Report finds baby Axton Mead’s death could have been avoided had continuous monitoring taken place.
A midwife who stopped monitoring a baby during birth - against instruction from an obstetrician - has been ordered to apologise to the infant's mother over his death.
In a report to be released today, Health and Disability Commissioner Anthony Hill said Priscilla Punita's care of Denise Simpson-Vogan and baby Axton Mead was unsatisfactory.
Now retired, Ms Punita must make a written apology to Ms Simpson-Vogan over the February 2009 death of her second child, who suffered a lack of oxygen during delivery at Rotorua Hospital and survived only 26 hours.
The director of proceedings will now decide whether Ms Punita should go before the Health Practitioners Disciplinary Tribunal.
Ms Simpson-Vogan said she hoped Ms Punita would be held accountable by the tribunal but that any apology would be five years too late.
"To me it's a forced apology and it doesn't mean much when it's forced."
Mr Hill found:
• Ms Punita did not perform continuous fetal heart rate monitoring;
• She did not discuss with Ms Simpson-Vogan her decision to cease the cardiotocography (monitoring the heart and contractions);
• She did not record her reasons for stopping the monitoring;
• She also made misleading notes and did not communicate adequately with Ms Simpson-Vogan.
During her pregnancy with Axton, Ms Simpson-Vogan was advised by an obstetrician that she needed continuous monitoring throughout labour because her first pregnancy ended in an emergency caesarean when the labour failed to progress and her daughter Shana, now 9, showed signs of fetal distress.
There was also the risk with a natural birth that her caesarean scar could rupture and Axton was considered compromised because Ms Simpson-Vogan smoked.
When Ms Simpson-Vogan's waters broke on February 21 she went with her partner Russ Mead to Rotorua Hospital at 3.15am, despite Ms Punita telling her not to attend until contractions were five minutes apart, and later trying to send her home.
In a coronial inquest into Axton's death in 2010, Ms Punita told the court Ms Simpson-Vogan did not want to be restricted to the bed during labour so she disconnected the CTG monitor.
She assessed the fetal heart rate intermittently between 4am and 10.45am but an expert midwife told the coroner if the fetus had been continuously monitored it would have been the pattern of the heart rate, rather than the actual rate, which would have alerted health professionals to the developing hypoxia.
Without the continuous monitoring the midwife did not know Axton was being deprived of an adequate oxygen supply, after he swallowed baby faeces in the womb.
Axton was born pale and not breathing at 11.50am.
He was rushed to intensive care and flown to Waikato Hospital but died the next day.
A post mortem report showed Axton, born at 6lb 3oz (2.8kg), was malnourished and poorly equipped to deal with the stress of labour, but a consultant obstetrician said the death would have been avoided if CTG recording continued throughout the labour.
Ms Simpson-Vogan, 29, said she regretted trusting Ms Punita and warned others to speak out if they had concerns.
"People put so much faith into midwives but you can stand up if you feel something's not right. Go with your gut feeling, don't just go with it because the medical professional said so."
Ms Punita told the Herald: "That has all happened long back. It's all completed. I have no comment."
Norma Campbell, midwifery adviser at the NZ College of Midwives, said it was a very sad case but would not comment further as she had not read the full decision.