A midwife who failed a labouring mother during her pregnancy and birth which led to her having to undergo a lifesaving hysterectomy has been told to apologise.

Deputy Health and Disability Commissioner Rose Wall, in a decision released today, found the midwife was in breach of the code of Health and Disability Services Consumers' Rights for the care she provided to the woman in labour by not giving her enough information about the possible risks and options of transferring to hospital earlier.

Wall found both her lead midwife and a duty midwife at the birthing centre she was at failed to communicate the risks the woman's slow labour could pose to her and her baby.

The 20-year-old woman ended up having an emergency C-section and a hysterectomy after doctors were unable to keep the bleeding from a post-partum haemorrhage under control.


The first-time mother had been labouring at a birthing centre for hours in 2014 when she became distressed. The midwife documented that she had discussed transferring the woman to hospital because of her state and the woman declined.

The woman kept labouring with little progress when the duty midwife was called for a second option.

The duty midwife said she spoke with the woman about transferring to hospital to have a an obstetric appointment, but the conversation was not documented.

But neither the woman nor her partner could recall at any point being told by either midwife about their concerns about the labour not progressing.

The woman's partner said they were under the impression that there was no need to go to the hospital.

When the woman had been in labour for well over 12 hours and had still made little progress, she was eventually transferred to hospital and seen by the obstetric team.

Her baby was delivered via C-section and when she suffered a post-partum haemorrhage and did not stop bleeding, a "life-saving hysterectomy" was performed.

In her findings, Wall criticised the midwife for not recommending an obstetric consultation to the woman due to her slow progress in labour.

Wall found the midwife in breach of the guidelines and said the woman would not have been able to make an informed decision without being presented with all the information.

Wall also criticised the midwife for not recommending the woman see an obstetrician when her blood pressure was found to be high during pregnancy.

The midwife was ordered to apologise to the woman and was recommended to undertake a Special Midwifery Standards Review, and undergo training on the referral guidelines and documentation. Wall also recommended the Midwifery Council review the midwife's competency.