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Fetal and maternal assessment in labour (15HDC00189)
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29 June 2016)
Obstetrician ~ Midwife ~ Birthing clinic ~ Uterine
hyperstimulation ~ Right 4(1)
A woman engaged a private birthing clinic to provide her
maternity care. The woman went into spontaneous labour when she was
39+3 weeks' gestation and went into hospital where she was met by
the duty midwife who worked for the clinic. The duty obstetrician
arrived shortly afterwards and carried out a full assessment,
noting that the cervix was fully effaced, 1cm dilated and central,
and the fetal head was at station ‒3. The obstetrician planned to
review the woman again in two hours.
Two hours later the obstetrician reviewed the woman as planned.
At that time she noted that the fotus was in a potentially
undesirable position for delivery and the contractions varied
between two and three every 10 minutes. The obstetrician made the
decision to commence Syntocinon in an attempt to try and regulate
contractions, achieve descent of fetal head, and encourage rotation
of the fetal head into a better position for delivery.
The Syntocinon infusion was subsequently commenced at 2.04pm.
The midwife noted changes in the fetal heart rate (FHR) variability
and then a deceleration down to 70bpm and turned off the Syntocinon
infusion. At that time she noted the woman's contractions continued
to be "slightly irregular".
After a discussion with the obstetrician the midwife turned the
Syntocinon back on at a reduced infusion rate. The woman then began
feeling rectal pressure, and the midwife performed a vaginal
examination, noting that the cervix was 6‒7cm dilated and the fetal
head was at station ‒1. The FHR was 151bpm and contractions were
documented to be six every 10 minutes. The midwife turned down the
A short time later the obstetrician reviewed the CTG, noting
that the contractions were still irregular with four to five every
10 minutes. 45 minutes later the obstetrician noted that the CTG
was showing decreased FHR variability. She performed a vaginal
assessment, noting that the woman was almost fully dilated and that
the fetal head was in a better position. The obstetrician then made
the decision to proceed with an instrumental delivery owing to the
deterioration in the FHR pattern.
The obstetrician commenced a ventouse delivery. The fetal head
was delivered after three tractions. Shoulder dystocia was then
noted and the obstetrician performed various manipulations to
deliver the shoulders, and, subsequently, the baby was delivered
with good Apgars. Approximately two hours later the baby's
condition deteriorated and he was transferred to the neonatal
intensive care unit. He was later diagnosed with severe dystonic
cerebral palsy disease.
The obstetrician was found to have breached Right 4(1) for
continuing the Syntocinon infusion in the presence of a
hyperstimulated uterus, and for her failure to recognise that this
was the likely cause of the FHR abnormalities.
The midwife was found to have breached Right 4(1) for failing to
comply with the DHB's policies and guidelines in relation to the
Syntocinon infusion, and by failing to recognise the clinical
concerns and request the obstetrician's assessment in person.
Criticism was also made of the failure by the midwife to document
her discussions with the obstetrician, including the rationale for
the decision to recommence the Syntocinon.
The birthing clinic was not found to have breached the Code.
Both the obstetrician and midwife have undertaken, or agreed to
undertake, further training relating to fetal and maternal
assessment in labour. The midwife has also undertaken further
training on clinical documentation. Both the midwife and
obstetrician agreed to provide a letter of apology.