A midwife failed to fully recognise potential problems in a baby's heartbeat print-out during labour and the baby was stillborn, the Health and Disability Commissioner says.
In a report made public this afternoon, Anthony Hill finds that the midwife, whom he does not name, breached the code of patients' rights in her care of the pregnant woman.
The woman was pregnant with her first child and went into labour at about four days overdue.
The midwife, the woman's lead maternity carer, noted when the woman arrived at a hospital delivery unit, that she was experiencing regular contractions and that the cervical opening could not be reached.
Monitoring of the fetal heart rate in relation to labour contractions was started with a CTG machine - a cardiotocograph - which produces a printed trace.
The midwife noted "non-reassuring features" on the CTG recording and continued monitoring but did not interpret the trace as requiring consultation with the obstetric team.
A second vaginal examination was done an hour after hospital admission and the cervix was dilated by 2cm. The woman was given pethidine and Droleptan to help her sleep.
Soon after, the midwife noted a prolonged deceleration of the fetal heart rate. Five minutes later she called the on-call locum obstetrician as she could now not detect a fetal heartbeat.
The obstetrician arrived 20 minutes later, confirmed the absence of heartbeat and proceeded with a caesarean delivery of the baby, who was stillborn.
Mr Hill acknowledged that the CTG was difficult to interpret, but criticised the midwife's failure to fully recognise the non-reassuring features, which led to a failure to identify the possibility of fetal compromise and contact the obstetrician in a timely way.
The commissioner was also concerned about the medicines given to the woman and criticised the obstetrician's caesarean decision.
The midwife apologised to the woman and confirmed that she done further training in CTG interpretation, as recommended by the commissioner.