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A midwife has been criticised over her management of a woman in labour whose baby boy was born dead.
Health and Disability Commissioner Ron Paterson found that the midwife at a rural maternity unit failed to check the woman and her baby often enough.
In March the Government strengthened controls on private midwives - and doctors - following a damning report by Mr Paterson on the death of another baby after a series of mistakes at North Shore Hospital.
In his decision on the latest case, published yesterday, Mr Paterson said the woman, aged 19 at the time of the stillbirth in July 2005, had miscarried her first baby a year earlier.
She was admitted to the maternity unit at 2am on July 3, 2005, more than a week past her estimated date of delivery, and the progress of her labour was monitored.
At 9.15am, faecal staining - called meconium and an indication the fetus may be stressed - was found in the fluid that surrounds the baby during pregnancy.
The woman - all parties' names have been omitted from the report - was taken to a public hospital 75 minutes away. It was decided there that she needed an emergency caesarean delivery.
Her baby boy was stillborn at 11.51am. He did not respond to attempts to resuscitate him.
The placenta, instead of being sent for examination by a pathologist, was disposed of by mistake. A post mortem examination did not reveal the cause of his death.
Mr Paterson said the midwife's failure to monitor the woman regularly - and inadequacies in her documentation - were breaches of the code of patients' rights.
"The midwife acknowledged the fetal heart rate was 'not checked as frequently as it could have been'," Mr Paterson said. "She pointed out that Ms A [the patient] was a heavy smoker and frequently went outside the building to smoke cigarettes. When inside the building, Ms A was either in the bath or trying to sleep."
The midwife apologised to the woman and reviewed her practice.
An independent obstetrician, Dr Jenny Westgate, told the commissioner the 53 minutes from admission to birth was reasonable "given the constraints" at the public hospital and because the appearance of the fetal heart rate recording (the cardiotocograph or CTG) "was not one which required a 'crash' or vitally urgent caesarean section".
In retrospect, given the baby's state when born, he was probably dead or virtually so when the mother got to the hospital.
The heart rate recorded by the CTG machine's ultrasound transducer was probably the mother's, something which occurred when there was no detectable fetal heart rate.
