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Monitoring and care during labour (12HDC00481)
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Midwife ~ Obstetrician ~ District health board ~ Risk
factors ~ Labour ~ CTG monitoring ~ Information ~ Informed consent
~ Resuscitation ~ Delayed call to NNU ~ Professional standards ~
Rights 4(1), 4(2), 4(5), 6(1)(b), 7(1)
A woman was pregnant with her first child and her antenatal care
was shared between her general practitioner and her Lead Maternity
Carer (LMC), an obstetrician and gynaecologist. The nature of the
shared care arrangement was somewhat unclear, and the woman saw her
LMC only three times during her pregnancy.
The woman was admitted to hospital at midday, and was assessed
and monitored with a CTG, the results of which were reassuring. At
5.30pm the woman's waters were artificially ruptured with the
liquor stained with old meconium. As the evening progressed, the
woman laboured in a birthing pool and continued to be monitored,
but no further CTG monitoring occurred.
At 11pm the midwife (employed by the DHB) came on duty and took
over the woman's care. At that time the woman had a raised
temperature and had started to feel unwell. The midwife instituted
cooling measures, and the woman's temperature returned to normal by
11.30pm. However, the woman had a raised pulse that was within the
same range as the fetal heart rate (FHR), and had begun to feel
tired and thirsty.
Between 12am and 1am, the woman's condition deteriorated. In the
context of the woman having had a raised temperature and a pulse
that was significantly above normal limits (and within the same
range as the FHR), there was a raised FHR and copious amounts of
meconium stained liquor was draining. The midwife called the
Neonatal Unit (NNU) at 1.10am to advise of the possibility of being
called for resuscitation following delivery, but did not contact
the LMC obstetrician or institute CTG monitoring. At 2.20am the
woman's temperature was again raised. At 2.37am, following further
assessment, the midwife contacted the LMC obstetrician.
At 2.50am the LMC obstetrician arrived. He considered an
instrumental or forceps delivery but discounted those options,
partially because of an unfounded assumption that the woman did not
want obstetric input into her care. At 3.20am a Syntocinon infusion
was commenced in the continued absence of CTG monitoring and, at
3.50am, the baby was born - pale, floppy, and covered in meconium.
At 3.55am the LMC obstetrician consented to the midwife's third
request to call the NNU, once his own attempts to resuscitate the
baby had failed. The baby was transferred by air ambulance to
another hospital, where she was treated for hypoxic ischaemic
encephalopathy, seizures and suspected sepsis, and has since
experienced significant health difficulties and developmental
It was held that the LMC obstetrician did not provide services
to the woman or the baby with reasonable care and skill, failed to
adhere to professional standards, did not provide the woman with
information that a reasonable consumer in her circumstances would
have expected to receive, and failed to obtain informed consent.
The LMC obstetrician was found in breach of Rights 4(1), 4(2),
6(1)(b) and 7(1).
The midwife did not provide services to the woman with
reasonable care and skill and failed to adhere to professional
standards, and was found in breach of Rights 4(1) and 4(2).
The LMC obstetrician and the midwife were referred to the
Director of Proceedings. The Director decided to institute
proceedings in both cases.
Multiple individual failures at the hospital suggested that
there were inadequate systems in place to ensure that women
received safe care. Some of the guidelines in place at the
hospital's labour ward were suboptimal and/or not routinely
complied with, and a culture existed that compromised the standard
of care provided in this instance. Overall, the DHB did not provide
services to the woman and the baby with reasonable care and skill,
and did not ensure quality and continuity of services. The DHB was
found in breach of Rights 4(1) and 4(5).