Midwifery failings led to newborn suffering severe brain damage, health watchdog finds

The health watchdog has found two midwives and a former DHB failed in their duty of care to a birthing mother. Stock photo / 123rf

A baby who didn’t take her first breath until 14 minutes after she was born suffered a severe brain injury caused by a lack of oxygen.

Now the health watchdog has identified multiple failings on the part of the midwives who cared for the child’s teen mother, who says she hopes no other expectant parent goes through the same experience.

The teen, who suffered from anxiety and bipolar disorder, spent 12 hours in the birthing unit, watching her newborn daughter be resuscitated in the room the moment she gave birth.

According to findings from deputy Health and Disability Commissioner Rose Wall released today, two midwives failed to adequately respond to signs of fetal distress during birthing.

The decision says that the woman, who was in her late teens, had recently moved to the Nelson Marlborough region when she was transferred to the care of a local midwife in 2019 and underwent a 33-week growth scan.

That scan showed the baby was measuring large for its gestational age. An obstetrician recommended her pregnancy not go beyond 41 weeks, and that labour be induced if it hadn’t eventuated by then.

At 40 weeks and three days into the pregnancy, the woman asked to be induced that day, which the obstetrician and senior midwifery staff agreed to.

Her waters were broken shortly before 2pm that afternoon, followed by a Syntocinon infusion at 5pm to encourage contractions. At 9.20pm, the tocograph monitoring the woman’s contractions was removed at her request due to discomfort. Shortly before 10pm, she entered the second stage of labour.

Around 11pm there were signs of “suspicious abnormalities” suggesting fetal distress, but this was not recognised by medical staff. Twenty minutes later, another midwife entered the room. By 11.45pm, the teen had been pushing for two hours with little progress.

At around midnight, the fetal heart rate became pathological, but medical staff didn’t notice this for another half an hour.

The baby’s head was born at 12.40am, but shoulder dystocia (shoulders stuck inside the pelvis) was identified. The teen’s midwife attempted manoeuvres to free the newborn but was unsuccessful.

The obstetrician arrived and took over. The baby was born a minute later, not breathing and in “poor condition”. The call bell was pushed and full resuscitation began. The pediatrician arrived nine minutes after this and took over resuscitation.

The baby took her first breath, aged 14 minutes. She was transferred to neonatal intensive care in a larger hospital, later being diagnosed with severe hypoxic-ischemic encephalopathy or HIE.

Midwives, DHB failed in care

After the birth, the then-Nelson Marlborough District Health Board (now Te Whatu Ora) undertook a review that identified multiple failings.

The woman also lodged a claim with ACC, which obtained independent advice from another midwife. That midwife also identified concerns in the level of care.

Wall considered these findings in her investigation, ultimately finding multiple failings of care on the part of the lead midwife, another midwife and the DHB.

“This was a young woman having her first baby, and she relied on her care team to monitor her baby’s wellbeing adequately, to collaborate effectively, and to escalate care promptly when indicated,” Wall said.

“Unfortunately, this did not occur and as a result, the baby suffered serious complications, which potentially will have a profound impact on her future wellbeing.”

Wall found the lead midwife failed to abide by the DHB’s induction and fetal monitoring guidelines. Those failings included failing to fully explain to the woman the risks of removing the tocograph, and her failure to discuss this with the obstetrician.

Her consultation with the obstetrician was further criticised in other aspects of the care, and her documentation efforts during the latter stages of labour were also criticised. Once the woman had been pushing for two hours, Wall said the midwife should have sought an obstetric consultation. “I am critical that this did not occur,” she wrote.

Rose Wall, Deputy Health and Disability Commissioner. Photo / Supplied

Wall further found there were possible signs of fetal distress as early as 11pm, when a cardiotocography (CTG) trace showed fetal heart rate decelerations.

“While I acknowledge that [the midwife] sought additional assistance from the core midwives at this point, I do not consider this to be an adequate substitute for obstetric review in these circumstances.”

By 11.58pm, the CTG showed a heart rate pattern that should have indicated an immediate pause to the delivery of Syntocinon.

She acknowledged this midwife was balancing concerns for the woman’s comfort and mental health with adequate birthing care.

When it came to the second midwife who contributed to the care, Wall found this midwife should have raised concerns about a replacement tocograph. The midwife told Wall she regretted not being more “forceful and opinionated”.

Wall also found this midwife failed to appropriately respond to the signs of fetal distress at midnight.

Finally, Wall criticised the former Nelson Marlborough District Health Board, which left her with the impression of a workplace where staff felt stressed, unsupported, and unable to work together efficiently.

Wall recommended both midwives and Te Whatu Ora provide a written apology to the woman. Te Whatu Ora was also asked to undertake a recommendation of the changes made since the incident, which included new guidance for when a patient declines CTG monitoring, audits of rostering and updated fetal monitoring guidelines.

Ethan Griffiths covers crime and justice stories nationwide for Open Justice. He joined NZME in 2020, previously working as a regional reporter in Whanganui and South Taranaki.