Thursday, November 24, 2011

Cojocaru versus BC Children and Women's Hospital Goes to the Supreme Court of Canada

Giving birth has risks, giving birth after a previous c-section has additional risks. Vaginal birth after c-section (VBAC) carries with it a 1 in 200 risk of uterine rupture. What this means is that the baby is expelled into the mothers abdominal cavity during labour and deprived of oxygen. If a c-section cannot be performed immediately, there is a danger of permanent brain damage.

This is what happend during Eric Cojocaru's birth at BC Women and Children's hospital in 2001. According to the information in the original judgement and the appeal judgement (found at and ), Eric's mother, Monica, arrived in Canada pregnant and went to an OBGYN in Vancouver. Monica was told by her doctor in her home country that any future deliveries should be done by c-section. Monica told her OBGYN in Vancouver she wanted a c-section. The OBGYN offered Monica a VBAC indicating that it was successful in most cases (70 to 80 percent), and that the risk of uterine rupture was small. Monica, whose first language is not English, believed that she had to go through a trial of labour to get a c-section.

Monica's labour was induced when she was 10 days overdue by way of vaginal insertion of a prostaglandin gel. It is noted in the appeal judgement that the unchallenged evidence was that the Hospital had four operating rooms (“OR”s) but only one anaesthetist and one OR team on duty at any given time throughout the day that Mrs. Cojocaru was induced. Anticipating these conditions, the Hospital had scheduled no caesarean sections for the day, as it would have on a normal day. Rather, the operating room was taking only statim (urgent, emergency) caesarean sections. The undisputed evidence was that the waiting list that day for caesarean sections designated “urgent” was one to two hours long and that they were given priority. A bradycardia was detected at 6:18pm, Monica was assessed at 6:22pm and found to have signs of a partial tearing or rupture of the uterus, an attempt to attach a scalp electrode to the fetus was unsuccessful and a stat c-section was ordered. Monica arrived at the OR at 18:29, the c-section was started at 18:30 and Eric was deliveried at 18:41 (23 minutes after the initial bradycardia was detected). The evidence, unchallenged and uncontradicted, was that the only anaesthetist and OR team at the appellant Hospital were engaged between 18:00 and 18:30 in performing an emergency caesarean section; that the decision to call in a second anaesthetist was for the anaesthetist at the hospital to make; and that, had the on-duty anaesthetist called for them, it would have taken 20 to 30 minutes for a second anaesthetist and OR team to be assembled to perform an emergency caesarean section on Mrs. Cojocaru. It was found that the bradycardia detected at 6:18pm was caused by a uterine rupture and complete placental abruption. In order to avoid brain damage, a baby must be delivered within 10 to 15 minutes of a placental abruption (by 6:28pm and 6:33pm, which due to resource constraints would not have been possible). Eric Cojocaru suffers from a form of cerebral palsy and has many physical disabilities, as well as impairments to his ability to think, learn and develop social skills. The orginal judgement awarded the Cojocarus $4 million dollars and found that there was negligence in regards to "informed consent" and "malpractice".

The decision was reversed on appeal and will be heard by the Supreme Court of Canada.

I am struck that a woman, attempting a VBAC would be induced on a day when the hospital is short-staffed and at risk of being unable to provide timely access to medical care (a c-section within 10 to 15 minutes) should they be needed. There was only 4 ORs and 1 anesthetist on duty that day. A back up anesthetist would take 20 to 30 minutes to arrive. There was a 1 to 2 hour wait for urgent c-sections. How is it that a woman, who was at risk of a uterine rupture (1 in 200) was allowed to be induced and proceed to a Trial of Labour when, should she need a c-section the wait would likely exceed the 10 to 15 minute wait that would avoid brain damage? Does the hospital not have a responsiblity to ensure that such services are available if a known high-risk patient is labouring? Why wasn't a second anesthetist at the hospital on that day, given the prevailing conditions (a full high-risk ward, a 1-2 hour wait for urgent c-sections)? Was the risk of being unable to access timely medical care communicated with the patient at the time the induction was started? Under the circumstances should Monica have been offered a repeat c-section that day instead of a trial of labour?

I wish the Cojocarus the best under the circumstances, and hope that the Supreme Court of Canada will uphold the $4 million award of damages - it seems to me that the system failed to deliver quality care to the Cojocarus and that Eric's injuries were entirely preventable. I will be watching this case with interest.

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