Four days later a scheduled scan found she had reduced amniotic fluid, the discharge was changing colour and her abdominal pain remained.
She was booked for induced labour two weeks later, discharged by the consultant obstetrician and gynaecologist and advised to return to hospital if she had concerns.
The following day, the woman returned to the maternity unit experiencing contractions.
A fetal heartbeat could not be found and the baby was found to have died in utero.
The findings stated the baby likely died as a complication of unrecognised chorioamnionitis.
It described the condition as an acute inflammation of the membranes and chorion of the placenta, typically due to infection following rupture of the membranes.
In her report, deputy commissioner Rose Wall said the presence of green discharge and abdominal pain should have raised concerns with the consultant as placing the fetus at risk. The woman should have been admitted to the maternity unit for further investigations.
She found the decision to discharge the woman was a severe departure from accepted practice and as such the doctor had failed to provide the woman with reasonable care and skill.
Independent advice prepared for the commission by Dr Judy Ormandy, a senior lecturer in obstetrics and gynaecology and women’s health based at the University of Otago, Wellington, said the presence of green discharge was a known indicator for chorioamnionitis and not a difficult clinical diagnosis to reach.
“This is a significant red flag symptom,” she said.
“The crux of this case is that [the woman] was incorrectly discharged from her maternity assessment. Had she at that point been admitted to hospital and delivery via induction of labour or caesarean section occurred, it is likely the baby would have survived.”
The consultant accepted the woman should have been admitted to the maternity unit. He told the commission he could not understand why he discharged the woman when he did.
“I still cannot think of any human factors that might be relevant as, although they would not have excused my mistake, they might have explained why it occurred.
“Their absence is a concern to me, as I would like to understand why I made such a basic mistake. I cannot reverse it (unfortunately) but would like to have better confidence that I wouldn’t make such a mistake again.”
The consultant met with the woman, apologised, and further researched the subject. The Medical Council has also been provided with a partly anonymised copy of the decision and advised of the doctor’s name.
Health New Zealand has developed a pamphlet providing advice for women who are self-monitoring at home with preterm rupture of membranes.
Catherine Hutton is an Open Justice reporter, based in Wellington. She has worked as a journalist for 20 years, including at the Waikato Times and RNZ. Most recently she was working as a media adviser at the Ministry of Justice.
