Neonatal safety requires the dual consideration of both the mother and the child, therefore, the principles of neonatal and obstetric safety must be integrated cohesively.
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Learn MoreSanjeev and Ekta Neupane were doing very well in their careers in Dhapasi, Nepal and the timing just felt right to start their family. When Ekta became pregnant, they were able to afford to go to the esteemed international hospital in their city to get the very best care. They met with the medical staff and wanted to know exactly what they needed to do in the next 9 months to have a healthy baby and mother. They followed their doctor’s direction and trusted the private hospital completely.
At 36 weeks, their doctor selected to do an emergency C-section. Their son Rihan was born premature weighing only 2.85 kilograms on June 26, 2018. After 30 minutes, he had uncontrolled breathing and was placed on a ventilator. Rihan was placed in the NICU for twenty-one days and they gave him high doses of variety of expensive medications. He finally went home but ended up back to NICU after developing a fever. After a spinal tap, they found him to have meningitis. Five surgeries later, they told the family his brain was not functioning and there was nothing else they could do. Rihan is at home and in a vegetative state and all his parents can do is monitor his vitals and make sure he is not in pain. The doctors and hospital took no responsibility for what had happened.
Sanjeev and Ekta spent every penny they had to save Rihan and worked day and night to take care of him. Soon both lost their jobs. They never expected so many mistakes from a private hospital. They were deeply disappointed at the lack of consensus and communication between Rihan’s doctors and medical team, which led to many medical complications. For example, Rihan was prescribed 4 ml of Paracetamol but ended up getting 66 ml.
After consulting with multiple other doctors, they were told that the treatments Rihan underwent did not have any potential to provide improvements to their son’s quality of life. Since the hospital and doctors did not take any responsibility for what had happened, Sanjeev decided to take the documentation to the organization that oversees hospital safety in Nepal. At this point, all they wanted was for the hospital to take responsibility for what had happened and a promise to take care of any additional medical complications that may come up in the future. They also wanted safety measures to be put in place so that no parent must go through what they had to. The hospital safety inspectors found the hospital negligent on many counts. To their surprise, the hospital continued to deny any wrongdoing or responsibility, so the family had to take the case to through their court system.
Sanjeev says, “there was no transparency, and the accountability was not there. If they had explained the pros and cons of his condition and clearly mentioned everything about his future, things would have been different. We are all humans…everyone is going to make a mistake. The thing here was that they knew what was happening to him and were not explaining the whole process to us. That is why he (my son) has to suffer.” Today, Sanjeev Neupane recounts that one of the most valuable lessons he has gained from his experience is to seek multiple medical opinions. His advice to new parents is to feel open to asking questions and to “cross check the findings told to you by other doctors and experts.” Their story has spread on social media and has begun the conversation about the urgency of implementing healthcare reform for patient safety in Nepal. Despite the nightmare they lived, the Neupane family remains optimistic, resilient, and hopeful. They have recently welcomed the birth of their second child. Sanjeev is committed to improving patient safety in his city and is constantly contacted by mothers wanting to avoid a similar fate for their baby.
Due to lack of knowledge, communication, and negligence, my daughter was taken from me in an emergency June 3rd, 2018. Miscommunication between transfer hospital and new hospital caused the life if my beautiful 7oz baby girl. I was transferred to this hospital for observation for placenta previa. My bleeding was under control, until the resident doctor gave me pitocin and cytotec causing my cervix to dilate, placenta to explode, and the birth of my baby, who died during the process. There is much hope in my fight for truth. The state is investigating, and I have a great support system from my family. Misjudgment and negligence also led to end another woman’s pregnancy the same night as mine by the same facility. I found this woman by chance—although unfortunate, our combined events help build a stronger case against the hospital. Every day is a fight to the truth and every day I get closer to it. The closer I get to the truth, the more I will be willing to share as well. Due to being in the middle of the case, I am hesitant to share too much. I hope this helps. Thanks, Erin
It was a normal, uneventful, joyful pregnancy, albeit filled with a little anxiety since our first pregnancy ended in a “missed miscarriage” just three shorts months into our marriage. I was thrilled to be pregnant again after losing our first child at 9 weeks’ gestation and my anxiety led me to be very diligent in watching over my health to keep the baby as safe as possible. After doing thorough online research, I did everything I could to ensure my and the baby’s health: I changed my diet to a completely organic one, drank recommended amounts of water daily, exercised daily and got plenty of natural sunlight, and after copious amounts of online research and reading reviews, I decided to get prenatal care from the midwifery services at a well-known teaching hospital near our home in Northern Virginia. I was adamant about having a natural birth and chose the midwifery services for this reason. It was reassuring to know they were “experts in the birthing process” yet were still supervised by doctors and practiced in a hospital environment.
I went into labor a day before my due date. Everything progressed as normal. We followed the midwives’ suggestions to a ‘T” and checked into the hospital once the contractions got stronger. The day we checked into the hospital just so happened to be my due date. I was brought to a labor room and was immediately monitored and checked by a midwife. I was already at 8 cm and was told that the baby should arrive in a few hours. Although in an extreme amount of pain because I was already in active labor, I was so excited to meet our little girl. This was at 9am. I chose not to have an epidural because I wanted a natural birth with no interventions, a philosophy to which the midwives prescribe. At noon, when I was at 10 cm and completely effaced, I was told to push.
This is when it all went horribly wrong. At the time I was told to push, Gianna’s head was not yet engaged. The head needs to engage in the pelvic inlet, which allows the rest of the body to engage in delivery. Her head was in a transverse position and never rotated to a face down or face up position, which is essential for a natural delivery. This scenario of pushing a baby in a transverse position should not have lasted more than 90 minutes. An unengaged fetal head is a sign that vaginal delivery might be difficult and after 90 minutes without signs of progression, vaginal delivery will definitely not happen. And if there is no progression in the baby’s position, a C-section is protocol. This is basic knowledge learned in the second year of medical school. A baby cannot withstand hours of contractions because their oxygen is restricted during that time and they do not have enough reserve to withstand the pushing. But the pushing continued for six more hours. I was told it was normal for a first-time birth to take this long. I was told that everything was okay. I was told to just keep pushing. There are time limits of every stage of delivery and 6 hours of pushing with no progression is unheard of and completely negligent. As I was told by a member on our investigative team, “It was like you were in a jungle having a baby with no person of medical expertise around.” I finally asked for an epidural because I thought I was going to die, literally. The pain from pushing that long with no painkillers was indescribable. Even when I asked for an epidural, I was questioned by the midwives who seemed to think that it wasn’t necessary. Despite their resistance, I insisted. Once I had the epidural, they noticed the baby’s heart rate decreasing and called a doctor in to assess the situation. It was now around 6pm. The doctor found meconium and a C-section was discussed. I was eager to have the C-section so it would all be over and we would have our child in our arms.
Our baby was delivered via C-section at 6:57pm with no spontaneous cry. She was rushed to the NICU and immediately intubated. She continued without spontaneous respiration and was limp and apneic. A physical exam at 7:15pm revealed a comatose baby and EEG results showed no brain activity.
I had no idea what happened. All I knew at that point was that our baby didn’t cry when delivered and was taken out of the operating room. I hadn’t seen her yet. Once I was in the recovery room, I was told by the NICU doctor, in a vague way, that she wasn’t doing very well and wasn’t breathing on her own.
The next four days were a blur. We had friends and family constantly visiting her and us in the hospital. We had strangers reach out via social media telling us they were praying for Gianna. Her situation never improved and was slowly deteriorating. We were overwhelmed and felt lost and devastated. What had happened? We had no idea. No one was giving us any answers. We were strictly updated on Gianna’s current status but were never given reasons as to how she got to that point, comatose, with no brain activity. During those four days in the hospital, we didn’t have enough energy to focus on what happened although it was constantly in the back of our minds. We had to focus our energy on what decisions we should make about Gianna’s present situation, which were overwhelming enough. After days of devastating lab reports and tests, Gianna showed not one sign or hope of recovery. After much prayer and thought, we decided to let her pass naturally in our arms. It was the saddest and most traumatic moment of my life.
I entered the hospital with a living, kicking, thriving baby in my womb. Four days later, we left empty-handed and heartbroken.
After a healthy pregnancy, great prenatal care, and being given a clean bill of health at the hospital, Kristine took her seemingly healthy, pink-toned newborn Cora home in December, 2009.
Three days later, she was feeding Cora when she suddenly stopped breathing and died in her arms. She learned from the coroner that Cora had a critical congenital heart defect.
Kristine has since become an advocate for newborn heart defect screening. She championed thorough CCHD screening legislation in her state and started the organization Pulse Ox Advocacy to help other advocates across the world, with a goal of saving other mothers the pain of learning about their child’s heart defect from the coroner.