Two midwives have been forced to apologise after causing a pregnant woman's baby to be born with brain damage, according to the Health Disability Commissioner (HDC).
Deputy Health and Disability Commissioner Rose Wall released a report on Monday finding two registered midwives and Nelson Marlborough DHB (now Te Whatu Ora Nelson Marlborough) breached the Code of Health and Disability Services Consumers’ Rights.
The woman, who was in her late teens at the time, had a growth scan when she was 33 weeks and three days gestation.
It showed her baby was measuring large for gestational age and an obstetrician recommended the pregnancy not go beyond 41 weeks.
But at 40 weeks and one day, the woman was admitted to Wairau Hospital and induced that afternoon.
During labour, a recording of the fetal heart rate showed possible fetal distress. The two midwives caring for the woman did not recognise the signs of fetal distress for an hour and a half.
"Specialist support was then sought and one of the midwives attempted to deliver the baby, whose shoulders were stuck," Wall said.
When the obstetrician arrived and took over care, the baby was born in poor condition, requiring resuscitation.
The report showed attempts were made to manoeuvre the baby's head free, but they were unsuccessful, which saw doctors push the emergency call bell.
The on-call paediatrician responded and took over resuscitation efforts.
The report said the baby didn't take its first breath until 14 minutes after it was born.
The infant was diagnosed with severe HIE - which is a brain injury caused by insufficient oxygen delivered to the brain that can cause severe complications.
Wall said she understood the events would've caused the woman, her daughter and her whānau distress.
"This was a young woman having her first baby, and she relied on her care team to monitor her baby’s wellbeing adequately, to collaborate effectively, and to escalate care promptly when indicated," Wall said.
"Unfortunately, this did not occur and, as a result, the baby suffered serious complications, which potentially will have a profound impact on her future wellbeing."
Wall found the woman’s lead maternity carer (LMC) midwife breached Right 4(2) of the Code which states, "Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards".
The LMC failed to provide the woman with services that complied with professional and other relevant standards, including Nelson Marlborough DHB's internal induction of labour guidelines and fetal monitoring guidelines, according to Wall.
The second midwife also breached Right 4(2) of the Code for failing to comply with professional and other relevant standards, including advocating for appropriate monitoring of contractions; appropriately responding to the signs of fetal distress; and appropriately using the emergency call system.
The report was also critical of the working environment at Wairau Hospital, which meant staff members felt stressed, unsupported and unable to work together effectively.
The report found a number of concerning features in the way the woman was cared for by multiple staff at Wairau Hospital.
Wall concluded Nelson Marlborough DHB breached Right 4(2) of the Code for failing to ensure services provided to the woman were managed efficiently and in an effective manner that ensured the provision of timely, appropriate and safe services.
"Since the events, the LMC has made changes to her practice, including obtaining support from a midwifery mentor and undergoing a competency review by the New Zealand Midwifery Council," Wall said.
Changes have also been made at Nelson Marlborough DHB to better support staff and improve staffing levels. The DHB has also updated its fetal monitoring guidelines.
Following the changes, Wall recommended both midwives and the DHB each provide a written apology to the woman for the failings identified in the report.
It also recommended the Nelson Marlborough DHB conduct a review of the effectiveness of the changes made.
