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Management of an undiagnosed breech delivery (08HDC10923)

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(08HDC10923, 11 September 2009)

Midwife ~ Senior midwife ~ New graduate midwife ~ Labour and delivery ~ Breech presentation ~ Water birth ~ Standard of care ~ Right 4(1)

A woman was admitted in labour to a primary maternity unit where she was met by her lead maternity carer (LMC) midwife, a new graduate. The LMC performed a vaginal examination to assess the progress of the woman's labour, and felt small bumps to one side of the cervix. The LMC was not sure what they were and contacted her senior midwife mentor to discuss her findings. She asked the senior midwife to come to the unit to support and assist her, and when she arrived about an hour later, the woman was in a birthing pool.

Shortly afterwards, the LMC attempted to perform a vaginal examination, but because of the woman's position in the pool she had difficulty adequately feeling the cervix. However, she was still able to feel the bumps. The LMC obtained the woman's permission for the senior midwife to examine her, but when asked to do the examination the senior midwife refused to do so, telling the LMC that she was "doing fine". A few minutes later, when the LMC again examined the woman vaginally, she found that the woman's cervix was fully dilated and the "bumps" were still evident. Fifteen minutes later, the woman pushed with a contraction and it was apparent that the baby was in the breech position. The senior midwife notified the duty midwife that there was an imminent delivery of an undiagnosed breech, and asked for oxygen.

The baby was born 22 minutes later, flat and unresponsive. The emergency bell was rung and medical assistance arrived within seven minutes, but the baby could not be resuscitated.

It was held that the senior midwife failed to act with reasonable care and skill when she declined to examine the woman at the LMC's request, and breached Right 4(1). It was noted that even if she had examined the woman at this time, it would not have altered the care they provided from that point, or the outcome.

It was also held that the LMC took reasonable steps to follow up her unusual findings by seeking the senior midwife's assistance. Although she was falsely reassured, her actions were appropriate in the circumstances and she did not breach the Code. She provided adequate information and appropriate antenatal care. She did very well, with the senior midwife's assistance, to manage the actual breech birth.

The case highlights the importance of effective mentoring, support and oversight for new midwives and the duty of care owed by the mentoring midwife to the consumer. The mentoring midwife acts as a safety net and is not simply a bystander.