Health and Disability Commissioner finds midwife failed to recognise risks of undersized baby who died

The midwife failed in her duty of care to the mother, and the baby girl who died in hospital.

A baby girl born in poor condition after an emergency caesarean later died after her life support was turned off.

Now the midwife involved has been criticised for her care of the mother, who was in her thirties and pregnant for the first time, after she failed to recognise the baby had stopped growing in utero.

Deputy Health and Disability Commissioner Rose Wall found the midwife breached her duty of care to the mother, including failing to arrange obstetric consultation after scans at 36 and 38 weeks revealed the baby appeared to be smaller than expected and failing to recognise the significance of signs of growth in the final weeks of pregnancy.

“Recognising and appropriately responding to concerning symptoms as they arise over the course of a woman’s pregnancy, including seeking input from a specialist when it is called for, is critically important to the safety and wellbeing of both the woman and their unborn child,” Wall said in a decision released today.

“[The woman] was pregnant with her first baby, and she relied on her LMC [lead maternity carer] to identify and explain potential concerns about the baby’s wellbeing and recommend obstetric consultation appropriately in accordance with relevant guidelines.

“Unfortunately, it appears that this did not occur and, as a result, crucial opportunities were missed to identify and manage concerns about the baby’s wellbeing.”

A scan taken about 36 weeks showed the baby had effectively stopped growing. The midwife said she explained to the mother that a small baby might be a compromised baby, explained what that meant and recommended a further scan be done in two weeks’ time.

At that next scan, the baby’s condition appeared to have improved, it appeared to be “growing well” and maternal and fetal observations were noted as normal. However, the fundal height had not increased.

Despite this being an indicator of when a growth scan referral should be made the midwife didn’t arrange an obstetric referral because she didn’t recognise the signs of static fetal growth.

In a response to the Midwifery Council, the midwife said she was “not overly concerned” about the static fundal height measurements, as throughout the woman’s pregnancy it hadn’t been “indicative of actual growth” and the results may have been “skewed” by the woman having a full bladder at a previous appointment.

The antenatal record from that appointment notes the woman declined another scan but Wall said in her decision there was no documentation of the discussion that led to this decision.

The midwife and woman also gave differing accounts of what that discussion entailed but the midwife told the HDC said she did recommend a scan.

The mother recalled the discussion about a further growth scan with the midwife differently.

“The nurse said that my baby was healthy enough and growing well so doing further [scans] [made] no sense and [was] just a waste of money. I followed her [recommendation] and I didn’t decline any scan going against [her] recommendation,” she told the Health and Disability Commission.

At the 41-week appointment, when the woman was past her due date, the midwife failed to document the content of her discussion with her recommending a growth scan and failed, in her referral for induction, to document the growth concerns noted in the weeks prior.

The mother went into labour the day before she was due to be induced. The birth, at a maternity hospital, was difficult. The baby was in fetal distress and she needed to be airlifted to a public hospital for a caesarean section.

The baby was born in poor condition and was transferred to the neonatal intensive care unit. Her condition did not improve and she died in hospital when life support was withdrawn.

Deputy Health and Disability Commissioner Rose Wall.

Wall said that at a 41-week appointment, the nurse failed to document the discussion she’d had with her patient in her notes and had failed in the weeks before to raise the issue of the baby’s static growth.

“I am critical that the registered midwife did not explain the implications of static fetal growth to the woman at the 41-week appointment.

“I consider that in failing to do so, she did not provide the woman with the information that a reasonable consumer in her circumstances needed to make an informed choice about whether to undergo a further growth scan.”

During the birth, the baby’s heart rate dropped and the nurse failed to accurately document and report signs that the heartbeat was abnormal.

Since the incident, the midwife has made changes to her practice and undergone further training.

However, Wall recommended even further training for the midwife and for an audit to be done of her patient records to make sure she was conveying the options and risks to mothers in her care.

Jeremy Wilkinson is an Open Justice reporter based in Manawatū covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.