Monitoring of woman in labour; resuscitation of infant
Deputy Health and Disability Commissioner Rose Wall today released a report finding a self-employed midwife, a hospital employed midwife and a DHB in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for the care provided to a woman in labour and her newborn baby.
The woman booked the self-employed midwife as her Lead Maternity Carer. Ms Wall was critical of the care provided to the labouring woman by the midwife LMC, in particular the inadequate monitoring of the baby’s heart rate. When the LMC had difficulty with managing the woman’s labour, assistance was provided to the inexperienced LMC by hospital employed midwives. However, there was a delay in picking up that the baby had become distressed and in calling for obstetric and paediatric support. The baby was born not breathing and later passed away in intensive care.
Ms Wall considered that the LMC midwife did not provide care to the woman and her baby with reasonable skill and care during the labour. Ms Wall was also critical of a hospital midwife for not advocating for adequate monitoring of the baby’s heart rate, and found there were failures in the care, communication systems, and emergency equipment at the DHB which resulted in delays in providing care to the woman and the baby.
Rose Wall recommended that the Midwifery Council of New Zealand consider whether any further review of the LMC midwife’s competence was required and that the DHB report to HDC on its communication systems for maternity emergencies, and the frequency of the fetal surveillance education being provided to its staff and to self-employed lead maternity carers.
Ms Wall advised that the Ministry of Health would be provided with a copy of her report so that it can take into account the findings from the investigation in its ongoing review of maternity services.
The full report for case 16HDC00977 is available on the HDC website.