I don’t have the expertise or experience to comment on what they should have done - 100% of my experience with OB is c-sections; I’ve just seen how shit can go from bad to haunt-you-for-the-rest-of-your-life in less time than it takes to process and act on wtf just happened in that room.
Sounds like you do have that experience/expertise, so I’ll take what you’re saying at face value; my only goal here was to caution folks against going straight for the torches and pitchforks considering the high likelyhood of contributing factors that either weren’t reported or are outside of our normal scope of thinking.