18 February 2002 – Kam Agong experienced labour pains and was taken to the Lawas District Hospital at 9.45 pm.
At 10.30 pm the hospital artificially ruptured her amniotic sac. The hospital found meconium staining, which is a sign of fetal distress.
After 10.30 pm, the hospital should have monitored the fetal heart rate (FHR) but fetal distress was not recorded. Instead, the medical records show a FHR of 140 beats per minute at 10.30 pm.
At midnight, Kam Agong’s cervix was dilated from 7 to 8 cm. Her cervix dilation was progressing normally. However, at this point, the hospital said she had gone into obstructed labour.
After 2 am, the hospital realized that there was fetal distress and the FHR had dropped to 80-90 beats per minute, and Kam Agong’s cervix had dilated 9 cm.
2.30 am, the hospital decided to perform a Lower Segment Caesaran Section.
The caesaran was performed at 4.15 am. Between 12.30 am and 4.15 am there was no monitoring of the fetal heart beat or contractions.
Kam Agong’s chart did not record when oxytocin was administered. A record of an oxytocin drip in the labour chart is vital because oxytocin can enhance the labour process, but too much oxytocin can result in cord compression, which causes fetal distress.
Before a caesarean is performed, a ph reading of the fetal blood should be done to determine if it is less than 7.25. This lets doctors know if the baby is suffering from a lack of oxygen. Kam Agong’s records do not indicate if this test was done.
The labour chart was incomplete after 10.30 pm. Between 10.30 pm and 2 am there were no records of the baby’s condition or the mother’s vital signs. The record only shows cervix dilation.
The labour chart presented by the hospital in the court case was not the original chart. It was a fabricated copy.
Kam Agong lost up to 2 litres of blood during the operation. This is an excessive amount.
Post operation, on 1 March 2002, Kam Agong went to the health clinic in Long Semadoh. She was attended by nurses JM Lily and Tia Tindin, they noted that her wound was dirty and infected, and her uterus was still bulky. She was not referred to Lawas Hospital or a gynaecologist, instead an appointment was set for 8 March 2002 in the records.
On 8 March 2002, Dr Hasimah went to Long Semadoh to give a talk to women in the village at the health clinic. Kam Agong went to the health clinic and was examined by Dr Hasimah and treated for her infection. JM Lily who earlier attended to Kam Agong, witnessed Dr Hasimah’s treatment of Kam Agong and noted, “Fundal height was still height.” The fundal height is usually an indication of a fetus’s growth.
According to JM Lily, Dr Hasimah told Kam Agong that her fundal height was high due to her age. JM Lily also claimed that Dr Hasimah prescribed antibiotics. Again, a referral to a gynecologist was not made, and another appointment was not given.
On 14 March 2002, Kam Agong was admitted to the Lawas Hospital again. On the way to the hospital, JM Lily called the hospital to inform them that Kam Agong was in a state of shock and had lost 500 ml of blood. Syncometrin, which contracts the uterus, was administered to stop the bleeding. The attending doctor was Dr Fazilah.
Kam Agong was given a pad to monitor bleeding. According to JM Lily there was very little bleeding, but there are no records to confirm this. At admission Kam Agong’s vitals were recorded as blood pressure: 90/50 and hemoglobin: 10.2 with a pallor and pulse of 78. No further vital signs were recorded in the 48 hours she was admitted at Lawas Hospital. She was not given a blood transfusion.
On 16 March 2002, the family requested that Kam Agong be transferred to the hospital in Miri. Instead, the Lawas Hospital staff discharged Kam Agong and considered the case resolved with no need for further consultation. A blood test was given, and though Kam Agong appeared weak, hospital staff insisted she could return home.
Kam Agong stayed in Lawas, at the home of a friend/family member (not sure). She was weaker than the day she went into labour. The only follow up care was an appointment at the health clinic in Long Semadoh on 16 April 2002.
On 18 March 2002, Kam Agong returned to Long Semadoh. Kathy Busak Padan, her daughter, noted that evening that Kam Agong’s uterus was bulky, there was pus on her wound and her pads were soaked with blood.
The next day, our mother, Kam Agong died from secondary post partum haemorrage, or massive bleeding. A post-mortem was not carried out.
We are left with many questions:
Why was a gynaecologist not consulted?
What was the cause of the fetal distress that caused the doctors to decide on a caeserean section?
What kind of caeserean section was performed? One set of records indicate a lower section caeserean, but another indicates classical caeserean.
What caused Kam Agong’s post partum heamorrage?
During the court case it emerged that Kam Agong’s signature had been forged on the consent form. Who signed the consent form for the c-section?