Description of Event or Problem · 0
EVENT DESCRIPTION: THE PATIENT INDICATED FOR IOL (INDUCTION OF LABOUR) DUE TO PRE-ECLAMPSIA USING DILAPAN-S. ON (B)(6) 2024 AT 18:35 VAGINAL EXAMINATION (VE) PERFORMED: CERVIX 1CM DILATED, 1-2CM LONG, POSTERIOR, PRESENTING PART AT -3 TO SPINES, MODIFIED BISHOPS SCORE OF 4, THE HEALTH CARE PROFESSIONAL (HCP) INSERTED FOUR RODS OF DILAPAN-S DIGITALLY WITH SPONGE HOLDING FORCEPS AS PART OF INDUCTION PROCESS. AT 19:00 THE PATIENT REPORTED RUPTURE OF MEMBRANES. AT 23:40 THE HCP REMOVED THREE RODS, 4TH ROD MISSING - SPECULUM EXAMINATION PERFORMED TO TRY AND LOCATE THE 4TH ROD, BUT NO ROD FOUND. ON (B)(6) 2024 AT 11:30 USS TRANSVAGINAL EXAMINATION PERFORMED, UNABLE TO LOCATE 4TH ROD ON SCAN. AT 11:45 VE PERFORMED: PATIENT 2CM DILATED, MID POSITION, 1CM LONG, ARM PERFORMED WITH CLEAR LIQUOR. AT 12:50 THE HCP (AFTER DISCUSSION AND OBTAINING THE PATIENT'S CONSENT) DECIDED TO PERFORM A CAESAREAN SECTION (CS) DUE TO UNCERTAINTY OF LOCATION OF THE 4TH ROD. AT 16:00 THE PATIENT HAD UNCOMPLICATED LOWER SEGMENT CS, 4TH ROD LOCATED DURING PROCEDURE IN THE UTERINE CAVITY. CONCLUSION OF INVESTIGATION: NO QUALITATIVE ISSUE. MIGRATION OF THE DILATORS (DEVICE RETRACTION INTO THE UTERUS) IS A POSSIBLE COMPLICATION THAT MAY OCCUR DURING THE PROCEDURE. THE DECISION ABOUT CS WAS DONE BY THE RESPONSIBLE HCP BASED ON THE PATIENT'S PREFERENCE, MEDICAL CONDITIONS AND PHARMACOLOGICAL INTERVENTION AFTER EVALUATION OF POSSIBLE OPTIONS AND RELATED RISKS FOR THE PATIENT. NO CONCERNS ABOUT DETERIORATION IN STATE OF HEALTH OF THE PATIENT OR BABY. HOWEVER, THE IMPOSSIBILITY TO LOCATE/RETRIEVE THE MIGRATED DILATORS MIGHT CONTRIBUTE TO THE CS.