Photo: 123RF
A baby died during birth after the midwife failed to act quickly enough when his shoulders got stuck, the health watchdog has found.
In a just-released decision, the Health and Disability Commission found the locum midwife failed to do adequate monitoring during Ms A's lengthy labour, or call in medical assistance at an earlier point.
On the day Ms A went into labour, her midwife was on leave, and had handed over her caseload to the only other independent midwife working in the rural community.
Following the birth, the locum midwife also failed to identify the woman was suffering from sepsis.
Notes from the time indicate the baby's head was born around 12.30am, nearly 24 hours after the woman's labour began.
Ms A's mother noted in her statement to the Coroner that after the head was born, she felt that more should have been done, and that his head had been out for "way too long" with "no progress".
The locum midwife called for help at 12.38am and a nurse responded and was asked to phone Ms A's usual midwife (midwife C) - who was at the hospital, and earlier came in to give the locum a break.
The nurse noted at that point, she was unaware that there was any difficulty with the birth, as no information was given to her by the locum midwife.
Ms A's mother told the HDC the family in the room had "no idea what was going on".
"There was no communication that something was not right. I could see by the nurse's face that she was unaware of what was happening either."
According to the Coroner's report, Midwife C arrived at 12.43am and asked the locum what help she needed.
The midwife simply said she needed help to deliver the baby and Midwife C took over.
She examined Ms A and discovered the baby was suffering "severe shoulder dystocia" and was trapped.
She asked the locum to put the woman's legs into the "McRoberts manoeuvre" but this failed to release the baby.
She then asked the woman's partner to push the emergency call bell for help.
Meanwhile, she successfully freed the baby's shoulder using internal rotation manoeuvres, and the baby was born at 12.53am showing no signs of life.
Resuscitation was carried out by the midwives and two doctors, and the baby was given eight doses of adrenaline, but was pronounced dead at 1.47am.
A post-mortem examination confirmed the cause of death was asphyxiation following a prolonged labour, complicated by shoulder dystocia.
Family's heartbreak
The baby's mother told the HDC she had wanted to give birth at a birth centre that was closer to a larger hospital, but had been assured by her usual midwife that the smaller rural hospital was "a safe place to birth".
"This is a decision I regret every day."
Her mother said her daughter and grandchild "did not get the care they deserved".
"Because of this we lost our moko and almost lost our daughter too. In this day and age a healthy mum with a healthy baby should have the best care and our moko should not have died."
Her parents-in-law said the loss of their grandson had "shattered the family in ways words cannot fully express".
"Our grandson's life was precious, his loss screaming out the critical importance of diligent, compassionate, and timely medical care.
"We believe systemic changes need to happen to ensure all families receive the highest standard of care. Improved training, better communication, and timely escalation of care are essential to prevent families from experiencing the same preventable loss."
Midwife was working '24 hours' - expert adviser
Midwifery expert Isabelle Eadie, who was asked to provide the HDC with expert opinion on the case, found the locum midwife's care during labour, birth, and the early postnatal period reflected "several significant departures from expected practice".
She noted there were several occasions during the day when nursing staff directly involved in Ms A's care recognised there was a problem, "but arguably felt unable to 'speak up' and override [the midwife's] instructions".
One nurse on night shift told the HDC she asked the midwife why Ms A was still at the hospital, but the midwife "was confident and reassured [her] that all was well".
The nurse told investigators that she and her coordinator talked about "mentally preparing for a difficult delivery/flat baby scenario and checked through resus equipment which was in the room".
Eadie said existing relationships and ways of working between lead maternity carers and hospital staff contributed to "conflicts regarding escalation".
She also found the midwife's monitoring of the baby's heart rate was not regular enough - a common problem identified by an ACC working group with which she had been involved for the last six years.
That group was looking at developing a national education programme for midwives about foetal monitoring to prevent brain damage during birth.
"Unfortunately, this working group (and the taskforce) have been discontinued, and the work unfinished."
The fact the mother was a Jehovah's witness and had signed forms saying she did not wish to receive any blood products suggested the need for guidelines to deal with that risk, "as some literature suggests women who are Jehovah's witness should be advised to birth in secondary/tertiary units".
The expert adviser also noted the locum midwife had been working 24 hours caring for Ms A, except for one hour when she was relieved by Midwife C.
"I think that anyone's capacity to apply critical thinking and decision making and the attention to detail that is required when providing care to people in labour and acute situations, is surely compromised after working for so long."
It was not the first such case involving midwives working long hours with minimal support, she said.
"To be honest, I am not really sure what HDC can do, and especially given the critical midwifery shortages in New Zealand and the additional challenges in rural communities to find midwifery support to take over care to allow lead maternity care midwives sufficient rest."
Midwife acknowledges she 'should have done better'
The locum midwife told the HDC that she had been "utterly devastated by this terrible outcome for [Ms A] and her whānau" and had "never experienced anything like this outcome in her long professional career".
She acknowledged her shortcomings in the care provided and said that "she should have done better in certain areas", and accepted she had breached the code.
Breach
Deputy Health and Disability Commissioner Rose Wall extended her heartfelt condolences to the woman and her whānau "for the distressing set of circumstances that led to the loss of their baby".
She acknowledged the challenging environment in which the registered midwife was working, but said she did not consider this accounted for the deficiencies in the care.
She has referred the midwife to the Director of Proceedings, and advised the Midwifery Council consider further review of her competence.
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