Case 1 | A 21-year-old Afghan mother, 0P, in 38 weeks of gestation, was admitted to hospital with labour pains in latent phase. She was delivered by emergency CS due to foetal distress on the day shift. Ten hours after operation she was pale, had pre-shock status, and the reported haemoglobin level was 7.4 g/dl. Re-operation was performed, a very large hematoma in left broad ligament was detected, and 12 units of different blood products were transfused. She went back to the hospital two weeks after discharge due to fever and haematuria. Further examination revealed left ureter injury. |
Care items | Audit findings |
Initial assessment | Foetal heart rates were monitored and assessed inadequately. |
Recognition | No evidence was found to agree foetal distress. Intra-abdominal hematoma was recognised with delay. |
Care plan | The indicated evidence for emergency CS was missing. |
Monitoring | Postpartum controls early after CS were not documented and were inadequate for early detection of intra-abdominal bleeding. |
Preventability | Near-miss events (decreased haemoglobin, re-operation, blood transfusion) and the injured ureter could have potentially been prevented by better obstetric practice (provider-related). |