A midwife whose work caused "serious concerns" when a baby was stillborn has been told she won't get a new annual licence unless she can prove she is competent.

The midwife has retired but professional misconduct or other legal proceedings are being considered against her, after Health and Disability Commissioner Anthony Hill found she had breached the code of patients' rights.

Hill is highly critical of the midwife because of the failings in her care of the woman whose baby's heart stopped beating during labour.

The woman, aged 27 when she was pregnant for the first time in 2014, was severely obese, with a BMI of 44.6. Neither midwife nor patient is named in Hill's report on the case, published today.


The patient, "Ms A", booked with the registered midwife, "RM C", but the midwife, contrary to Health Ministry guidelines, failed to recommend that because of her BMI being over 40 the woman should be transferred to an obstetrician.

Also because of her high BMI, the woman should have been placed on continuous fetal heart-rate monitoring during labour.

When the woman arrived at her local hospital after labour began spontaneously following a normal-length pregnancy, the midwife monitored the baby's heart for about 30 minutes using a cardiotocogram (CTG) which prints out a graph of the heart rate in relation to contractions.

"The CTG was non-reassuring," Hill said. "RM C discontinued the CTG monitoring so that Ms A could go to the toilet, and did not recommence it."

"RM C next tried to listen to the fetal heart rate (FHR) after about 90 minutes. She could not hear a heartbeat, so she attached a fetal scalp clip. The tracing was abnormal. RM C sought assistance from a hospital midwife, and then the obstetrics and gynaecology registrar. It was confirmed by ultrasound scan that there was no fetal heartbeat."

A post-mortem showed the baby died from infection with group B streptococcal bacteria.

Hill said the midwife later retired from midwifery practice.

The DHB where the baby died notified the Midwifery Council of its "serious concerns" about the midwife's handling of the case.

"RM C advised the Midwifery Council that she planned to complete the post-natal care of five women and then would retire from midwifery."

The council imposed conditions restricting her to those five cases

"Should RM C wish to return to midwifery practice at some future date, the Midwifery Council stated that it would decline to issue a practising certificate ... pending a review of her competence ..."

Hill has referred the midwife to his director of proceedings for a decision on disciplinary action or other legal proceedings. He also recommended the midwife make a written apology to the woman.