Source: Health and Disability Commissioner
The importance of recognising and responding to signs of a baby’s distress during labour was highlighted in a decision published by Deputy Health and Disability Commissioner Rose Wall.
A woman, aged in her twenties, booked a self-employed midwife as her lead maternity carer. After an uneventful pregnancy, the woman went into spontaneous labour at around 38 weeks pregnant. Throughout her labour at a public hospital, the woman was connected to a cardiotocograph (CTG) for continuous monitoring of her baby’s heart rate, but the midwife made limited documentation of the recordings. The woman started pushing, signalling the second stage of labour, but did not give birth until over three hours later. The baby was born in very poor condition and required resuscitation and intubation. The baby was transferred to the Neonatal Intensive Care Unit, where he was diagnosed with a brain injury caused by a lack of oxygen.
In her decision, Ms Wall found the midwife in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to recognise that the CTG showed abnormal recordings indicating possible fetal distress, and for failing to consult the obstetrics team about the abnormal CTG and lack of progress in labour. Ms Wall also found a breach of the Code for the midwife’s documentation, which fell seriously short of acceptable standards.
“The midwife’s failure to identify fetal compromise and her not seeking specialist input at various points meant the opportunity to respond to these issues in a timely manner was missed.
“Sadly these failures appear to have resulted in the baby’s hypoxic condition at birth,” says Ms Wall.
Ms Wall made adverse comment about the lead maternity carer’s back-up midwife, for her inadequate interpretation of the CTG recording, and for not escalating the woman’s care to the obstetrics team despite a prolonged second stage of labour.
“While I am critical of the shortcomings in the care provided by the back-up midwife, I consider these shortcomings were influenced by the lead maternity carer.
“The lead maternity carer was the midwife primarily responsible for the woman’s care, and she did not present an accurate account of the labour and how it was progressing. I therefore do not consider that the back-up midwife breached the Code,” says Ms Wall.
Ms Wall further commented that a recommendation for independent practitioners to carry out a fresh eyes review of CTG traces was not included in Te Whatu Ora’s guideline “Fetal heart rate monitoring in labour and management of an abnormal CTG and tocolysis in the event of uterine hyperstimulation”.
Ms Wall recommended that both midwives complete further training in documentation and fetal surveillance monitoring, and that the Midwifery Council of New Zealand consider whether a further review of the lead maternity carer’s competence is necessary. The lead maternity carer provided HDC with an apology letter to the woman and her whānau.
Ms Wall also recommended that Te Whatu Ora undertake an audit of how often a fresh eyes review is being requested, and report back on the findings.
“I note that Te Whatu Ora has now incorporated a fresh eyes approach into routine care, with education to support this. I endorse this change.
“I am also pleased to see the further training undertaken by the midwife, and the changes made to her practice, which should improve her standard of care and help to prevent other women having a similar experience in the future,” says Ms Wall.
Names have been removed from the report to protect privacy of the individual involved in this case. We anticipate that the Commissioner will name DHBs and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. HDC’s naming policy can be found on our website here https://www.hdc.org.nz/decisions/naming-policy/
