Doctors admit C-section error in tragic baby's botched birth
TWO consultants have admitted to the parents of a baby deprived of oxygen at birth they should have performed a caesarean section earlier.
Baby Senan Michael Christopher Dodd was born at Mount Carmel Hospital, Dublin, on March 28, 2008.
There was a delay in performing the emergency birth procedure and the baby boy suffered severe brain damage due to oxygen deprivation, Dublin City Coroner's Court heard yesterday.
He died at the National Maternity Hospital, Holles Street, Dublin, on March 30, 2008.
Two consultants obstetricians, Dr Gerry Rafferty and Dr Valerie Donnelly, acknowledged yesterday the caesarean section should have been performed earlier.
Dr Rafferty said he contributed to the delay in delivering the baby and expressed his "profound apologies" to the baby's parents, David and Roberta Dodd.
Midwife Philomena Beglan, who broke down in tears in the witness box, told the court she called Dr Rafferty to review Roberta, at 4.45pm on March 28, due to lack of progress of labour, following an hour of active pushing.
The doctor said he gave the parents the option of a caesarean section or of an epidural with syntocinon, an agent used to speed up labour, after an examination and considering the trace of the fetal heartbeat.
Syntocinon and an epidural were administered.
But the doctor failed to look back at the trace of the foetal heartbeat, which indicated a slow heart rate at 2.45pm and another slow rate after pushing began.
He accepted he should have looked back on the record and said there were "a number of systems failures".
He told the inquest he should have, "been more direct and said a C-section was the way to go".
He agreed with counsel for the family, Bruce Antoniotti, that he did not tell the Dodds there was foetal distress because he failed to perceive it, as he failed to look back far enough on the trace.
The baby's heart rate was monitored intermittently, the court heard.
Dr Valerie Donnelly, who took over from Dr Rafferty, reviewed Mrs Dodd around 6.20pm after a prolonged period of slow foetal heart rate.
Dr Donnelly proceeded as planned and recommenced the syntocinon although it had been turned off by the midwife, who was preparing for a C-section.
"I regret I did not deliver the baby by C-section at that point. I believe my delay in making the decision to deliver him by caesarean section has contributed to his death," said Dr Donnelly.
She agreed it was the "second occasion" during the delivery when a caesarean section should have been carried out.
Coroner Dr Brian Farrell recorded a verdict of death by medical misadventure.
He said there were a number of risk factors associated with the management of labour, in particularly in relation to the tracing of the foetal heartbeat and the delay to the caesarean section.
He said an external review should be carried out if it had not already been undertaken.
The inquest heard foetal blood sampling was not available at Mount Carmel at the time of the baby's birth.
Speaking after the inquest Mr Dodd, accompanied by his wife, said the verdict was all they could have hoped for.
He said they wanted to see the standards in Mount Carmel improving. "The errors were very basic," he said.
He added that after Senan was born he had to be taken to Holles Street Hospital because they didn't have the facilities in Mount Carmel.
"If most parents knew this they would go to Holles Street in the first place," he said.