The girl was her mother's second child. The labour began 35 weeks into a pregnancy at risk of intrauterine growth restriction and pre-eclampsia.
The woman phoned her independent midwife about 4pm, although there is a dispute over the exact time and some other facts. She said she told of regular painful contractions. The midwife, however, recalled being told of "mild tightenings" and concluded labour had not started.
The woman phoned again in the early evening and went to a primary maternity unit about 6.45pm.
The unit midwife, observing that labour had begun, called an ambulance. The woman's waters broke.
At 7.12pm, the ambulance arrived, departing with the woman and the independent midwife at 7.27pm. Soon after, the woman felt something "fall out" of her vagina during a contraction. She said the midwife opted to go back to the unit because she saw the baby's head, but the midwife said she did not look until they arrived, when she saw a foot and leg out.
The midwife said that as the woman needed to push, she told the driver to return to the unit because it was safer to deliver there than in the ambulance. She phoned ahead.
The commissioner, ruling on disputed facts, said the midwife more likely than not made a visual check in the ambulance and made the "unwise" decision to return to the unit.
The unit midwife said the return was an unsafe decision because of the woman's risk factors. "I rang the ambulance call centre to ask them to proceed as planned to the hospital but by this time the ambulance was back at the maternity unit."
The unit midwife boarded the ambulance and ordered it to the hospital.
Mr Hill says she found a "large loop of umbilical cord extending out of the vagina by approximately 20cm". The woman was moved on to her hands and knees to reduce the pressure on the cord. The unit midwife "kept her hand on the cord to try to keep it warm. With her other hand she applied pressure to the baby's presenting part in an attempt to keep any pressure off the cord.".
Mr Hill identified several failings in the independent midwife's care of the woman, including not adequately assessing her on arrival. He has referred her to his independent prosecutor to decide whether to lay disciplinary charges.
Teenage mum-to-be managed by text
An independent midwife has been faulted for using text messages to manage a teenage patient whose baby girl was stillborn soon after.
The young woman's impending delivery was overdue after a largely uneventful pregnancy.
At 40 weeks and seven days' gestation, the teen texted her midwife on a Sunday night to say she was experiencing unbearable pain.
The midwife instructed the woman to take Panadol - two every four to six hours. When told later that it had not helped, she said, "Okay, you can take four at once."
Health and Disability Commissioner Anthony Hill said in a report on the case that the midwife's second advice was "clearly inappropriate" as it exceeded maximum dosage. Drug instructions should not be given by text.
The following day, the midwife handed the case to a stand-in midwife by text message before leaving town for the day, without telling her about the Panadol exchange. In the afternoon, the woman was taken to a public hospital by ambulance, where the stand-in midwife was unable to detect a fetal heartbeat and reports that the patient was "in shock with this finding". The baby girl was stillborn with a "true knot" in her umbilical cord, which occurs when the fetus passes through a loop of the cord.
Mr Hill recommended the midwife write an apology to the woman for her breaches of the code of patients' rights, and said she had completed a competency programme last year and now strongly discouraged the use of texting for communication with patients.
Timeline
About 4pm: Woman phones midwife, exact time disputed.
Either 6pm or 6.20pm: Woman phones again.
6.45pm: Woman arrives at maternity unit.
6.48pm: Ambulance requested.
7.12pm: Ambulance arrives at maternity unit.
7.27pm: Ambulance departs for hospital.
About 7.30pm: Ambulance heads back to maternity unit.
7.47pm: Ambulance arrives at hospital.
7.57pm: Baby delivered by caesarean operation.
