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Midwifery and obstetric care provided during labour (12HDC00876)

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(12HDC00876, 17 December 2013)

Midwife ~ Obstetric registrar ~ District health board ~ Birthing centre ~ Prolonged second stage ~ Pethidine ~ Assessment ~ Documentation ~ Obstructed labour ~ Rights 4(1), 4(2)

Factual background

At 37 weeks' gestation, a 31-year-old woman chose a midwife to be her Lead Maternity Carer (LMC), after her first chosen LMC commenced long-term sick leave. During the woman's antenatal appointments with the midwife, it was noted that the baby was in a posterior position, the woman had experienced difficulties with the birth of her first son, and the couple was anxious and were concerned that the woman should give birth at hospital. The midwife reassured them that it was safe to give birth at the birthing centre (the Clinic)

At 12.30am, five days past her due date, the woman's waters broke spontaneously at home and contractions started. At 3.30am, the woman and her husband telephoned the midwife and informed her that the contractions were strong, painful, occurring every two to four minutes and were lasting 60 seconds. The midwife instructed them to meet her at the Clinic.

At 4am, the midwife assessed the woman at the Clinic. The woman was in pain, and was using pain relief. The midwife assessed the woman as being in early labour and recommended that they return home. The woman and her husband did not want to go home, and asked to be transferred to hospital. The midwife discouraged them from going to hospital. She recommended pethidine for pain relief, which was administered to the woman at 5.15am. The couple were then sent home against their wishes, when the woman was experiencing significant pain. The midwife did not assess the woman's vital signs or the fetal heart rate prior to or after the administration of pethidine.

At 9.30am, the husband called the midwife to come to their home, as they were scared, anxious, and exhausted. The midwife arrived at 10am and found the woman to be fully dilated, experiencing strong contractions, and pushing involuntarily with the contractions. The midwife instructed the woman not to push, and an ambulance was arranged to transport the woman to the Clinic.

The woman arrived at the Clinic at 11am, and commenced active pushing. At 12.30pm, because of her failure to progress, the woman was transferred to the public hospital by ambulance. The midwife listened to the fetal heart on only four occasions between 11am and 12.30pm, and did not take any maternal observations other than the woman's temperature at 12.15pm.

At 1:20pm, the woman was assessed at the public hospital by an obstetric registrar. At that stage, the fetal heart was assessed by the registrar as not reassuring, but still within normal limits. The registrar instructed the midwife to take the woman's observations, insert an intravenous (IV) luer and commence IV fluids, and to monitor the fetal heart rate and call her if there were any concerns.

The midwife failed to identify that the fetal heart rate was abnormal until she called the registrar back to assess the woman at 2.25pm. The registrar attended with a consultant. At 2.40pm, it was decided to proceed with an emergency Caesarean section for possible uterine abruption. The baby was delivered at 3pm by emergency Caesarean section, but could not be resuscitated and, sadly, died shortly after birth. The woman suffered a spontaneous uterine rupture and required emergency surgery, including an abdominal hysterectomy.

Findings

It was held that the midwife failed to provide services to the woman with reasonable care and skill, and breached Right 4(1). In particular, the midwife: failed to assess and treat the woman adequately at the Clinic from 4am to 6am; sent the woman home against her wishes and when it was not clinically appropriate to do so; failed to adhere to the Clinic's pethidine policy and to monitor and assess the woman and the baby adequately before and after the administration of pethidine; failed to monitor the woman and the fetal heart rate adequately at the Clinic between 11am and 12.45pm; failed to consult a specialist and/or transfer the woman to secondary care in a timely manner; failed to clarify who was responsible for the woman's ongoing care at the public hospital; and failed to monitor the woman's condition and the fetal heart rate adequately at the hospital. The midwife also breached Right 4(2) for failing to adequately document her assessments and care of the woman and the fetal heart rate.

Adverse comment was made that the midwife failed to work in partnership with the woman by failing to provide her with sufficient information about the midwife's experience and involve the woman in important decisions regarding her care.

The midwife's care of the woman was a major departure from the accepted standard of care. She was referred to the Director of Proceedings to determine whether any proceedings should be taken. The Director filed a claim at the Human Rights Review Tribunal which proceeded by agreement. The Human Rights Review Tribunal made a declaration that the provider had breached Rights 4(1) and 4(2) of the Code.

The obstetric registrar breached Right 4(1) because she did not assess the woman adequately, and her treatment plan for the woman was inappropriate.

The woman received poor midwifery care from the hospital midwives while she was in labour at the hospital and the DHB breached Right 4(1).

The Clinic did not breach the Code.

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