Joseph's Law

This is a copy of a post I put on Glow a couple of weeks ago...


6 months today since he died. 6 months and 5 days since he was born.

This is going to be a long post, so bare with me.

I was handling the grieving as best i could, for the most part moving thought the day, functioning, laughing and looking after his 3 big brothers.

What I wasn't dealing with was the guilt. The feeling that if I hadn't been so stupid wanting a VBA2C, if I'd agreed to a routine cesarean at 38 weeks, the maybe he'd be here, on the boob, fat and happy.

Dealing with the guilt that it was my fault my uterus ruptured so badly that it had to be taken from my body to save my life. Thinking to myself that I deserve to be in this pain, because it was me and my body that killed him. So, of course I don't deserve to have any more children.

Then, a month or so ago, I received the medical examiner's report from the Coroner, as well as mine and his medical records from the hospital, and this has blown my world apart all over again.

First, the examiner's report. I didn't read that BTW, no way I'm going there. But my sister did (she's a midwife), as well as my independent midwife. It says the cause of death was global cerebral hypoxic injury. We all knew that. My uterus ruptured, he was deprived of oxygen, was born and then died. But key words were 'without the placenta as evidence, it's difficult to determine if this happened before, or after birth' (or something like that).
After birth? WHAT?!?!

Then, my records, and his.

It seems, once we arrived at hospital, his heart rate was fine. We moved from home, to hospital in about 10 minutes, because his heart rate had dropped at home. My midwives figured he'd need assistance to be born, so it was best to moved from here to there.
Then, his heart rate was fine once we got there, everyone relaxed in the room.

The OB then pulled him out of me with the vantouse (suction). I remember it felt so violent at the time. My husband likened it to getting off a train and the doors slamming on your briefcase, and you're pulling at it with huge force to get it back.
As a result of this, he was born flat and needed some assistance.

They had him on the first neonate resuss cot for 6 minutes before they realised that the oxygen pressures weren't working. They then pulled over the standard receiving cot and those tanks were also broken, they then sent someone, out...of...the...room, to get another neonate resuss cot, before they had 'success' intubating him. This was a total of between 12 & 18 minutes that he was deprived of oxygen - after he was born.

He also suffered a subgilael hemmorhage (bleeding between the skull and the scalp), which can happen as a result of head trauma from the vantouse, which wasn't positioned properly. Babies born from this kind of traumatic birth are often born flat, but need assistance to get them going. The assistance he relied on failed. IT FUCKING FAILED!

Then, the OB says he thinks I'm bleeding from my placenta, so he needs to do a manual removal, with no pain relief. Two nurses are pushing on my abdo and I remember how excruciatingly painful that was. Nothing like the pain of pushing out an 11lb baby, and unaware of that fucking OB's arm inside of me. I truly believe, with all my heart, that this is when my uterus ruptured.
It ruptured, but the way, through the broad ligament (right hand side of my uterus), my previous scar remained intact.

If it had ruptured like that at home, I wouldn't have made it to the car and then onto hospital, I would have bled out and died before I got to my front door. I felt none of that excruciating pain at home.

From the day after I came out of the ICU, I had nurses coming in doing obs, asking about homebirth, saying they'd heard I'd been pushing at home for hours, asking why I wasn't in hospital (uh hello! I WAS in hospital). It got so bad I had to report it to the head of the unit to ask her staff to back off, as they were being unprofessional and breaching confidentiality guidelines. And let's not forget, I'm recovering from near death and my baby is dying.
I only include this bit because I believe there was alot of rumour mongering going on to point the finger at homebirth (again, he was born in hospital, I just laboured at home with an independent midwife). I also believe that this is when the wheels were in motion to cover themselves, to perpetuate a belief that my uterus ruptured at home. Call me paranoid, but who wouldn't be after an horrific experience like this?

I had 2 post natal visit with the OB consultant who did the emergency hysterectomy. I'd sit there in tears saying it's my fault, I'll never life with the guilt and all she'd say is 'oh, it's understandable you'd be feeling like that, time will heal'.

All they said to me and any of my family was that they didn't know when my uterus ruptured, and they there was some difficulty intubating him. That was it. No more explanation.

The fact that they did this, all of this is bad enough. The system I feared the most through previous birth trauma, I had to put all my trust and faith in, failed me and my poor baby at the worst possible level. But for them to carry on, for the 5 1/2 months after, allowing me to believe that I did this. Knowing what that kind of guilt does to a person. That I could well have topped myself. That my marriage would surely break down. That these 3 other boys could suffer a broken family unit, on top of losing their baby brother.

They did all this to protect their arses and said nothing. No sorry. Nothing.

His records even have a report, done by a neuro consult, the day before he was taken off life support, stating that this was a hypoxic injury from a sentinel event due to resuscitation failure. (google sentinel event - it's mighty.)

My family, especially those who were present at his birth (2 of my sisters, as well as my husband), have said from the night that he was born that things just didn't add up. That something was missing, that there was more to this than we know. I've been oblivious to any of these intuitive feelings because I've been living in the hell fog of grief for the last 6 months. But they knew. They knew something wasn't right and for the sake of my guilt, the truth had to come out. Then there it is, in black and white, written all over our records.

Sentinel events are meant to, by law, be reported to the Department of Health within 3 days of them happening. We don't even know if they've done that. There are also guidelines for working with families when these things happen. First and foremost, apologise to the family. Secondly, show empathy. Then, immediately start working on mediation, conciliation and compensation. We received none of this.

I feel like I was almost able to cope with my own guilt of all of this. But to know that this was all entirely preventable and that they did it feels like it makes the pain of him gone even worse. I feel like I've landed back in the earliest, most raw days of grief.

It's a living nightmare.

I have to fight. I have to fight for him, his honour, our integrity and our respect. But it's so fucked that we've been put in this position in the first place. To have to fight. They need to be accountable. They have to apologise. They fucking took his life, his future and my womb, my future, our future with him.

They have to know that he was alive, he was here and he mattered.

My motivation for litigation is to hold them accountable. Put it where it belongs. To change policy. To make the Department of Health's guidelines on sentinel events as mandatory as reporting the event itself is. So no family will have to go through what we are going through. To have to try to live on with so many unaswered questions. And guilt.

It will be Joseph's Law.

Stay angry with me. I feel like I'll be writing alot on this in the years to come, because it's certainly going to take years for this process. Let alone the missing him. That will never end.