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Care provided to young pregnant woman (12HDC00301)

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(12HDC00301, 9 July 2013)

Midwife ~ Lead maternity carer ~ Antenatal, intrapartum and postnatal care ~ Perineal tear ~ Breastfeeding ~ Documentation ~ Rights 4(1), 4(2)

This case concerns the care provided by a midwife to a 16-year-old woman. The midwife did not record a birth plan and advised the woman that because of her age she may feel uncomfortable attending antenatal classes.

The woman went into labour when she was 37 weeks and 4 days pregnant. The woman, her partner and her partner's mother called the midwife several times advising that the woman was in a lot of pain and were told to wait and not to go to hospital. Shortly thereafter the woman gave birth on the bathroom floor. Following the delivery the midwife arrived and assessed the woman. She advised the woman that she had a small perineal tear that did not require sutures. The woman subsequently began to experience severe pain in her perineum, and the tear pulled open while she walked. The woman tied her legs together to minimise this. The midwife thought that this was funny but did not provide her with any further assistance.

The woman also had difficulty breastfeeding but the midwife did not offer a referral to a lactation specialist.

The midwife went on leave and upon her return observed that the woman was clammy and cold, and had a fever and cramps and offensive smelling lochia. The midwife prescribed an antibiotic and took a swab.

The woman later attended an after-hours doctor and was seen by the on-call obstetrician, who immediately admitted the woman to hospital for IV antibiotics, and examination under anaesthetic which confirmed an infected labial and perineal laceration that had failed to unite, and that a posterior vaginal wall skin flap had fibrosed onto the raw perineal edges. The woman subsequently underwent perineal debridement and perineal reconstruction.

It was held that the midwife failed to: provide adequate antenatal advice; communicate effectively with the woman and her supporters; attend the labour; provide adequate breastfeeding advice and support; adequately assess the perineal tear and provide appropriate treatment of the tear; and appropriately prescribe medications. Overall, the care the midwife provided was seriously sub-optimal, and she breached Right 4(1). By failing to document significant events, discussions and decisions, and keeping inadequate and misleading records the midwife also breached Right 4(2).

The midwife was referred to the Director of Proceedings. The Director decided to issue proceedings in the Human Rights Review Tribunal against the midwife.

The Director brought proceedings against the midwife. The midwife was found to be in breach of Rights 4(1), 4(2) and 4(4) of the Code for failures in midwifery care provided to the woman. The midwife failed to develop a sufficient birth plan, provide adequate information about the labour process and caring for a newborn, and appropriately document her care of the woman.  She failed to attend the birth when birth was imminent, failed to adequately examine the woman for perineal damage, refer the woman to a medical practitioner for examination and assessment of her perineal damage and failed to appropriately manage her puerperal sepsis. In addition, The midwife prescribed antibiotics without a clinical rationale (for example test results) and failed to adequately respond to requests for assistance with breastfeeding.

Issues relating to damages and costs were resolved between the parties by negotiated agreement.

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