She went to the hospital later that afternoon in 2015.
At 4am she went into active labour, however, her risk factors were not presented to doctors during the morning hand-over.
The on-call registrar was told she was a second pregnancy at term case with an above average body mass index (BMI), a pre-labour rupture of membranes and she was receiving antibiotics.
He was not told of her high BMI, ambiguous Hepatitis C status and recurrent UTI.
Syntocinon was given at 10.20am.
The baby's heartbeat climbed from 138bpm at 8.30am to 180bpm at 11.10am.
The midwife paged for the doctor but his pager had gone flat. She was not aware of the on-call registrar mobile phone that could be used instead.
By 12pm, the doctor was back with the patient and surgery was arranged.
The registrar's supervising consultant was not always readily free due to being rostered on for a clinic list at the same time.
The supervising consultant was elsewhere in the hospital when they had planned for the Caesarean together.
The registrar later told the Commissioner the service at Hutt Valley DHB was "chronically under-resourced".
"Things might have played out differently if the Hutt Valley unit was one which had a consultant obstetrician at the unit working alongside the junior staff," he said.
The anaesthetist noted that the mother seemed "extremely distressed from pain" but two attempts to give spinal anaesthetics failed and a general anaesthetic was used.
The baby arrived in 40 seconds by Caesarean section with the doctor recording that this was "through clearly infected waters with thick meconium".
The mother lost about 1200ml of blood.
Resuscitation of the still-born baby was undertaken for 30 minutes without success.
"Hutt Valley DHB had a responsibility to provide services to Ms A with reasonable care and skill,' the Health and Disability Commissioner said.
"It failed to do so, because it did not create an environment that ensured that resident
medical officers were supervised appropriately, its handover practice was suboptimal, there were deficiencies in internal communication, and its policy relating to syntocinon
was inappropriate."
For these reasons, the care provided was "seriously compromised".
The Commissioner recommended that both the DHB and the midwife give written apologies to the mother.
Hutt Valley DHB chief executive Dale Oliff said the board accepted the findings.
"This follows the HDC's investigation into the antenatal and obstetric care provided in 2015 to a Hutt Valley mother," he said.
"We have sincerely apologised to the family for the tragic outcome they suffered and acknowledge our systems and processes failed to protect them.
"We are confident the improvements we have made to our systems and processes will support our clinicians to provide safe care.
"We acknowledge this must be very painful for the family at the centre of this event and in respecting their privacy, we will not be commenting further on this matter."
Changes implemented by the DHB
Hutt Valley DHB has put in place the following measures to minimise the possibility of a similar situation occurring:
1. Two additional senior medical officers (SMO) have been recruited, allowing the on-call SMO to be free of clinic duties.
2. All women with a BMI over 40, and anaesthesia high-risk patients, are highlighted on
the birthing suite whiteboard to ensure that they are reviewed during the ward round.
3. Junior medical staff and resident medical officers are freely advised to contact SMOs if
in doubt.
4. An associate clinical midwifery manager (senior midwife) role has been introduced
during week days. This covers the delivery suite and postnatal areas.
5. CTG interpretation cards are now attached to all CTG machines.
6. An SMO escalation policy has been made available in case an SMO is busy or not
contactable.
7. The "Oxytocin infusion for induction and augmentation of labour policy" (revised June
2016) now clearly states that syntocinon is prescribed by the obstetric team, following
review of the woman.
8. The maternity unit holds weekly CTG education meetings, which include discussion on
the outcomes of recent Caesarean sections and instrumental delivery cases. The
meeting is attended by midwifery and medical staff.
In addition, the following recommendations were made in the internal review:
1. Doctors are to check their pager battery level at the commencement of a shift.
2. Ward phones are to be enabled to make calls to mobile phones.
3. If an SMO is called to attend a patient, the SMO will attend in person rather than send a registrar.
4. When a CTG is in progress, maternal pulse is to be monitored concurrently.
5. All practitioners in maternity care will undertake refresher fetal surveillance
education.
The midwife
The Midwifery Council of New Zealand undertook a formal review regarding the competence of the midwife. She underwent training and practised under supervision from November 2015 onwards. She completed a programme of education and monthly supervision reports showed good progress against goals. Supervision ceased in November 2016.
