Baby dies after scar ruptures

Tammylee Rapana and her partner Theodore, with their two small children. Photo / John Cowpland

An investigation has been launched into the death of a near full-term baby in Middlemore Hospital after her mother's scar from two previous emergency caesarean sections opened up.

Baby Tammylee Monica Josephine Rapana died on March 3 when her life support was switched off three days after her traumatic birth.

Her mother - who is also named Tammylee Rapana - has two other children, son Leon, nearly 3, and Merenia, 17 months. Both were born by emergency caesarean at Middlemore. She'd been told a vaginal birth would be impossible.

The chain of events leading to Tammylee's death makes for disturbing reading.

Rapana's independent midwife Fiona Clement was suspended in December, but Rapana said she was unaware of it. Puzzled about why her midwife abruptly stopped caring for her, and having trouble contacting her, Rapana worried about who would arrange for her vital caesarean.

She saw her GP in late December, or early January. He was concerned she wasn't receiving specialist attention. On February 7 she had a referral appointment with Counties Manukau District Health Board maternity services. She had another appointment on February 20 when a booking was made for her to have a caesarean on March 9, two days before the baby's March 11 due date.

But on February 28, the day before Tammylee's fatal birth, Rapana went to Middlemore Hospital by ambulance experiencing pains. She was allowed to go home that afternoon and told she might have pulled a muscle - although the hospital rejects this.

The next day, back home, contractions started in earnest with fatal consequences.

The baby was born by emergency caesarean in Middlemore but by then it was too late. Rapana's scar had ruptured, baby Tammylee's brain had gone too long without oxygen.

In a final cruel blow, about two weeks after losing her baby, a letter arrived from authorities congratulating Rapana on the arrival of her newborn, and urging her to arrange a tuberculosis vaccination. By then Rapana had gone with her partner Theodore Naden to stay with relatives, and her mother, Josephine Rapana, tore the letter up in anger.

Counties Manukau District Health Board largely agrees with Rapana's account, although it disputes she was told she might have pulled a muscle.

The DHB has arranged to meet Rapana this week.

In a written statement to the Herald on Sunday, the DHB's chief medical officer Dr Gloria Johnson, and clinical lead of obstetrics, Dr Sarah Wadsworth, said "The death of a baby is always tragic."

An investigation into Rapana's care was under way to see what could improve outcomes in similar cases in future.

The statement said the date of the elective caesarean was chosen as late in the pregnancy as possible to maximise development of the baby's lungs.

"There is always a small risk that labour will start prior to a booked caesarean and there is an extremely small chance that, if labour does occur, then the uterus will rupture."

According to the statement, Rapana arrived at hospital the day before the birth with "intermittent abdominal pain suggestive of possible early labour". By that afternoon she was no longer in labour and asked to go home. This was considered "reasonable" and she was discharged. She was told to come back if any symptoms recurred.

The doctors said despite resuscitating Tammylee immediately after the caesarean the next day, it was not possible for her to recover.

"This is an extremely rare but tragic outcome and a detailed investigation will look at the whole process of care from the time Ms Rapana was first referred to Counties Manukau DHB. A follow up meeting with the family is planned for Friday, 30 March, and we will keep them informed about the process and outcome of our investigation." The statement ends with the DHB offering "sincere condolences" to Rapana and her family following the sad loss of Tammylee.

The other key figure involved in Rapana's pregnancy was independent midwife Fiona Clement, who the Midwifery Council website says was suspended on December 8.

Clement told the Herald on Sunday she'd asked people to visit Rapana and tell her she was no longer caring for her. But she declined to comment further and referred inquiries to her College of Midwives lawyer Carla Humphrey, who has lodged an appeal against Clement's suspension. She couldn't discuss Rapana's case.

Council of Midwives chief executive Sharron Cole said the action was taken against Clement as the council wasn't satisfied she met requirements of a competence programme. It would be expected a midwife would inform her clients about her suspension.

Auckland Regional Public Health, the organisation which wrote the letter about a vaccination, has apologised.

Spokeswoman Jessie Sampson said: "Staff would like to express their deepest sympathy to the family concerned. We understand this is a very difficult time, and one that will have been worsened by receiving the letter from ARPHS."

The service was often unaware when families' circumstances changed.

"Unfortunately, in this case the family did receive a letter about... vaccination eligibility. We acknowledge the distress that this must have caused."

Tammylee's story:

In between her overwhelming sadness, Tammylee Rapana's incredible strength somehow shines through as she recounts the ordeal which ended in the death of her precious baby.

The oldest of eight, she's the 22-year-old mum of two young children and she lives with her own mum, Josephine, in Manurewa. Rapana's partner Theodore Naden is away on a course he hopes will help him get into the army.

They don't have much, but they are looking forward to their new arrival. Then one morning things begin to unravel and the pain starts.

She's at home when contractions begin. This isn't good, because Rapana, who's had two previous caesareans, can't give birth naturally.

"I rung up the ambulance and ... I went in and ... " she sobs and carries on.

"The pains didn't feel like contractions. It felt like my caesarean scar was going to split open. I was trying to tell the ambulance woman 'something's wrong, the pain's not coming from a labour pain, it's coming from my scar'. And that's when my uterus ruptured. It felt like somebody had cut me open."

She got to hospital 20 minutes later and was taken to theatre. "They told me they thought my uterus had ruptured. I woke up, they said that baby had been in my abdominal area not inside my placenta. They said she had a faint heart beat. I went to go and see her in the neonatal unit and the woman told me that she wasn't going to make it."

"I wish I could have seen the colour of her eyes."

Timeline:

* First trimester. Baby due March 11. Rapana arranges care with midwife Fiona Clement.
* December 8. Clement suspended (this is under appeal).
* Late December-early January. Having pains, sees own GP who makes specialist referral.
* February 7. Sees Counties Manukau DHB maternity services. Baby is fine.
* February 20. Antenatal clinic, caesarean booked for March 9.
* February 28. In pain. Goes to Middlemore about 1am, but home again in the afternoon with doctors' approval. She says they tell her she might have pulled a muscle. Hospital refutes this.
* February 29. About 8.30am ambulance called. Contractions and intense pain coming from the caesarean scar. Uterus ruptures. Baby girl Tammylee Monica Josephine Rapana born by emergency caesarean.
* March 3. Life support switched off.
* March 5. Funeral
* March 16. Letter arrives from Auckland Regional Public Health congratulating Rapana on Tammylee's birth and reminding her of the tuberculosis vaccination.