Care and information provided to woman

Care and information provided to woman with a high risk pregnancy 16HDC00719

Deputy Health and Disability Commissioner Rose Wall today released a report finding an obstetrician and a District Health Board in breach of the Code of Health and Disability Services Consumers’ Rights for Care and information provided to a woman with a high risk pregnancy.

The woman was in her fourth pregnancy and was being monitored for cervical shortening owing to a previous miscarriage at 19 weeks. At around 15 weeks gestation shortening and mild funnelling[1] of the cervix was noted on an ultrasound scan (USS). A referral was made to the obstetric team by the woman’s midwife. However, due to communication issues and public holidays the woman was not seen for a further eight days, at which time a further USS showed significant changes. A cervical cerclage[2] was arranged for the following day. At the time the stitch was inserted, the membranes were visible from the external cervical opening, and the prognosis for a successful ongoing pregnancy was poor.

At exactly 23 weeks gestation the woman went into premature labour. The reviewing obstetrician considered that the extreme prematurity in association with infection indicated a poor prognosis. Steroids were not given and 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% survival rate without severe handicap. An hour later the baby was born alive, gasping with a heart rate of 60. 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.

Findings

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

Ms Wall noted the recent developments in the care of premature babies, including the detailed analysis undertaken by the Perinatal and Maternal Mortality Review Committee (PMMRC) in its 12th Annual Report. Ms Wall strongly supported the ongoing development by the Paediatric Society of New Zealand and the New Zealand Newborn Clinical Network of a consensus statement on the care of mothers and babies at periviable gestations to ensure a consistent and informed approach across all DHBs.

Recommendations

Ms Wall recommended that the DHB provide additional training to relevant staff on its guideline on the management of pregnancies at borderline viability, and advise how it will act on the PMMRC’s recommendation that lead maternity carers and DHBs employ strategies to reduce preterm birth by targeting identified high-risk groups. Ms 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, Ms Wall recommended that the DHB provide an apology to the family.

Ms Wall recommended that the obstetrician provide a written apology to the woman, and support the DHB in reporting back to HDC on developments in the availability of appropriate information and counselling about birth outcomes prior to 25 weeks gestation.

The report is available on the HDC website: https://www.hdc.org.nz/decisions/search-decisions/2019/16hdc00719/

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Explanation of clinical terms

[1] Signs of cervical weakness which could lead to a preterm birth

[2] Inserting a stitch around the cervix to prevent it from opening too early and causing preterm birth

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