“Sadly these failures appear to have resulted in the baby’s hypoxic condition at birth.”
The mother, referred to in the report as Ms A, had booked the self-employed midwife, RM B, as her lead maternity carer just over halfway through her pregnancy.
After a healthy and “uneventful” pregnancy, Ms A went into labour when she was 38 weeks pregnant.
Throughout labour she was connected to a baby heart monitor, however, RM B made limited documentation of the recordings that are now acknowledged to have been abnormal.
Lack of documentation, especially during the period when Ms A was pushing for hours during labour, was criticised by the deputy commissioner who found the midwife to be in breach of the Code of Health and Disability Services Consumers’ rights.
Failure to recognise the abnormal readings and consult with other medical practitioners about the abnormal heart monitor readings and the lack of progress in labour were also in breach of the code.
Notes were made by the midwife sporadically over the first few hours Ms A was in active labour, however at around 6.30am she stopped only to make notes retrospectively three hours later.
The midwife said Ms A had started to “actively push” at around 7.30 am. An hour later the baby was in the wrong position for delivery and Ms A was encouraged to shower so the baby would turn around.
The midwife told the HDC she had, up until that point, interpreted the readings did not need any further action but in another statement said her interpretations between 7.03am and 9am, when Ms A was pushing, were “faulty”.
At 9.30am RM B notified the Associate Clinical Midwife Manager (RM D) that she was concerned with Ms A’s lack of progress despite actively pushing for two hours.
However, despite RM B being concerned, she did not seek assistance until calling her backup midwife who was a 30-minute journey away from the hospital.
At around 11 am the baby was born in “very poor condition” and an emergency call was made and resuscitation started immediately.
The infant was just 12 and a half minutes old when he was intubated. Tests showed the baby was born with low blood oxygen levels.
This led to a diagnosis of severe hypoxic ischaemic encephalopathy, or “birth asphyxia”, a condition that causes permanent brain damage in the child due to lack of oxygen during birth.
RM B acknowledged that her interpretation of the data at the time “was not of an appropriate standard” and said it wasn’t routine to record observations unless they were abnormal.
“I am now aware I should have recorded my observations regardless, and have changed my practice accordingly,” she said in a statement to the HDC.
She has since given a written apology to Ms A.
Although the monitor was recording continuously from 3.28am until 11.10am when the baby was born, except for two short periods for toilet and shower breaks, RM B failed to document her findings between 6.29am and 10.52am, nearly the whole time Ms A was actively pushing during her labour.
The Midwifery Council of New Zealand reviewed Rm B’s competence as a midwife and found that she was meeting expectations and no further action would be taken.
Ms A was in her 20′s and pregnant with her first child when she employed RM B as an independent midwife. She had put her trust in the midwife whose actions would contribute to her son’s now life-long condition.
Her memories of what happened that day are still vivid and she is still “very very upset” about what happened to her “healthy baby boy”.
She said it made her sad and upset at reliving the painful memories she had “under RM B’s care” when reading the notes made on the day.
Ms A told the HDC she had tried her best to “get the baby out” but she was tired and sore after pushing for so long.
She said that she wished RM B had asked for help from the nurses or doctors at the hospital, instead of calling her backup midwife, who was 30 minutes away.
Deputy Commissioner Wall made multiple recommendations, including further training for Ms A’s midwife and her backup midwife, and that the Midwifery Council consider if a further review on RM B’s competency is necessary.
Wall also recommended that Te Whatu Ora audit 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 from having a similar experience in the future,” Wall said.
