Two midwives have been found at fault in the case of a baby who was born without an audible heartbeat and could not be resuscitated.
The baby's mother, accompanied by her husband, was admitted to an unnamed public hospital in late 2010 after she started having contractions, Health and Disability Commissioner Anthony Hill said in a decision made public today following his investigation.
A midwife checked and found the fetal heart rate was adequate. Almost three hours later, the midwife checked again and recorded the fetal heart rate was 102 beats per minute, which was unsatisfactory.
The midwife then used a cardiotocograph (CTG), a device that prints a paper graph of the fetal heart rate and uterus contractions over time. The trace showed a potential fetal heart rate of between 60 and 105 beats per minute.
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One of the CTG machines pick-ups, called transducers, was not working. The midwife left the birthing room to get another transducer and to seek midwifery help.
After the midwife returned with an assistant charge midwife, the latter spent at least nine minutes trying, unsuccessfully, to find a fetal heartbeat. She paged the obstetric registrar (doctor) who ruptured the amniotic sac around the fetus and attached a CTG electrode to the scalp, but no heartbeat was detected.
"He [the doctor] expedited the delivery with forceps but, tragically, the baby was born with no audible heartbeat and immediate resuscitation was unsuccessful."
Mr Hill found the midwife breached the code of patients' rights by failing to seek help as soon as she suspected the fetal heart rate was inadequate. She also communicated poorly with the couple, did not do adequate reviews in line with an individual assessment of the woman's needs, and her documentation was not of an acceptable standard. Taken together, these failings pointed to a pattern of inadequate care.
The commissioner also found the assistant charge midwife was in breach of the code, by failing to request a doctor's help soon enough. In addition, her documentation was brief and did not describe her examinations.
Mr Hill said the midwife had written an apology to the couple for her breach of the code, which would be forwarded to them. He had also recommended that the assistant charge midwife provide a written apology.
The Midwifery Council would be asked to conduct competency reviews of both midwives.