A midwife could face disciplinary action for failing to take proper care for a young woman whose baby was born with no heartbeat after she went into early labour.
The 24-year-old woman was pregnant with her first baby when the midwife took over her care at 38 weeks' gestation because the woman's lead maternity carer was on leave.
A week before her due date, the woman sent the midwife a text message concerned with her baby's lack of movement.
The midwife texted back and advised the woman to drink ice-cold water and sit quietly on the couch to feel the baby move.
Health and Disability Commissioner Anthony Hill said in a report released today that the midwife did not follow up her advice or the woman's concerns that day.
A day or two later, the woman met the midwife and a student midwife for the first time for an assessment.
Both midwives had difficulty detecting the foetal heart rate (FHR), but the midwife said that she eventually heard it "in the background", Mr Hill said.
Early the following morning the woman began having contractions and the midwives assessed her at her home that afternoon.
Again, the midwives had difficulty finding the FHR. Although the woman was in established labour, the midwives left her, advising her to call them when she felt bowel pressure.
That evening the midwives returned to the woman's house, Mr Hill said.
"They could not find the FHR and, when meconium was discovered, decided to transfer the woman to hospital.
"The woman's membranes had ruptured and she was in advanced labour."
The woman's mother drove her to hospital while the midwives drove separately.
"The woman was on all fours in the back seat, having contractions close together.
The woman's mother started panicking and got lost on the way to hospital. At one point, they crashed through a barrier and the woman fell off the back seat, Mr Hill said.
She gave birth to her baby minutes after arriving at the delivery suite.
"Sadly, the baby was born with no heartbeat or respiratory effort, and resuscitation was unsuccessful."
Mr Hill said the midwife breached the Code of Health and Disability Services Consumers' Rights in several respects.
She should not have responded to the woman's concerns via text message without also calling her to clarify and follow up her concerns.
She also failed to check the maternal pulse and arrange a CTG (cardiotocograph) when the woman reported reduced foetal movement.
The midwife left the woman in established labour when the FHR was still difficult to find, instead of staying with her to monitor the maternal and foetal well-being.
And the midwife left the woman unsupported in travelling to the hospital when she was about to give birth, Mr Hill said.
The midwife was referred to the Midwifery Council for a review of her competence.
She was also referred to the Director of Proceedings, for the purpose of deciding whether any proceedings should be brought against her.
No decision has been reached yet by the Director of Proceedings.