She was reviewed by an obstetric registrar at 3am the following day and noted to only be 4cm dilated. If the labour didn't progress she would be taken for a Caesarean section at 5.30am.
However, that doctor was then called to do an emergency C-section on another patient but told Deputy Commissioner Rose Wall she directed standard measures to stabilise the mother which the woman had responded well to.
"I believed Mrs A and the baby would remain at low risk through the few hours I was operating," the doctor said.
She said stopping the Syntocinon infusion, which brings on labour, was a measure taken to ensure this, as was instructing the midwife to contact her in theatre if required.
However, the registrar known as Dr C said "with the benefit of hindsight, and having thought deeply about this case" she appreciated she should have sought review by a senior doctor of the 3am cardiotocograph [CTG], which monitors the baby's heart rate.
The senior doctor was not consulted at that stage, however Mrs A was mentioned to him during the C-section and he did not suggest any changes to what the registrar had already organised.
The DHB stated there were "significant and unanticipated delays" in the C-section for the other woman.
From 3.53am to 3.56am, there was a period of increased abnormal variability on Mrs A's CTG and by 5.30am she had progressed to 7- to 8cm dilation.
At 6am, there were variable decelerations [dropping heart rate] for the baby and an unstable baseline, and at 6.10am a complicated heart rate.
Dr C left her surgery at 6.20am and found another CTG to be abnormal. A fetal scalp lactate was performed showing high levels of acid in the blood which requires urgent
delivery.
A C-section was recommended at 6.34am.
Difficulties with ventilation were encountered as the operation commenced and Mrs A's oxygen levels "dropped rapidly" for about two minutes.
Her baby was subsequently born in a "poor condition".
"He was floppy, pale, and not breathing, and thick meconium [first stool] was present. He was resuscitated and treated in the Special Care Baby Unit.
"However, at six hours of age, Baby A experienced a seizure accompanied by a drop in oxygen saturation and heart rate."
He was transferred and treated in the Neonatal Intensive Care Unit for 20 days.
He was diagnosed with moderate neonatal encephalopathy, neonatal seizures, and a stroke.
Since the incident, the Hawkes Bay DHB midwives and medical staff had been mandated to complete annual online fetal surveillance CTG training, the shift coordinator or clinical charge midwife is now required to review CTGs every two hours, and a shift leader is available overnight and at the weekends.
In response to the HDC, the DHB apologised that gaps within its maternity unit impacted on the baby's welfare, while the mother was left frustrated by the lack of communication at the time.
"At no stage during our time in the specialist maternity facility did anyone communicate
their concerns ... " she told the HDC.
"Had they done so we absolutely would have been advocating for better monitoring and earlier intervention. As far as we were aware everything was fine with [Baby A], I was simply progressing slowly.
"[If] they had communicated their concerns and made a recommendation for a
caesarean section, we absolutely would have considered this and likely proceeded.
"In our opinion, they did not provide us with effective communication and we were not
fully informed."
The HDC said this case highlighted the importance of all team members having situational awareness of an evolving picture of a baby in distress.
"I do not consider that the poor outcome for Baby A or Mrs A was the result of the failings of any individuals; rather, it was the combination of factors within HBDHB's system that night that meant that the Caesarean section was delayed."
The commissioner also noted expert analysis from Professor Peter Stone around obese patients who "labour less efficiently".
The mother had a Body Mass Index [BMI] of more than 35 but there was no warning about the extra risk this created for a natural birth.
"So, in these circumstances by the time labour progresses, not infrequently the baby is compromised and requires urgent delivery," Stone said.
Prof Stone noted that these circumstances should be well recognised by obstetricians and
midwives alike, and anticipated and planned for.
The HDC found the DHB had a responsibility to provide Mrs A services with reasonable care and skill - which it did not do.
The woman's midwives were cleared of any wrongdoing.
