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Care Of Pregnant Woman And Her Identical Twins

Deputy Health and Disability Commissioner Rose Wall today released a report finding a radiologist and a district health board (DHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in the obstetric and paediatric care provided to a woman and her identical twins.

The woman, aged in her twenties at the time, was pregnant with mono chorionic, diamniotic twins (identical twins who share a placenta but not an amniotic sac). At 28 weeks gestation, a sonographer performed a USS at the radiology service. The reporting radiologist reviewed the sonographer’s worksheet and images. There were issues and limitations noted in the sonographer’s worksheet and with the images but the radiologist did not document this in his report. Following the scan, the radiologist did not undertake any follow-up action.

Three days later, the woman experienced abdominal pain and was admitted to hospital. Here, the obstetrician performed a USS, noted obvious TTTS, and immediately recommended an urgent C-section. The first twin to be born was floppy with no heartbeat, and required immediate resuscitation. The second twin was born in good condition.

Theatre staff had not been advised that two babies were to be delivered. A small theatre room was used and a second resuscitaire had to be located quickly. Three attempts to intubate the first twin were made but there was no improvement in the baby’s ventilation. Following the third attempt, staff noticed that the oxygen cylinder had not been turned on.

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Once the cylinder was turned on, the baby’s oxygen saturations gradually improved, but did not rise to the expected saturation. The paediatric consultant called a main centre NICU and was advised that the endotracheal tube being used was too small for the baby. It was agreed to wait for the NICU team to arrive to change the endotracheal tube and once the the NICU team arrived, they changed the tube to a larger tube, and the baby’s oxygen saturation improved to the expected level of 90-100%.

Subsequently, the baby was diagnosed with right hemiplegia, a condition that leads to paralysis on one side of the body. The woman was not advised about the equipment issues until her first paediatric appointment.

Deputy Commissioner Rose Wall considered that the radiologist’s report was inadequate, and was critical that he did not undertake any follow-up action after the scan. Ms Wall was also critical that the DHB did not have in place appropriate policies to ensure the early involvement of a paediatric consultant for an urgent or emergency birth. She found that the operating theatre was not prepared for the delivery of twins; initially the oxygen tank on the portable resuscitaire was not turned on; and that incorrect storage of a 2.0mm endotracheal tube meant that it was mistakenly used for intubation.

"I consider that at the time of the incident, [the DHB] had several systemic issues," said Ms Wall. "This affected the care provided to [the woman] and [twin 1]."

The Deputy Commissioner recommended that the radiology service report back to HDC about the changes it implemented after this event, and that the radiologist apologise to the woman. Ms Wall noted that since these events the DHB had commissioned an external review of its maternity services and taken a number of steps to improve its systems.

In response to the recommendations made in the provisional report, the DHB provided an apology to the woman and provided HDC with an update on the steps taken to carry out the external reviewer’s recommendations. These included increasing staffing in the Women’s health area, reviewing equipment, and implementing Care Capacity Demand Management in Maternity.

The full report for case 18HDC00279 can be found on the HDC website.

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