Eva Grace Donaldson was born prematurely by emergency caesarean after her mother suffered a maternal collapse.
Eva Grace Donaldson was born prematurely by emergency caesarean after her mother suffered a maternal collapse.
A premature baby suffered brain damage and died because her mother’s uterus ruptured before she was born, 17 hours after the woman was admitted to hospital with severe abdominal pain.
However, a coroner has found it was a rare aneurysm that caused the rupture and Waikato Hospital doctors “missed opportunities” to prevent the catastrophic event that led to the baby’s death.
Eva Grace Donaldson was born via emergency caesarean at Waikato Hospital on January 15, 2017, after her mother suffered a “maternal collapse”.
Andrea Donaldson had a complicated gynaecological history and Eva’s “spontaneous conception” was a rare phenomenon.
Donaldson was in severe pain for 17 hours leading up to her maternal collapse and it was 43 minutes after the collapse that Eva was delivered at 28 weeks and six days gestation, or three months early.
The baby was found to have a catastrophic brain injury and went on to be cared for in the Newborn Intensive Care Unit (Nicu) of Waikato Hospital.
Coroner Donna Llewell said in chambers findings released today into the death of Eva that following increasing respiratory distress, other complications, and a poor prognosis for the quality of her life, Eva’s parents asked for her life support to be withdrawn.
A blessing was performed and “Baby Eva passed away peacefully in her mother’s arms”, on February 9, 2017.
Baby Eva was born at Waikato Hospital on January 15, 2017. Photo / NZME
The quality of medical care and treatment Donaldson received leading up to Eva’s birth later became the subject of a complaint by the Donaldsons to the Health and Disability Commissioner (HDC).
The HDC’s investigation took almost four years but eventually found Waikato District Health Board, now Te Whatu Ora Waikato, had failed to provide services to Donaldson with reasonable care and skill, and to ensure cooperation among providers to ensure quality and continuity of services.
The report made “strong criticisms” of the care provided to Donaldson, which included the obstetrics consultant’s “overall management, responsibility and lack of oversight”, communications failures between the obstetrics and surgical teams, and “missed opportunities”.
The Coroner’s findings noted the maternal collapse occurred in the absence of ascertaining and treating Donaldson’s rare internal iliac artery aneurysm after her history and symptoms of vomiting and blood in her urine were not fully investigated.
There was a lack of earlier and comprehensive investigation of Donaldson’s pain in the hours leading up to her maternal collapse, and then a lack of urgency in responding to the collapse and its consequences, the Coroner found.
While the caesarian section took 16 minutes, falling within Te Whatu Ora Waikato’s service expectation of 30 minutes, Coroner Llewell said guidelines and expectations needed to be applied in the context of any given situation and on a case-by-case basis.
“The combination of a mother with a significant and complex gynaecological history, the diagnostic uncertainty up to the point of maternal collapse and increasing risks of foetal brain hypoxia the longer maternal oxygen was unstable – all pointed to a critical and urgent need to operate.
“The 16-minute interval ignores the reality that maternal collapse had occurred 43 minutes before delivery, at which time Andrea was no longer fully functioning as life support or incubator for baby Eva.”
A post-mortem examination took place and determined the direct cause of Eva’s death was lack of oxygen to the brain in the womb, leading to the brain injury.
The pathologist’s opinion was that the likely time baby Eva’s extensive brain injury occurred was during the period of maternal collapse that followed the rupture of the uterus.
In her findings, the Coroner said all medical professionals involved and the underpinning narrative of the HDC’s report has been that the events that unfolded were extremely rare, and it would be outside the scope of expertise for an obstetrician, gynaecologist, or a general surgeon to recognise or diagnose an aneurysm from an ultrasound unless he or she had specialist training in pelvic or vascular ultrasonography.
“In my opinion, the characterisation of ‘rare’ for many aspects of this case appears to have been an ends to justify the means,” the coroner said.
“The actions [or inactions] of medical care and treatment did not respond to or fully recognise the complexity and rareness of Andrea’s gynaecological history.
“One striking example has been the significant delay [over 12 hours post-admission] for the responsible obstetrics consultant’s initial in-person review of Andrea’s situation.”
The coroner said that against Donaldson’s history, red flags and symptoms should have created “a more urgent and conscientious” approach to establishing an effective assessment and management plan for her and Eva.
An MRI might have helped but was not performed and earlier surgical intervention could have prevented the aneurysm’s rupture and thereby the uterus rupture, and saved Eva’s life, it was found.
Coroner Llewell made several recommendations including the introduction of a policy and procedures concerning Obstetric Registrar Supervision, to improve the planning and monitoring of pregnant women with a complex gynaecological history, and to consider and develop standards associated with maternal collapse for delivery of the foetus within five minutes.
In her closing remarks, Coroner Llewell acknowledged the “tenacity and courage” of Donaldson and her husband, who have an older son.
“Not only have they lived with the grief and personal challenges associated with losing a child, but Andrea has been diligent and persistent with providing information for my inquiry so that other pregnant women and their families do not experience the same loss.”
