Description of Event or Problem · 0
EVENT DESCRIPTION: DILAPAN-S INSERTED FOR INDUCTION OF LABOUR (IOL). RESPONSIBLE HEALTH CARE PROFESSIONAL (HCP) NOTED BLEEDING IMMEDIATELY UPON INSERTION OF FIRST DILATOR. THE BLEEDING WAS EXCESSIVE ([SIC! ] "MORE THAN TO BE EXPECTED") AND HCP REMOVED DILATOR. CAUSE OF BLEEDING COULD NOT BE DETERMINED UPON REMOVAL, HCP SUSPECTED A PERFORATED VAGINAL WALL. DECISION FOR CAESARIAN SECTION (CS) WAS TAKEN. CAUSE OF CS WAS HEAVY BLEEDING. EXAMINATION UNDER ANESTHESIA (EUA) PERFORMED AT CS. UTERUS SHOWED NO SIGNS OF PERFORATION. PATIENT PLACED TO LITHOTOMY POSITION TO CHECK THE VAGINAL WALL, WHICH WAS FOUND INTACT, HOWEVER CERVICAL GRAZE (ECTOPY OF UTERINE MUCOSA TO CERVIX) FOUND AND IDENTIFIED AS SOURCE OF BLEEDING. ONE SUTURE PLACED TO CLOSE WOUND. TOTAL ESTIMATED BLOOD LOSS (EBL) WAS 300 ML. CONCLUSION OF INVESTIGATION: CERVICAL LACERATION OCCURRED DURING INSERTION OF DILAPAN-S FOR IOL CAUSING BLEEDING. THE CAUSE OF BLEEDING WAS RELATED TO THE PATIENT'S CERVIX CONDITIONS (PATHOLOGICAL CERVICAL TISSUE - UTERINE MUCOSA ECTOPY). BASED ON HCP'S OPINION IT WAS DECIDED NOT TO CONTINUE WITH IOL BUT PROCEED WITH CS BECAUSE OF BLEEDING. DURING CS THE BABY WAS DELIVERED AND AN EXAMINATION WAS PERFORMED - NO VAGINAL WALL PERFORATION WAS CONFIRMED, HOWEVER THE CERVICAL GRAZE REQUIRED MINOR SUTURE. A SUPERFICIAL MUCOSAL BLEEDING (MINOR TRAUMATIC INJURY) WAS IDENTIFIED AS THE SOURCE OF BLEEDING. THE RESPONSIBLE HCP DECLARED IT AS A KNOWN COMPLICATION OF TREATMENT AND LOW HARM. THE CAUSAL RELATIONSHIP BETWEEN USE OF DILAPAN-S, BLEEDING AND SUBSEQUENT CS IS INDIRECT. HOWEVER, THE CONSEQUENCE OF THE INTERVENTION RESULTED INTO MAJOR SURGERY (CS) THAT POTENTIALLY MIGHT HAVE LED TO SERIOUS DETERIORATION IN STATE OF HEALTH.