Health NZ Southern made multiple breaches during Māori mum’s labour: report

By Emma Andrews, Henare te Ua Māori Journalism intern, for RNZ

• Mother experienced distress after South Island hospital staff dismissed her cultural wishes during childbirth.
• The Deputy Health and Disability Commissioner found breaches in informed consent and cultural respect.
• Health NZ implemented changes, including cultural education programmes and amended policies on cord blood testing.

A mother birthed her baby into chaos after health staff at a South Island hospital dismissed cultural wishes.

A report by the Deputy Health and Disability Commissioner (HDC) followed a complaint to Health NZ made by the mother who felt as though the southern hospital’s maternity centre staff were “unnecessarily aggressive” towards her, with no consideration of te ao Māori beliefs.

In the lead-up to the birth in 2017, the mother and the private lead maternity carer had made a birth plan. The only preference the mother disclosed was that she wanted to keep the placenta, and this showed a discussion around cultural preferences occurred.

No other cultural preferences were documented, according to the lead maternity carer.

Though the pregnancy itself was straightforward, it was after 18 hours of labour that the medical staff decided to expedite the baby’s arrival, leading to breaches of the Code of Rights.

It was documented at 9.45pm that the woman was nearing the 18th hour and was given the option for IV antibiotics and continuous cardiotocography monitoring; after an hour the mother requested entonox (short-term pain relief).

At 1.10am, the obstetric registrar was contacted to enter the room to confirm the baby had shown signs of distress. The obstetric registrar recommended for the mother to have an episiotomy (a surgical incision of the perineum).

A transfer of care took place that Health NZ Southern (formerly Southern District Health Board) had no policy for, and there is no documentation of specific consent to an episiotomy or that it was specifically discussed with the mother.

The mother was given lignocaine to numb the perineum and a kiwi cup (vacuum assistant) was applied, but she claimed she was pressured into the procedure and it left her feeling “totally violated and ashamed”.

“An episiotomy was cut and I was unable to refuse,” she said.

The complaint

After the baby was born, the woman raised multiple concerns about the care she received, including standards of communication and the informed consent process for episiotomy and umbilical cord blood testing.

There was a list of six options that were discussed in the birth plan and an episiotomy was not one of them.

Although, the obstetric registrar said, they never proceeded with any obstetric intervention without a woman’s consent.

“I am sorry that in my well-intentioned actions I was making them feel so disempowered and traumatised.

“In obstetrics we look after two people, mum and baby, and often need to balance the urgency and emergency nature of a situation in which the baby’s wellbeing is at risk, with allowing time for discussion with the parents, questions and informed consent.”

The window was short – in the 10 minutes from entering the room to starting the procedure, the obstetric registrar had to introduce themself, assess multiple situations, discuss the need for delivery and the methods, perform an examination and prepare for the procedure.

A midwife stated it would be “harsh” to expect that the obstetric registrar had the opportunity to fully explain the options within the timeframe.

Before the placenta was delivered, the obstetric registrar had left the room to tend to another emergency delivery.

While the mother did not recognise the trauma at the time, she pieced it all together weeks after the baby was born – she was developing signs of PTSD.

Her claim for PTSD and treatment of injury involving the episiotomy and its repair was accepted by ACC.

The woman felt maternity centre staff were “unnecessarily aggressive” towards her. Photo / 123rf

Breaches

Consent to cord blood testing breach – Right 7(10) of the code states that no body part or bodily substance removed or obtained in the course of a healthcare procedure may be stored, preserved or used other than with the informed consent of the consumer.

Without the mother’s knowledge, the umbilical cord blood was tested and presented an abnormal pH level of 7.02.

“We had no knowledge this was done until much later in our journey. The first we heard of the cord blood being tested was [the obstetric] calling across the room the pH level and saying, ‘Good call’!”, the mother recalled.

Health NZ stated in the report it was not a usual process to get consent for cord blood testing because taking blood from the cord is considered the appropriate standard of care for the baby and is used to inform ongoing care.

“The fact that it is not usual practice to get informed consent, in my opinion, is the problem,” the mother stated.

Cultural safety and respect were also breached.

In te ao Māori, the mother, the child and the whenua (placenta) are tapu (sacred). Some mothers, in particular Māori, keep their baby’s placenta and return it to Papatūānuku (Earth Mother).

“[The lead carer] respected our choices. She understood tikanga without us having to explain it and when a hospital midwife made her negative comment about our choice to keep the placenta, the carer corrected her without her or us losing face, which is a skilled and culturally appropriate way to correct a mistake of that nature,” the mother stated.

Sharron Wipiti, a former midwife with no relation to this birth and now a Well Child nurse, said it was “crazy” there were cultural breaches because she only knew tikanga as being a strict practice.

“We trained all the midwives to let people do their own tikanga and that’s for any nationality and religion.”

Wipiti said when she was younger, there was no consideration for tikanga when a māmā was in labour.

“You got on the bed, you had your baby and they just got rid of the placenta. I never knew there was such thing as keeping the placenta.”

But it is something she had learned since “regaining being Māori”, and is what got her and another midwife to create the Hapū Wānanga in Taranaki – a programme to help wāhine hapū to reclaim traditional birthing practices.

Regardless, Wipiti said consent was everything.

Communication and environment a point of concern

The complaint stated the strategies staff and the obstetrician used to “motivate” the woman to deliver her baby were damaging.

Multiple staff members said the tone and manner of the experienced registrar were not unusual, but could be taken as “unsympathetic” in a situation.

“Everything [seems] more dramatic than needs be when you’re in a heightened state of pain,” Wipiti said.

The mother agreed the interventions were necessary, but raised concerns around the need for tikanga of manaakitanga.

She stated she did not want to risk not having the assisted birth, but she felt there was time to be kind, respectful and calm.

As a result of the mother’s complaint, Health NZ has since implemented nine changes, including readily available information, two new roles created for Māori cultural education programmes, a dedicated Kaiāwhina position in Health NZ Southern Maternity Services, a Hua Oranga midwifery performance appraisal tool, and cultural safety training.

Health NZ Southern amended its policy on cord blood testing to include the consumer’s right to informed consent prior to cord blood being taken for testing.