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HDC: care provided to pregnant women and their babies

The Office of the Health and Disability Commissioner today released two reports which found Waikato DHB in breach of the Code of Health and Disability Services Consumers' Rights (the Code) for failures relating to maternity services provided to two families.

Health and Disability Commissioner Anthony Hill noted that the DHB had made significant changes to improve the quality of its women’s health services since these events occurred but said that the cases raised issues which remained pertinent to providers of maternity services nationwide.

Monitoring of woman with premature rupture of membranes (17HDC01030)

Health and Disability Commissioner Anthony Hill released a report about the care provided to a woman who experienced premature rupture of membranes (her waters broke) when she was 29 weeks’ pregnant. The woman was admitted to hospital so the wellbeing of her baby could be monitored.

Six days after her admission there were signs the woman’s condition was changing and she reported reduced fetal movements. A midwife, who was a new graduate, carried out routine CTG monitoring of the baby’s heart rate that evening, but was unable to obtain a clear tracing. She consulted a second midwife, who has a different account of what information and advice was exchanged. No action was taken for the next hour until another midwife came on duty, assessed the CTG and called the obstetric team. A scan showed the baby was severely compromised and the woman had an emergency caesarean. The baby was resuscitated, but suffered significant brain damage.

That evening, there had been two registered midwives (one the new graduate) and a student midwife working on the antenatal ward which had nine high-risk patients. The more senior midwife said it was a very busy shift, and she felt unsupported. The DHB noted that the midwives appeared unable to effectively escalate the unsafe staffing on the ward.

Mr Hill found that the care provided by the DHB was seriously suboptimal and that it did not have in place adequate systems to ensure that staff were supervised and supported in their decision-making, and its culture did not support staff to report concerns and ask for assistance. He noted that since these events the DHB has made a significant number of changes to its women’s health service, which showed a strong commitment to improve the quality of its service.

Mr Hill recommended that the DHB ensure that midwives in their first year of practice have unimpeded access to senior support; develop a protocol for how staff should access obstetric care when rostered staff are unavailable; facilitate interviews with midwifery staff to determine whether the changes made have improved the level of support. Mr Hill also recommended that apologies be provided to the baby’s parents, and that the Midwifery Council of New Zealand undertake a competency review of the first midwife’s practice, and of the second midwife’s practice should she re-apply for a practising certificate.

The full report for case 17HDC01030 is available on the HDC website.

Ventouse delivery - care provided to mother and baby (16HDC01786 & 18HDC01259)

Deputy Health and Disability Commissioner Rose Wall released a report about the care provided to a woman in labour and to her newborn baby.

The woman’s labour was progressing slowly. A doctor proposed rotating and delivering the baby with a ventouse but did not fully discuss the alternatives and risks with the woman, and she did not seek supervision from a more senior doctor. The delivery was difficult and the baby was born not breathing. The baby was resuscitated, transferred to the Neonatal Intensive Care Unit and found to have a large subgaleal haemorrhage under the scalp. The baby continued to bleed, and required more than three and half times her total blood volume before she was stabilised. Due to a delay in providing adequate blood replacement she suffered some renal impairment.

Ms Wall was critical that the DHB did not provide adequate guidance to staff in relation to seeking senior support when undertaking potentially difficult deliveries, and that a number of staff did not respond sufficiently promptly and effectively to the baby’s haemorrhage. Ms Wall was also concerned that the doctor did not fully discuss with the woman the risks of an instrumental delivery, and the option of a Caesarean delivery. Although there was no reason to recommend a Caesarean section, it was important that the woman understood the reasons for recommending a vaginal delivery with ventouse as the preferred option.

Rose Wall recommended that the DHB apologise to the baby’s parents, review the implementation of its new protocol on when to seek senior support; adopt a guideline on managing neonatal subgaleal haemorrhage, and review the effectiveness of its "Speaking up for Safety" programme and the pathway to follow in serious events with adverse patient outcomes.

The full report for cases 16HDC01786 and 18HDC01259 are available on the HDC website.


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