Obstetrician criticised over birth failures

By Martin Johnston

Ariana Lawn with her parents Cerise and Tim at their rural Opunake home. Photo / Glenn Jeffey
Ariana Lawn with her parents Cerise and Tim at their rural Opunake home. Photo / Glenn Jeffey

Cerise Lawn says pregnant women must speak up when things don't look right, after signs of distress were overlooked and her baby was left struggling with disabilities from a damaged brain.

She believes her daughter's troubles could have been avoided if proper monitoring had been done and if antibiotics were given during labour.

Ariana had to be resuscitated when she was born, six days overdue, on January 24, 2012 because she was pale, floppy and "flat with no respiratory effort", according to a report published this afternoon by Health and Disability Commissioner Anthony Hill.

Staff at Taranaki Base Hospital had noticed meconium - fetal poo - coming out of Mrs Lawn four times between when she was admitted at midday and Ariana's birth at 3.50 the following morning.

Meconium can indicate a fetus is in distress, but after a flush of liquid stained with fresh meconium at 1am, Mrs Lawn and Ariana's father Tim Lawn were given reassurances.
Mrs Lawn, now aged 23, told the Herald she and her husband Tim and a support person present at the birth repeatedly expressed concerns about the meconium.

The staff reassurances were repeated: "You're coping beautifully. Everything is fine."

But it wasn't.

At 2.37am, the midwife called Mrs Lawn's lead maternity carer (LMC), a private obstetrician who was also employed by the hospital.

He arrived 13 minutes later. He had wrongly assumed that Mrs Lawn, although opting to have an obstetrician as LMC in a shared care arrangement with another doctor, did not want obstetric intervention.

He rejected emergency caesarean because the other staff were at home asleep and a vaginal delivery would be quicker than calling them in, Mr Hill said. He ruled out forceps, "on the basis of his impression that [Mrs Lawn] did not want obstetric 'interference' and wanted a 'perfectly normal delivery without [his] input'."

This belief - although he did not discuss it with Mrs Lawn - was reinforced when he did not receive the welcome he had become accustomed to at the birthing unit.

"I got the impression," he told the commissioner's investigators, "that I was pretty much ignored by the woman and her husband. Mind you I guess if you had been in labour as long as she had, she was probably pretty tired anyway."

When asked what welcome he normally expected, he said, "Patients would recognise the fact that I am there, or say 'thank God you have arrived' or whatever or some comment or other when I arrive in the room. On this occasion, nothing was said by the patient."

Asked if this might have influenced his care, he said, "Well I guess I had in my own mind that she preferred to do it all herself, if she could, and I guess at that time I went along with it."

Investigator: "Did you ask [her]?"

Obstetrician: "No I didn't."

Mr Hill found he and the midwife - and the Taranaki District Health Board - had breached the code of patients' rights and that the obstetrician's departures from expected standards were severe. Both have been referred to the commissioner's director of proceedings to consider charges at the Health Practitioners Disciplinary Tribunal.

It is understood the obstetrician has retired. He remains on the medical register, but does not hold a current practising certificate. He refused to answer Herald questions today and hung up the phone. The midwife could not be reached. The DHB did not answer questions on what action it had taken against the two staff.

Mrs Lawn, 23, a social worker and Opunake dairy farmer's wife, said her trust in both practitioners and the hospital had been betrayed by the mismanagement of her first birth.

"I want to have another kid, I want to have heaps of kids - but I don't want to have another birth."

"The day we found out we were pregnant was the day our hearts were filled with joy and excitement. During my pregnancy I did absolutely everything right ... I know for certain that our baby girl was completely healthy in my pregnancy."

But the disastrous labour and birth became "a day we would never forget." It culminated in Ariana being born "pale, floppy and covered in meconium", Mrs Lawn said.

"At 3.55 [the obstetrician] consented to the [midwife's] third request to call the neonatal unit, once his own attempts to resuscitate Ariana had failed."

Under the hospital's guidelines, the obstetrician, as the lead maternity carer (LMC), should have called for the neonatal team immediately. The midwife said she needed his approval as the LMC. When previously she had phoned for help without his approval he had become angry.

"He asked me at that time who I thought I was and did I think I was the obstetrician and did I not think he was capable of resuscitating a baby. He said this in front of the patient and her partner."

Mr Hill said the midwife's fear of reprimand by the obstetrician did not justify her initial inaction in Ariana's case and, anyway, the hospital guidelines permitted her to make the call independent of the LMC if she held concerns.

Citing an obstetrician who advised the Accident Compensation Corporation on the case, Mr Hill said that in the presence of fresh meconium, the hospital obstetrician's attempted resuscitation was inappropriate and might have aggravated Ariana's "meconium aspiration syndrome".

The failure to carry out appropriate monitoring with a CTG (cardiotocograph) machine - which monitors the fetal heart rate in relation to labour contractions - was a major departure from reasonable care, especially in light of the babies excessive heart rate, and the fresh meconium which suggested the fetus had undergone stress from hypoxia (lack of oxygen).

The mother's raised temperature suggested infection and antibiotics should have been given during labour. The obstetrician's decision to give syntocinon medicine to bring on the birth could have increased the hypoxic stress and shouldn't have been done without ensuring the fetus was in good condition.

"Once the infusion was commenced," the ACC adviser said, "it is considered mandatory by most authorities to carry out continuous CTG monitoring of the fetus. This was not done, and further deterioration in the fetal condition may have been missed."

"In this case there were numerous indications to commence this monitoring, and if done so, fetal compromise may have been detected before birth."

Ariana was flown to Waikato Hospital's neonatal intensive care unit suffering respiratory distress from the meconium, brain damage from lack of oxygen, seizures and streptococcal infection. She has continued to suffer significant health problems and developmental delay.

Mrs Lawn said Ariana has moderately severe cerebral palsy and is unsure if she will ever learn to walk unaided. She is mostly tube fed through a skin port into her tummy and she has few words.

"She's probably got about 10 words. Each time she has a seizure, because she stops breathing during seizures, she loses a few words. It's one step forwards and 20 back."

Mr Hill said the hospital held a "debrief" for staff soon after the birth but no minutes were taken.

"Taranaki DHB did not initiate any internal process regarding the standard of care provided ... Following [the parents'] complaint to HDC, Taranaki DHB advised that it had 'undertaken a full and thorough investigation into the concerns raised by [the couple] ... "

But Mrs Lawn said the DHB's letter explaining the investigation led to her blaming herself for Ariana's injury, because it attributed the baby's outcome to the infection.

"I cried for the first week and for the first year I thought it was all my fault because of this infection I had that could have been treated."

She said parents should look out for "red flags" like lack of monitoring during labour or the presence of meconium - and make sure that staff do something about it.

The DHB said it accepted the commissioner's findings and had implemented his recommendations.

It had met the family and listened carefully to their concerns. Changes resulting from the case included updating various DHB maternity care guidelines relating to the baby's care, such as those on electronic fetal monitoring and what to do when meconium is detected.

Red flags in maternity care

* Lack of monitoring
* Going over due date
* Failure to progress
* Presence of meconium after waters break
* Staff insisting on delivery in primary care unit rather than hospital
* Family members' concerns being ignored

Source: Action to Improve Maternity

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