Counties Manukau DHB found in breach of Health Code, resulting in death of premature baby

An obstetrician and Counties Manukau DHB have been found in breach of the Code of Health for their treatment of a woman with a high-risk pregnancy whose baby later died. Photo / File

Counties Manukau DHB had to apologise to a grieving mother who lost her precious baby five hours after birth following several failings to manage the "high risk" pregnancy.

A report released today has found an obstetrician and the DHB in breach of the Code of Health and Disability Services Consumers' Rights for Care.

Deputy Commissioner Rose Wall said they failed to treat and assess the woman in a timely manner due to communication issues and public holidays.

They also failed to provide the woman with "information that a reasonable consumer in the woman's circumstances would expect to receive", the report said.

The woman was in her fourth pregnancy and was being monitored for cervical shortening - which increases the risk of preterm labor and premature birth.

At around 15 weeks she was referred to the obstetric team by her midwife, however "due to communication issues and public holidays" wasn't seen for a further eight days.

By this time, a further ultrasound showed "significant changes" and the prognosis for a successful ongoing pregnancy was poor, the report stated.

At exactly 23 weeks gestation the woman went into premature labour.

The report said that "the reviewing obstetrician considered that the extreme prematurity in association with infection indicated a poor prognosis".

The obstetrician told the woman that babies at this gestation do not survive and are not resuscitated.

Later while the woman was in strong labour a paediatrician tried to discuss the option of active treatment and explained that previous experience indicated there was a less than 10 per cent survival rate without severe handicap.

An hour later the baby was born alive, gasping with a heart rate of 60, the report said.

The attending midwife was asked by the parents if any assistance could be given. She confirmed to them that the baby was born too early to receive treatment.

The baby later passed away.

Wall considered that the nine days that elapsed between the midwife's referral and the cerclage was not consistent with accepted standards of service delivery, and that the DHB failed to assess and treat the woman in a timely manner.

She was critical that the obstetrician failed to advise the woman of the option of active intervention and the associated risks and considered "that was information that a reasonable consumer in the woman's circumstances would expect to receive".

Wall was also concerned that the obstetrician did not involve the neonatal services in his discussion with the woman and her partner.

She recommended that the DHB provide additional training to relevant staff on its guideline on the management of pregnancies at borderline viability

Wall also recommended that the DHB make available to parents and whānau appropriate information and counselling about birth outcomes prior to 25 weeks gestation.

Further, Wall recommended that the DHB provide an apology to the family, and the obstetrician provide a written apology to the woman.