I had three unexplained bleeds during my pregnancy, one at 28 weeks, one at 37 weeks and one on October 1^st 2002 at 41 weeks pregnant - the night before a planned induction (booked due to carrying a ‘good size’ baby). I rushed into hospital again at midnight loosing fresh red blood. Again I was given an internal examination using a speculum by the doctor on duty and was told that I was not going into labour.  I was told that they did not know what had caused the bleeding but that I would have to stay in hospital that evening and have the baby’s heartbeat monitored for a couple of hours. I was moved into a delivery suite and hooked up to the machine.  In the morning they told me that they were quite happy with the trace, the baby’s heartbeat was quite fast, but they seemed not to worry about this much as he had been awake throughout the monitoring.  I was then moved off the labour ward onto the maternity ward.

At approx. 8.30am a registrar came to see me. He asked if the bleeding had stopped, I said yes. He checked my stomach, told me that the baby’s head now felt engaged and was happy for the induction to continue. At 9am, the midwife examined me internally and said that she thought my cervix had dilated about 1cm, but she thought she could feel either membranes or blood vessels and therefore wasn’t happy about continuing with the induction without the doctor checking me out first. She went to find him and then came back to tell me that he was in theatre and that I would have to wait until he came out. Throughout the morning the baby’s heartbeat was monitored by a student midwife. I believe a Kleihauer-Betke test was carried out at some point during the morning as I’d lost some blood the previous evening and because my blood group is Rh-Negative.

At 13.15, the same registrar who had examined me earlier carried out another internal and said that he could not feel anything unusual and that he was happy for the induction to continue. I complained at the time of being given the internal examination that it was painful and I complained immediately afterwards that I had stomach pains similar to that of severe period pain in the lower part of my stomach and in my lower back and that I had a throbbing type pain in the right hand side of my groin (as if someone was pressing their thumb into me) but the midwife said it was normal to feel some discomfort after being given an internal. I was told that the pain was due to the baby’s head pressing on a nerve. Shortly after this (approx. 14hrs). Between 14 hrs and 17hrs I complained to the midwife on duty about the intense stomach and back pains that I was experiencing but was told that it is quite common for some women to feel ‘period type pains’ after having the prostoglandin gel inserted.  I crouched over 2 pillows on all fours for the next 3 hours waiting for the contractions to start. I sent my husband home to get some sleep as we’d been up all night and told my mum she may as well go home and get some rest too and that I’d call them both as soon as anything started to happen.

Just before 17hrs the midwife came back to monitor the baby’s heartbeat, which was fine. Shortly after she had left me, I felt a gush between my legs and suddenly thought, oh my god my waters must have broken. I staggered off the bed across the corridor to the toilet. I looked down to see that it wasn’t my waters breaking but was blood gushing out.. I screamed for help. I was rushed off the maternity ward on the 4^th floor into the lift and taken down to the theatre on the 1^st floor.

On the way down to theatre the doctor who had examined me earlier that day tried frantically to find the baby’s heartbeat.  He told me by the time we got to theatre that he had found it but it was slow.  I was given a general anaesthetic to knock me out so that an emergency Caesarean could be performed.

James Edward Gadd was born on Wednesday 2^nd October at 17.27. He weighed 10.9lbs! He was just gorgeous his dad’s build – 57.5cm long and was blonde like me. We were told that he had to be resuscitated and given a blood transfusion because he had lost so much oxygen when I lost that blood. I believe that he had also had seizures. He was put onto a life support machine and moved to the special care baby unit (SCBU).

Initially, James appeared to be responding to the treatment received, but after several hours we were told that James condition was deteriorating and were asked if to get James christened as the medical team were unsure if he would survive the night.  Gareth and I called our parents and at approx midnight James was christened. Following this Gareth and I sat talking to James. We held him and stroked him but he didn’t respond; in fact he never actually opened his eyes at all. Further updates throughout the morning detailed James’ worsening condition, the kidney failure and the potential that he had suffered some brain damage. Shortly afterwards we were told that we ought to be considering switching off the ventilator. As we were discussing this, a doctor came in and told us that James had suffered some internal bleeding and his blood pressure had dropped. We rushed in to see him and found that he had also had a nose bleed. It was at this point that Gareth and I decided that we could not put our little solider through any more of this, so we turned the ventilator off, wrapped our little man up in a blanket and took him outside to the small garden in the sunshine to say goodbye to him.

The histology of the placenta showed that there was a marginal insertion of the cord and that Vasa Previa (blood vessels running free within the membranes) was present.

The exact cause of James’ death was Hypoxic-Ischaemic encephalopathy (early neonatal encephalopathy).  We did not request a post-mortem.

We are following the hospital’s formal complaint procedure because we do not think that prostin should have been administered as “unexplained bleeding” is listed as a contra-indication for its use amongst a whole host of other areas where we feel that the care given was sub-optimal.

The sonographer who performed the scan at 37 weeks apparently would have used the colour Doppler scanner to look for signs of placenta separation and MAY have seen that there was a marginal insertion of the cord, but standard procedures state that this would only have to be recorded if the placenta was deemed to be low-lying. Obviously my husband and I are completely devastated. This was our first child and could not have been more wanted.

Conclusions

I made a formal complaint to the hospital where this happened Good Hope in Sutton Coldfield. A report compiled claimed that I did not receive substandard care as it is not standard procedure for sonographers to look for vasa previa or cord abnormalities (ie velementous insertions etc) even though a high percentage of these contribute to still births.

The report also acknowledged that prostoglandins were used on me despite them being contra-indicated in women with unexplained bleeding. I did contact the manufacturers (Pharmacia) of the gel used to inform them of what happened – they advised to take it up with my consultant.

This is tragic loss could have been prevented if only the sonographers knew what to look for and if the medical staff were aware of the condition. It is in the midwifery books so why they didn’t spot it either with warning signs is something I’ll never understand as long as I live.

A planned C-section would have saved James’s life. Instead the only child I have ever carried is now an angel.