Two midwives and their employer have been disciplined for their failure to take note of a baby's lack of growth in the womb, placing it at risk after birth.
Health and Disability Commissioner Anthony Hill today released a report finding the community-based midwives and their employer in breach of the Code of Health and Disability Services Consumers' Rights.
At 35 weeks' gestation, the 28-year-old first-time mother visited her midwife, where her fundal height was measured. The fundal height - the distance between the pubic bone and the top of the uterus, a measure of fetal growth - was plotted on a growth chart.
At the visit, the fundal height had dropped 4cm in a week, signalling the baby might not be growing well.
As the woman's lead maternity carer (LMC), the midwive referred her for an ultrasound growth scan, and the midwife was reassured by the scan's results. Despite further signs growth might not be adequate, the LMC and her backup midwife took no extra action, Hill said.
During labour, the baby became distressed, and was delivered by emergency caesarean section. The baby was in "poor condition" and required resuscitation. It was also noted to be intrauterine growth restricted, and weighed 2.7kg.
Hill began his investigation after the mother made a complaint against the midwives over care she received in 2014.
Hill said he was concerned that during antenatal assessments the two midwives had failed to appreciate signs of a potentially growth-restricted baby.
In his view, this contributed to the baby being incorrectly treated as low risk for the remainder of the woman's pregnancy, as well as during labour and birth.
He also criticised the care the LMC gave during birth and in the three weeks afterward, before the mother transferred to another midwife.
The employer also did not have support policies in place for staff, particularly in relation to the measurement of fundal height during pregnancy.
The midwives were required to provide written apologies to the woman, while their employer was made to develop policies and provide training on the measurement of fundal height during pregnancy.