTRODUCTION

It was identified that (18) vaginal deliveries were recorded within the period (i.e. Tuesday 8am, 4/02/2014 – Wednesday 8am, 5/02/2014) at the A1 Labour Ward of which 3 were SBs.   One other SB which had occurred the day before was still on the labour ward on the morning of 5^th Feb. 2014 and is part of the missing SBs and had therefore been added to the rest to make a total of 4. There were also 12 C/S of which one was a ruptured uterus leading to an SB. Therefore the SB arising from the ruptured uterus if added to the 4 SBs at the Labour Ward make up a total of 5 SBs.

It is important to set the records straight, in that a total of 30 deliveries and four 4 SBs and not 16 deliveries and 5 SBs were recorded during that 24hour period. As said earlier one of the SBs occurred the day before but because it was part of the missing SBs it is being included in this report.

2.0               WHAT LED TO THE DEATH OF THE BABIES

2.1 CASE1. SUWAIBA MUMUNI

Madam Suwaiba Mumuni, a 36yr old Gravida 4 Para 1^Alive+2SA with estimated gestational age of 43 weeks + 2 days, was referred from Amaamata Memorial Maternity Clinic as a case of postdatism on 31^st January 2014. She however reported at KATH Consulting Room 8 on 4^th February, 2014, four (4) days after she was referred from Amaamata Clinic. The doctor after attending to her at consulting room 8, processed her for admission to ward A4 at 2:50pm same day. She was seen by the Team on duty at ward A4 that same day at 3:20pm. She was clerked and examined by a House Officer and further discussions with the Resident on duty led to the documentation of the following clinical notes about Madam Suwaiba:

“A young woman, not jaundiced, not febrile and not pale. Her blood Pressure (BP) was 134/90mmHg. The pulse rate was 84 beats per minute, it was regular and of good volume. The heart sounds were normal and her chest was clinically clear.

Abdominal examination revealed that the abdomen was not tender and soft. The symphysio-fundal height (SFH) was 40 centimetres; the lie was longitudinal and the presentation was cephalic. The foetal heart rate was 142 beats per minute and was regular. She had 2 contractions in 10 minutes lasting 15 seconds. A speculum examination revealed a cervical os of 2 centimetres dilatation and with a pool of meconium stained liquor. ”

The impression formed was a primipara with postdatism and a premature rupture of membrane (PROM) in latent phase of first stage of labour. The plan well outlined in the clinical notes was to take blood sample for full blood count (FBC), grouping and cross-matching of her blood, ultrasound examination, antibiotics and monitoring for spontaneous onset of labour.

Further discussions between the House Officer and the Resident on duty revealed labour was not established hence the House Officer was instructed to start induction of labour with 50 micrograms of Cytotec (Misoprostol) sublingually. The induction of labour was started at about 4:30pm. Madam Suwaiba was scheduled to be reviewed after 4 hours, i.e. at 8:30pm.

She was however reviewed by the House Officer at 8:45pm. She complained of lower abdominal pain and on direct questioning, she said she could perceive foetal movements (FH⁺) and she had seen show.

On general examination, the patient was afebrile, anicteric and not pale. Abdominal examination revealed the lie of the baby as longitudinal with cephalic presentation. The contractions were one (1) in ten (10) minutes lasting 20 seconds. The foetal heart rate (FHR) was 146 beats per minute. Vaginal examination revealed a cervix which was 1 centimetre long, soft and central with a dilatation of 2 centimetres. The examination finger was stained with show. A repeat dose of 50 microgram tablet of Cytotec (misoprostol) was again given sublingually in consultation with the Resident. A review was scheduled at 12:30am, 5/02/14. However, 20 minutes later, at 9:05pm she was reviewed on ward A4 by the Resident. She complained of lower abdominal and waist pains. On direct questioning, she said she could perceive foetal movements. Madam Suwaiba had not bled per vaginam and she had not lost liquor.

On examination, she was afebrile, anicteric and not pale. The abdomen was soft and not tender. The symphysio-fundal height (SFH) was 40 centimetres. The foetal heart rate (FHR) was 148 beats per minute and regular. The contractions were 2 in 10 minutes lasting 40 seconds. On vaginal examination, the cervix was effaced; the os was 4cm dilated, the station of the baby’s head was -2 with intact membranes.  The Resident requested that the patient be transferred to A1 labour ward for further monitoring for vaginal delivery.

She was scheduled to be reviewed at 1:05am at ward A4 on 5/02/14. However, at 10:15pm (4/02/14), she was transferred from ward A4 to the Labour Ward as a case of active first stage of labour after a bed had been made available for her.

The Resident went to the A1 labour ward around 1:00am (5/02/14) to review Madam Suwaiba but upon entering the ward, he was confronted with another patient with dire emergency. This patient by name B.T. with a history of previous caesarean section had then been admitted to the labour ward after spending several hours outside the labour ward. This was because the ward was full to capacity. She presented with latent phase of first stage of labour but due to the congestion with no empty bed led to a ruptured uterus. She therefore had to be prepared for laparotomy and uterine repair in the theatre immediately.

The Resident after taking care of that emergency came back to the labour ward at 2:30am and reviewed Madam Suwaiba. She complained of intermittent lower abdominal and waist pains. On direct questioning, she said she could perceive foetal movements (FH⁺) and she had not bled per vaginam.

On examination by the Resident, she was afebrile, anicteric and not pale. General condition was satisfactory. Her abdomen was soft and not tender. The foetal heart rate (FHR) was 152 beats per minute. There were 3 contractions in 10minutes lasting 40 seconds. On vaginal examination, cervical os was 8 centimetres dilated. She had oedematous anterior lip and the station of the baby’s head was +1. There was no caput or moulding. Injection NOSPA was prescribed for her which was duly administered by a midwife.

After this review, the Resident left to ward A3 to attend to a patient with haemorrhagic shock from bleeding cervical cancer. However, he came back to the labour ward around 3:50am when Madam Suwaiba Mumuni had been positioned on the second stage bed for delivery of her baby and thus the Resident doctor was present at the delivery stage.

Madam Suwaiba had been positioned in the second stage bed at 3:40am following full dilatation.  She was encouraged to push with contractions and delivered at 3:50am just around the same time the Resident came to the labour ward from ward A3. The outcome was a dead male foetus that had the umbilical cord tightly wrapped around the neck twice. The umbilical cord was clamped and cut and he weighed 4.2kgs. The baby was fresh still birth with post maturity syndrome (Dried, cracked, desquamated skin with meconium staining of membranes), the skin at his back side had peeled off with an umbilical cord that looked greenish in colour. The placenta came out around 3:56am (5/02/14). Madam Suwaiba lost about 400mls of blood during the delivery process. At this stage, the Resident left Madam Suwaiba to attend to other patients.

The entire delivery process lasted for 5 hours, 42 minutes and the breakdown is as follows:

1. First stage: 5 hours, 30 minutes
2. Second stage: 6 minutes
3. Third stage: 6minutes

The baby was delivered dead (stillbirth). The midwife showed the baby to Madam Suwaiba (mother) to identify the sex and also to agree to the fact that it did not cry and was dead at delivery. According to the midwife, she was reluctant to accept that her baby was dead initially but she later agreed to that declaration.

She was then asked again three times by a midwife if she was aware about the death of her baby which she duly answered in the affirmative on all three occasions.

The mother had a perineal tear which was sutured by a midwife.  She was thereafter transferred to her bed and served with a beverage.

The midwife again showed the baby to the mother to identify the sex of the baby and that the baby was not alive. The midwife explained the process and how important it was for her to thumbprint the stillbirth records book.

Madam Suwaiba subsequently thumb printed in the labour ward’s stillbirth records book and also in her folder to agree to the death of the baby by standard protocol followed by the labour ward. She wept for some time over her ordeal and was consoled by a midwife to take heart. 

Madam Suwaiba Mumuni was thereafter transferred to ward A2 for post-delivery management (Injection Syntocinon 40units) by midwives which lasted for about two (2) hours. She was subsequently discharged from ward A2 on 5^th February, 2014.

SUMMARY

• Madam Suwaiba had failed to report to KATH four (4) clear days after being referred from Amaamata Memorial Maternity Clinic at Aboabo, Kumasi on 31^st January, 2014.
• Madam Suwaiba Mumuni’s baby presented with post maturity syndrome resulting from the prolonged pregnancy.
• The baby had the umbilical cord tightly wrapped around the neck twice upon delivery perhaps leading to the death of the baby.

2.2 CASE 2. M.O.

M O, 30 years G3P2^{both alive}+0, EDD=25/01/14, EGA= 41 weeks⁺³. She was referred from Maternal & Child Health Hospital (MCH) as bleeding per vaginum. She had bled heavily for two (2) hours prior to admission. She was admitted at 3:50am on 4^th February, 2014. 

The abdomen was felt to be hard and uniformly enlarged.  The symphysio-fundal height (SFH) was 38cm and presentation Cephalic. No foetal heart (FH) was heard.

Abdominal Ultrasound done on A1 Labour Ward showed an absent foetal heart (FH) and a posterior upper segment placenta with an obvious retroplacental clot.

Vaginal examination: She had two (2) pads in place which were not soaked.  There was no active bleeding.  Digital examination revealed posterior cervix which was not effaced, os was 2 centimetres dilated and station was -1.  Bishop score was three (3).

Impression of Placental abruption with Intra Uterine Foetal Death (UFD) at 41 weeks, 3 days and unfavourably cervix was made. Bedside clotting time was five (5) minutes. Two units of blood were cross matched and saved.  She was given 50 micrograms of Cytotec (Misoprostol).

She delivered at 7:55am on 04/02/14 to a male 3.1kg stillbirth and given 10 units of Syntocinon and placenta delivered.  Client however had Post-Partum Hemorrhage (PPH) which was managed with 600µg of Cytotec (Misoprostol) and 20 units of Syntocinon in 500 mls of normal saline.  Patient was sent to theatre for examination under anaesthesia.  No perineal, cervical or uterine tear was seen and patient sent to A2 ward on recovery.

SUMMARY

·         Foetal heart rate was completely absent (Ultrasound confirmed)

·         Placental abruption was identified as the cause of the IUFD.

2.3 CASE3. E.A.

She arrived on A1 LW at 11:20pm on 4/02/14.  No fetal heart was heard.  She had preterm labour IUD confirmed by Ultrasound. She delivered 45 minutes later to a preterm macerated baby 1.5kg. This baby was one of the babies the orderly picked up from the labour ward.

SUMMARY

·         Had preterm labour with Intra-uterine death (IUD) confirmed by Ultrasound.

2.4 CASE4. C.S.

C.S. is a 28 year old G3P2 who was admitted at 6:30am on 5^th February, 2014.  The nurse identified that there was foetal distress and called the doctor on duty to see, who after seeing confirmed the foetal distress and asked that  the patient be prepared for emergency Caesarian Section (CS) which included Intra-Venous fluids and placing patient on her left side.

The cervix was 7centimetres dilated, membranes were ruptured with thick meconium stained liquor.  She did not consent for the emergency Caesarian Section (CS) initially and kept on bearing down during the preparation for theatre but after further counseling she consented for the surgery.

Whilst being wheeled to the theatre it was noticed that the cord had prolapsed which was found not pulsating. She was again counseled on findings and allowed for vaginal delivery.  She delivered a fresh Stillbirth (SB). The Stillbirth was wrapped and packaged similar to the earlier ones.

SUMMARY

·         There was confirmed Foetal distress with ruptured membrane and freshly thick meconium stained liquor.

·         She failed to consent to an emergency caesarean section (CS) to save the child.

·         Umbilical cord prolapsed contributing to foetal death.

2.5 CASE 5. B.T.

G2P1 via C/S because of failed indication for postdatism was initially examined at 5:54pm 4/2/14 in latent phase of labour at 39 weeks 2 days gestation. The labour ward was filled to its capacity so she was sat on a bench at the waiting area of the labour ward until a bed became available at about 1:15am. She complained of severe abdominal pains and dizziness.  She was examined and found to have ruptured her uterus.  Emergency Laparotomy was done.  The outcome was dehiscence of the old scar and a Fresh Female still birth of weight 3.00kg.  The midwife that received the baby weighed it. A wrist band was applied and labeled with mother’s name and sex, birth weight and date of delivery. 

The baby was wrapped using mother’s cot sheet and labeled again on the cot sheet.  The label had mother’s name, diagnosis, baby’s sex, birth weight, APGAR score, date and time of delivery on it.  The report on condition of baby was read out to the hearing of the surgeon, assistant surgeon, anaesthetist and scrub nurse.  All findings were documented into mother’s folder and on baby’s head ticket.

3.0              THE HOSPITAL’S PROCEDURE FOR DISPOSING OF STILLBIRTHS.

Protocol of the hospital in handling and disposing of stillbirths as currently in practice are as follows:

1.    The child is shown to the mother to identify the sex as well as the evidence of live or no live. The mother is officially informed of the status of the child’s existence (Dead/Alive).

2.    If the child is pronounced dead, the mother is made to thumbprint the stillbirth record book (Official document) confirming or certifying the information about the baby’s status.

3.    Babies upon delivery are identified with a wrist band bearing the mothers name, sex, weight and date of birth. They are wrapped with the mother’s cloth and put in a paper box if dead. The box is sealed and labeled with the same information as written on the wrist band. The boxes are kept in a multipurpose room. This room is used for the following:

Ø  Temporary storage of dead still bodies, placenta, other waste materials and cleaning materials.

Ø  These dead babies are not under any lock and key.

4.    The nurses’ wait for the mortuary attendant to come for the body. They call the mortuary attendant when there is a delay in their routine schedule.

5.    The mortuary attendant reports with a register into which is recorded the name of the mother, date of delivery, sex, weight, ward and who collected the body.

6.    The nurses’ also document the following in their books:  name of mother, mothers’ thumbprint, age, date of admission, date of delivery, sex, babies weight, baby’s condition, date of collection of body and the name of the mortuary attendant who collected the body.

7.    At the mortuary, the bodies are put in a barrel containing formalin for preservation.

8.    These bodies are officially disposed of if not claimed by the relatives within a month coinciding with the hospital’s mass burial.

4.0              WHAT HAPPENED TO EACH OF THE FIVE (5) DEAD BABIES

In each of the still births recorded on that fateful day, the above protocol was followed. Unfortunately, the bodies of three of the still births could not be accounted for because the orderly on duty that day allegedly took the bodies to the incinerator.

The other two (Madam Clementina Somme’s and Bernice Tawiah’s babies) were sent to the mortuary.

SUMMARY

Madam Suwaiba Mumuni’s baby after it was shown to her to identify the sex and confirm his death by thumb printing the necessary documents; it was weighed, wrapped with the mothers’ cloth and put in a box which was placed at where stillbirths are kept in transit to the mortuary. Unfortunately, this baby happens to be one (1) of the three (3) babies allegedly picked up the Orderly and disposed of.

Madam M.O. baby also went through the same formalities as Madam Suwaiba’s baby and her baby also happens to be part of the bodies the Orderly allegedly picked up and disposed of.

Madam E.A. baby also went through the same process as protocol demands but unfortunately, her baby also happens to be part of the three (3) missing bodies allegedly picked up by the Orderly.

Madam C.S. baby also went through the normal process like the others, put in a box, labeled and was later taken to the mortuary by the Mortuary Attendant, Mr. Mumuni Awuni.

B.T. also went through the normal process like the others, put in a box, labeled and was later taken to the mortuary by the Mortuary Attendant, Mr. Mumuni Awuni.

5.0 ADDITIONAL INFORMATION

The acute congestion at the Obstetrics and Gynaecology directorate of the hospital continue to impact negatively on the provision of quality maternal health care despite the best efforts of staff.  The daily average bed occupancy rate is between 160 and 185 percent over the past three years. This is twice the acceptable standard. This has been compounded by inadequate equipment critical for the management of obstetric emergencies.

The Hospital and the Ministry of Health should therefore as a matter of urgency address the congestion at the Obstetrics and Gynaecology department to help improve the quality of maternal health care.

Ongoing efforts by the ministry to complete the 38 year old maternity and Children Block project should be intensified to help create a congenial working environment for the optimum management of Obstetric cases.

The Obstetrics and Gynaecology department should also be provided with all the needed equipment with back-up to improve the monitoring and management of cases.

Thank you.

CHIEF EXECUTIVE

PROF. OHENE ADJEI