Care provided to Ms D — breach

Introduction

155.          In 2019, Ms D registered with RM A as her LMC midwife.

156.          A breech presentation was identified during labour, and Ms D required immediate transfer to the operating theatre for delivery of the baby. Health NZ raised several concerns about the care RM A provided, including that serial growth scans were not arranged, and that the breech was not diagnosed until Ms D presented in labour.

Antenatal care

157.          Ms D was pregnant with her third baby. RM A noted in the clinical records that the birth of Ms D’s second baby had been complicated by shoulder dystocia.[31]

158.          At the booking visit, Ms D weighed 116kg, and she had a BMI of 40.86.[32]

159.          RM A documented that there were no risk factors present in relation to Ms D’s third pregnancy.

Anatomy scans

160.          Ms D had an anatomy scan, but due to Ms D’s body habitus, there was difficulty obtaining a clear view, and the scan was unable to be completed. The radiologist’s report states:

‘Conclusion: Incomplete anatomy scan. Visualisation of the fetal heart, profile and upper limbs were limited by maternal habitus. These views will be completed at a subsequent scan next week.’

161.          Ms D had a follow-up anatomy scan, but the scan was still unable to be completed due to limited views. The radiologist’s report states:

‘Conclusion: Incomplete anatomy scan. Visualisation of the fetal heart remains limited by maternal habitus. A [follow-up] scan has been arranged for three [weeks’] time …’

162.          Ms D had a further follow-up anatomy scan. The view remained limited, but the anatomy scan was able to be completed in conjunction with the earlier scans. The radiologist’s report states:

‘Fetal anatomy: Cardiac views remain slightly suboptimal, as a consequence of fetal position and maternal body habitus. Views obtained appear normal … Conclusion: … In combination with [two previous examinations], fetal anatomy review is complete. No abnormality has been demonstrated.’ 

Growth scans

163.          No serial growth scans were done during Ms D’s pregnancy.

164.          RM A met with Ms D for another antenatal follow-up appointment. RM A documented in the clinical records: ‘Discussed doing a scan. [Ms D] has declined. Knows she is going to have a big baby. Last one was over 5kgs.’

165.          RM A told the Midwifery Council that she recommended a referral for a scan at both 31 weeks’ and 37 weeks’ gestation, but Ms D declined the referral due to the costs involved. RM A said:

‘[Ms D] said she already knew the baby would be big. If I had suspected a breech baby, I would have arranged to take her to [the public hospital] for a bedside scan to confirm position. I had been sure I felt the baby was head down antenatally.’

166.          RM A told HDC:

‘I had discussed growth scans with [Ms D] and [her partner] due to the size of the baby and the difficulty palpating due to excess adipose tissue.[33] Every time I mentioned it, [Ms D] would say she knew the baby would be large so there was no sense confirming it.’

167.          There is no detail in the clinical records of what RM A discussed with Ms D in relation to the recommendation for growth scans, or the reasons for this recommendation.

168.          HDC has made several attempts to contact Ms D to obtain her recollection of the discussion with RM A in relation to the recommendation for growth scans, but these attempts have been unsuccessful.

Referral to obstetrician

169.          RM A told HDC that she discussed with Ms D a referral for consultation with an obstetrician, but Ms D declined the referral. RM A said:

‘I had mentioned the recommendation for an [obstetric] consult. [Ms D] wanted as little to do with the hospital system as possible and wouldn’t accept a referral.’

170.          There is nothing in the clinical records to indicate that RM A discussed referring Ms D for a consultation with an obstetrician, or a transfer of care, or what RM A discussed with Ms D about the reasons for a referral.

171.          As noted above, HDC made several attempts to contact Ms D to obtain her recollection of the discussions with RM A, but these attempts were unsuccessful.

Place of birth

172.          RM A recorded that she had discussed with Ms D her ‘choices for labour, birth and postnatal stay’, but there is no detail in the clinical records of what RM A discussed with Ms D in relation to this.

173.          Ms D’s plan was to birth at a primary birthing facility (birthing unit). RM A noted that Ms D was ‘not too keen’ on a waterbirth, and that if Ms D was to birth at the public hospital, she would ‘likely go home after’.

174.          Initially, Ms D was booked to birth at the birthing unit but due to Oranga Tamariki involvement and Ms D’s elevated BMI, she was precluded from birthing at the birthing unit.

175.          RM A told the Midwifery Council:

‘Even though [Ms D] and [her partner] requested to birth at [the birthing unit], I was aware of her history and not comfortable with a primary unit due to her body mass index (BMI) and history of shoulder dystocia. I was looking for any excuse to change to the hospital. At 36 weeks, due to Oranga Tamariki involvement, a social worker recommended birthing at [the public hospital]. I latched on to that excuse and said that was where we would go. I am not usually this deceitful about the place of birth with the birthing family, but there was no way I wanted to attend her birthing at a primary unit.’

Labour and diagnosis of breech presentation

176.          Ms D went into spontaneous labour at around 9am and was admitted to the public hospital at 10am. Another midwife provided Ms D with labour care until RM A’s arrival.

177.          RM A arrived at 10.22am but no palpation or maternal baseline observations were performed by RM A on admission. RM A told the Midwifery Council:

‘When I walked into the room at 1022, the core midwife immediately said to me that because [Ms D] had a history of shoulder dystocia she needed an intravenous line inserted, handing me the equipment to do so. I inserted the line, took bloods and sent them to the lab … I agree I should have done my own initial assessment and not relied on the core midwife’s assessment, however, things were happening very quickly.’

178.          At 12.03pm, Ms D had a spontaneous rupture of membranes.

179.          At 1.31pm, the emergency bell was activated, but it is unclear from the clinical records why this occurred, as there is no note from RM A and only an entry from another staff member outlining what occurred after the bell had been activated.

180.          An obstetric consultant and registrar Dr N responded to the emergency bell, and Dr N performed a vaginal examination. This was the first vaginal examination since Ms D’s admission to hospital. There is no record of any other vaginal examinations or palpations done by RM A during Ms D’s admission.

181.          On vaginal examination, Dr N diagnosed a footling breech presentation[34] and noticed meconium.[35] A breech presentation at the second stage of labour is considered an obstetric emergency. A decision was made for Ms D to be transferred to the operating theatre for spinal anaesthesia and to trial a vaginal breech delivery, but she was also consented for a possible Caesarean section.[36]

182.          Ms D was transferred to the operating theatre at 1.40pm. The baby’s foot was delivered, and it was decided to abandon the spinal anaesthetic. At 1.49pm, the baby’s legs and buttocks were delivered. At 1.52pm, the baby was rotated but there was difficulty delivering the baby’s right arm. An episiotomy[37] was performed, and at 1.57pm, the baby was ‘completely delivered’. The delivery was described in the clinical records as ‘vaginal breech delivery (difficult)’.

183.          The baby was admitted to the neonatal intensive care unit (NICU) and noted to have ‘dec[r]eased movement’ of her right arm with bruising evident over her shoulder. Subsequently, she was diagnosed with an upper arm fracture related to the difficult delivery. The plan was for non-operative management of the fracture. The baby was otherwise in good condition.

184.          Following the birth, Ms D recovered well and was discharged four days earlier than her baby.

Review of events

185.          The Charge Midwife Manager at the public hospital completed an incident report for the undiagnosed breech presentation that was identified only on presentation of the foot, and for the difficult breech extraction. The lack of baseline observations at admission and the absence of growth scans antenatally were noted in the report.

RM A’s response

186.          In response to the concerns raised by Health NZ, RM A told the Midwifery Council:

‘I was fully aware of [Ms D’s] history. I agree I should have done my own initial assessment and not relied on the core midwife’s assessment, however, things were happening very quickly. In spite of what [Ms U] says, none of these issues was ever discussed with me following the birth or at any other time.’

My opinion

Information and care provided

Recommendation for transfer of care and consultation

187.          At the booking visit with RM A, Ms D’s BMI was over 40 (40.86). Ms D had a known history of complications with shoulder dystocia in relation to her previous pregnancy.

188.          Manatū Hauora│the Ministry of Health published Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) in 2012, which were revised and published by Health NZ in March 2023. The Referral Guidelines provide health practitioners with a list of conditions and criteria about referring pregnant, birthing, and postnatal women and babies for consultations with other clinicians, transferring clinical responsibility for care to specialists, and transferring care in emergencies.

189.          The Referral Guidelines in place at the time of the events recommended a transfer of clinical responsibility for women with a BMI of over 40. The Referral Guidelines also stated that a woman with a previous maternity history of shoulder dystocia should be referred for consultation with an obstetrician.

190.          The Referral Guidelines stated that if a woman declined a referral, consultation, or transfer of clinical responsibility, the LMC could be left operating outside their experience or scope of practice, and/or might feel that they could not provide the level of care the woman needed for her safety and the safety of her baby.

191.          The Referral Guidelines stated that in the event that a woman declined a referral, consultation, or transfer of clinical responsibility, the LMC should advise the woman of the recommended care, including the evidence for that care, explain to the woman the LMC’s need to consider discussing her case with at least one other healthcare provider,[38] share the outcomes of the discussion and any resulting advice with the woman, and document in the care plan the process, the discussions, the recommendations given and decisions made, and the woman’s response.

192.          The Referral Guidelines stated that if after this process, resolution satisfactory to the LMC and the woman has not been reached, and the LMC decides to continue care, she should continue making recommendations to the woman for safe maternity care, including further attempts at referral, engage other practitioners as appropriate for professional support, and continue to document all discussions and decisions.

193.          RM A said that she ‘mentioned the recommendation’ to Ms D for a consultation with an obstetrician, but this was declined by Ms D. Nothing in the clinical records indicates that RM A discussed referring Ms D for a consultation with an obstetrician, or a transfer of care, or what RM A discussed with Ms D about the reasons for a referral.

194.          In the absence of contemporaneous documentation of any such discussion and confirmed documented declining of a referral by Ms D, and the limited evidence provided by RM A of what she recalled was discussed, I consider it more likely than not that while there may have been a brief discussion, it was limited and did not cover the reasons for referral and that it was needed for Ms D’s raised BMI and because of her previous baby’s shoulder dystocia.

195.          RM Emerson advised that the former DHBs did not always accept a referral based on BMI, and she noted that the current 2023 guidelines now suggest consultation for a BMI over 40, instead of a transfer of care, which is likely to reflect the increasing number of birthing people with an increased BMI. However, RM Emerson said that the change reflected since 2012 and the practice of each district does not mitigate the need for an LMC to discuss the guideline recommendations with the woman/birthing person at that time.

196.          RM Emerson advised that if it is accepted that referral for Ms D’s raised BMI and previous shoulder dystocia were not discussed with Ms D, this represents a moderate departure from accepted practice.

197.          I accept RM Emerson’s advice. As Ms D’s BMI was over 40, at the time of events the Referral Guidelines clearly recommended that clinical responsibility be transferred to secondary care services. In addition, Ms D’s maternity history of shoulder dystocia warranted a referral for a consultation with an obstetrician, as set out in the Referral Guidelines. I am critical that RM A did not discuss these matters with Ms D.

198.          As RM A decided to continue care, in accordance with the Referral Guidelines she should have continued to make recommendations to Ms D for safe maternity care, including further attempts at referral. As set out in the Referral Guidelines, RM A should also have engaged other practitioners as appropriate for professional support, and she should have continued to document all discussions and decisions.

199.          There is also no evidence to suggest that RM A made any further attempts at a referral, or that she had any further discussions with Ms D about the need for a referral, after the initial referral had been declined.

200.          In my view, RM A did not provide Ms D with the information to which she was entitled under the Referral Guidelines. I consider that this was information that a reasonable consumer in Ms D’s circumstances could expect to receive.

Recommendation for growth scans

201.          Ms D required three anatomy scans to complete the fetal anatomy review, given the difficulty in obtaining clear fetal views on these scans.

202.          RM A recommended that a growth scan be done, but this was declined by Ms D. RM A documented this in the clinical records, but there is no detail of what RM A discussed with Ms D in relation to this recommendation, or her reasons for recommending a growth scan. There is no record of any discussion about serial growth scans, nor were any undertaken.

203.          RM A said that she also recommended a referral for a scan earlier at 31 weeks’ gestation, but Ms D declined due to the costs involved. RM A said that she discussed growth scans with Ms D and her partner due to the size of the baby and difficulty palpating, but every time it was mentioned, Ms D said she knew that the baby would be large so there was no sense confirming it.

204.          The New Zealand Maternal Fetal Medicine Network Guidelines for the Management of Suspected Small for Gestational Age Singleton Pregnancies and Infants after 34 weeks’ Gestation 2014 (the SGA Guidelines) state:

‘The BMI at which fundal height measurement is unreliable is difficult to prescribe as it depends on distribution of maternal fat and also height. A plan for growth scans is recommended with a BMI of >35.’

205.          Similarly, the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Best Practice Statement Management of Obesity in Pregnancy[39] (RANZCOG Guidelines) state:

‘Pregnant women with obesity should be offered additional serial ultrasounds for fetal growth. The timing and frequency of serial scans should be based on the full clinical picture.’

206.          RM Emerson noted that serial growth scans were not undertaken despite difficulty obtaining clear fetal views due to maternal habitus on three anatomy scans, and these have not been documented as having been offered. She noted that a growth scan was declined by Ms D but that there is no documented discussion regarding why the scan was recommended. RM Emerson advised that if it is accepted that serial growth scans were not discussed, this represents a moderate departure from accepted practice.

207.          I accept RM Emerson’s advice. While I acknowledge that there is one recording of RM A having recommended a growth scan and this being declined by Ms D, there is nothing in the clinical records to indicate that RM A offered or discussed serial growth scans. Based on the evidence before me, I find it more likely than not that serial growth scans were not discussed with Ms D.

208.          In my view, RM A should have offered serial growth scans and provided Ms D with a detailed explanation of why they were recommended, especially given that there had been difficulty obtaining clear fetal views due to maternal habitus during the three anatomy scans. In my opinion, this was information that a reasonable consumer in Ms D’s circumstances could expect to receive.

Palpation and maternal baseline observations

209.          Ms D was admitted to the public hospital in labour. No palpation or maternal baseline observations were performed by RM A on admission, and RM A acknowledged that she should have done so.

210.          RM Emerson advised that the failure to undertake palpation and maternal baseline observations on admission was a moderate departure from the accepted standard of care.

211.          I accept RM Emerson’s advice. While I cannot determine whether palpation on admission could have diagnosed the breech presentation earlier, I am critical that no palpation or maternal baseline observations were done by RM A on admission. This was not appropriate care.

Conclusion

212.          RM Emerson advised:

‘Accepting that diagnosis of a breech presentation can occur in labour, reasonable steps were not taken by [RM A] to mitigate this possibility. Reasonable steps would have included recommendation for obstetric consultation … based on previous shoulder dystocia and elevated BMI. In addition, a recommendation for serial growth scans in the later stages of pregnancy. Palpation on admission to [the public hospital] in labour could possibly have diagnosed the breech presentation. It is impossible to determine retrospectively if the breech presentation would have been diagnosed prior to labour with Obstetric consultation, serial scans and palpation on admission in labour, however, all these actions would be in keeping with accepted midwifery practice for the reasons outlined above.’

213.          In conclusion, I find that RM A breached Right 6(1)(b) of the Code for failing to provide Ms D with the information she was entitled to receive under the Referral Guidelines (in relation to a transfer of care due to an elevated BMI and a consultation due to previous shoulder dystocia) and failing to offer serial growth scans to Ms D with an explanation and reasons for recommending them.

214.          I also find that RM A breached Right 4(1) of the Code for failing to perform palpation and maternal baseline observations on admission. In addition, RM A should have at least considered engaging other practitioners for professional support.

Documentation

215.          RM A said that she discussed with Ms D a referral for a consultation with an obstetrician, but this was declined by Ms D. RM A did not document the discussion, or her reasons for recommending a referral.

216.          The clinical records show that at 37 weeks’ gestation, RM A recommended a growth scan to Ms D, and that Ms D declined the scan. However, there is no record of what was discussed. RM A said that she had also recommended a referral for a scan earlier, at 31 weeks’ gestation but that Ms D declined due to the costs involved. This was not documented. However, I leave open the possibility that RM A did recommend a scan at this time.

217.          Standard Five of the NZCOM’s Standard of Practice states: ‘The midwife facilitates and records outcomes of conversations related to the decision-making process.’

218.          Standard Two of the NZCOM’s Standard of Practice also requires the midwife to document decisions and midwifery actions.

219.          I am critical that RM A did not document her recommendation for a referral to an obstetrician, or her discussion with Ms D in relation to the referral. In addition, I am critical that RM A did not document any recommendation or discussion of a referral for a growth scan at 31 weeks’ gestation, and I am critical of the lack of detailed documentation about exactly what was discussed regarding the scan at 37 weeks’ gestation.

220.          In my view, RM A’s documentation in her care of Ms D did not meet professional midwifery standards and, accordingly, I find that RM A breached Right 4(2) of the Code.

Care provided to Ms G — adverse comment

Introduction

221.          In 2020, Ms G registered with RM O as her LMC midwife. RM A provided Ms G with back-up LMC care during labour.

222.          In the morning of Day 3,[40] Ms G went into early labour. Ms G’s labour was progressing very slowly, and RM A remained with her for a prolonged period during this time. Health NZ raised concern that when Ms G was admitted to the public hospital at 2.30pm on Day 4, RM A appeared tired. Health NZ questioned whether RM A was able to provide Ms G with safe care, given how tired she appeared.

Labour

223.          Ms G planned on giving birth at her home. On the evening of Day 1, Ms G started to have mild contractions, which continued throughout the following day.

Day 3

224.          RM A said that in the ‘late morning’ on Day 3, she received a telephone call from RM O advising that Ms G was in early labour and that she (RM O) would be visiting Ms G shortly.

225.          RM A said that at 12.45pm, she received another telephone call from RM O advising that she was unwell and unable to visit Ms G. RM A was the back-up LMC and agreed that Ms G could call her when needed.

226.          At 3.13pm, Ms G’s husband called RM A to advise that they required her support. RM A arrived at Mr and Ms G’s home at 4.15pm.

227.          At 4.51pm on Day 3, RM A documented in the clinical records:

‘At [Mr and Ms G’s] place. Started mild contractions the evening of [Day 1]. They got stronger and more regular during the night last night. Had called [RM O] earlier today to come out, but things had slowed down.

Feeling tired and frustrated that things aren’t progressing as quickly as had hoped. Using hot towels on back with some counter pressure.’

228.          Ms G’s labour progressed slowly. At 6.28pm, RM A left Mr and Ms G’s home to have dinner. At 9.10pm, RM A documented in the clinical records: ‘Back at the home. Discussed what to do next. Decided to fill the pool. Getting in the water would either speed things up or slow things down and [Ms G] could rest.’

229.          Ms G’s labour continued to progress slowly, and RM A said that at 10.15pm, RM A and Mr and Ms G decided that they would rest. RM A said that because of the distance to her home, she decided to sleep in Mr and Ms G’s spare bed so that she could be available. RM A stated:

‘We had discussed the possibility of going to the hospital for medication for pain and sleeping, but they declined. Since they seemed to want my support, I agreed to stay in their spare bedroom. I really expected labour to either kick into gear or [Ms G] to decide she was too tired to cope and to go to the hospital. We all dozed off and on all night.’

Day 4

230.          The following morning, at 6.49am, RM A documented that she and Mr and Ms G got up ‘after snoozing off and on during the night’. Ms G’s contractions were noted to be ‘a bit irregular with most being about 8 minutes apart’, but ‘more intense’.

231.          At 8.17am, the contractions were noted to be ‘quite variable in frequency’. RM A documented that after discussion, it was decided that she would go home to rest. She discussed with Mr and Ms G what they needed to do if the birth happened ‘really fast’ and advised that they could call her at any time if they had questions, or if they wanted her to return to their home.

232.          RM A said that at 12.49pm, Mr G called her advising that Ms G was ‘exhausted’ and that she wanted to go to the hospital. RM A stated:

‘I called the ACMM[41] at [1.02pm] and was told they were very busy and would not be able to do an epidural handover and that it may be hours before we could consult with a doctor. I called [Mr G] back and explained this to him. After talking to [Ms G], they decided they still wanted to head to the hospital.’

233.          At 2.30pm, due to the delay in labour, Ms G was admitted to the public hospital.

234.          At 2.40pm, RM A documented in the clinical records:

‘[Ms G] arrived [at the public hospital] after labouring at home since evening of [Day 3] for planned home birth. Transferred in as exhausted [and] wanting epidural.’

235.          On admission, RM A performed a vaginal examination and palpation, but it is unclear whether she performed maternal baseline observations because this is not documented in the clinical records. RM A documented that Ms G was 4cm dilated and that the baby was at fetal station -2.

236.          RM A noted that at 3.01pm she saw the obstetrics registrar, who asked her to perform an artificial rupture of membranes (ARM). RM A performed the ARM and noticed meconium-stained liquor. Ms G was given morphine to assist with ‘intense contractions’, and at 5.32pm, she was reviewed by the obstetrics registrar. Another vaginal examination was performed and options for an epidural and oxytocin were discussed.

237.          Oxytocin was commenced at 7.19pm, and at 7.45pm RM A handed over care of Ms G to the core midwife for epidural care.

238.          RM A said:

‘My expectation going to the hospital was to hand over for epidural care since I wasn’t epidural certified. Due to staffing issues, it took much longer to get a staff member to do labour cares than anticipated.’

Day 5

239.          At 4.37am on Day 5, the baby was born in good condition.

Health NZ

240.          Health NZ raised concern that RM A had been with Ms G for a prolonged period. Health NZ questioned whether RM A was able to provide safe care to Ms G, given how tired she appeared. Health NZ told the Midwifery Council:

‘The afternoon ACMM confirmed with [RM A] that she was still feeling safe to practi[s]e … as she was concerned that she had been with the woman for 36 [hours] and perhaps she should have called in a back-up. [RM A] was reluctant to call a back-up. She stated she was happy to continue as she had been able to snooze on and off at the woman’s house.

About [8.00pm] approximately, there was a complete epidural handover so that she could go home. The ACMM felt uncomfortable with her being with the woman any longer given how tired she appeared. She also did not offer an epidural buddy as actually wanted [RM A] to go home and rest otherwise she may have stayed on and was too tired.’

RM A’s response

241.          RM A denies that she had been with Mr and Ms G for 36 hours. RM A told the Midwifery Council:

‘I had just woken up when [Mr G] called at [12.49pm on Day 4], and I was feeling rested. I had discussed that I was transferring to the hospital just after [1.00pm] with the [back-up midwife]. [The back-up midwife] and I thought it made more sense for me to meet [Mr and Ms G] at the hospital since they knew me and I knew what had been happening. I may have looked tired to the ACMM, but I felt rested and well able to care for [Ms G].’

My opinion

242.          RM Emerson noted that no baseline maternal observations are recorded, and that the handover to the core midwife occurred with ‘sparse handover information documented’. RM Emerson advised that it is not possible to assess retrospectively what the circumstances around the handover were, and that, due to insufficient information, she is unable to determine whether the care provided by RM A was appropriate.

243.          Having considered the matter, I am unable to determine whether RM A’s ability to provide safe care to Ms G was reduced because of fatigue. I accept that RM A was able to get some rest during the evening of Day 3, when she stayed at Ms G’s home overnight. In the circumstances, I am not critical of the care provided by RM A to Ms G prior to her admission to hospital.

244.          However, I am critical that RM A did not perform and document maternal baseline observations on Ms G’s admission to hospital. The responsibility for performing maternal baseline observations rests with RM A as the back-up LMC, and I would have expected these assessments to have been completed and documented prior to the care of Ms G being handed over to the core midwife at 7.45pm.

245.          In addition, I am concerned about the lack of professionalism shown by RM A when she elected to stay at Ms G’s home overnight. In my view, in the circumstances, it would have been preferable for RM A to return to her own home.

Care provided to Ms F and Baby F — other comment

Introduction

246.          Ms F gave birth to a baby in a healthy condition. RM A had stepped in to assist with the birth as both Ms F’s LMC and back-up LMC were not available. Health NZ raised concern about RM A’s lack of handover to the staff caring for Ms F and her baby following the birth, and, in particular, that RM A did not provide all relevant information that affected the provision of care to Ms F and her baby.

Initial LMC

247.          Initially, Ms F received LMC care from RM P.

248.          At 3.20pm on 4 Month1,[42] Ms F self-presented to a community maternity unit with back pain and lower abdominal pain. She had been ‘cramping’ since the afternoon on 3 Month1 and had not felt the baby move for three days. RM P was contacted by staff, and at 4.30pm, care of Ms F was handed over to RM P.

249.          Following a discussion with the obstetrics registrar, the decision was made for Ms F to be transferred to the public hospital by ambulance for review of the pain.

250.          At 5.30pm, an intravenous (IV) line was inserted to provide Ms F with fluids and antibiotics. The ambulance arrived at 5.40pm and Ms F was transferred to hospital.

Admission to hospital

4 Month1

251.          At around 7pm, the ambulance arrived at the public hospital. At 7.15pm on 4 Month1, Ms F was reported to be ‘crying and demanding’ that the IV line be removed. Following a discussion with the obstetrics and gynaecology registrar, Dr Q, it was agreed that the IV line could be removed if Ms F insisted, but that she be provided with an explanation of the reasons why the IV line was needed.

252.          At 7.20pm, the IV line was removed, after which Ms F was reported to be calm.

253.          At 7.32pm, Dr Q reviewed Ms F and documented in the clinical records that there had been ‘previous Oranga Tamariki[43] input’, and that Ms F had ‘complex social and behavioural issues’. Dr Q made an entry in the clinical records to ‘see [Oranga Tamariki]’. Dr Q’s plan for Ms F included ‘social work input’.

254.          A referral for social work was completed at 9.45pm.

5 Month1

255.          At 9.45am on 5 Month1, Ms F was assessed by social worker Ms R. Ms R noted that the staff had concerns because Ms F wanted to self-discharge and ‘did not appear to grasp the seriousness of her condition’. Ms R documented in the clinical records:

‘When I spoke with [Ms F] she was concerned about having to stay in hospital and miss [a family birthday] party. She did not feel there was anything wrong with her anymore. Staff wanted her to stay another night, and to be seen by a consultant but she was not willing … [Ms F] decided to leave regardless of medical advice as she did not wish to wait any longer but said she would come back after the party.’

256.          The clinical notes show that Ms F returned to hospital at 3.30pm. She was taken to have a scan and was reviewed by the registrar before she self-discharged at approximately 10pm.

Report of concern and Oranga Tamariki referral

257.          Ms R noted that she was concerned about Ms F’s ‘lack of insight into her condition and the impact her decisions could have on the baby and herself’. On 21 Month1, Ms R telephoned RM P, who advised that she had not seen Ms F since her admission to hospital. RM P said that Ms F had ‘cancelled and not turned up to her appointments’, and that she was unable to get in touch with her.

258.          On the same day, Ms R completed a report of concern (ROC) for Ms F. Ms R reported that she had concerns about Ms F’s ‘lack of support and ability to safely parent’, and that she was unable to contact Ms F or assess further as Ms F was in another town. Oranga Tamariki said that Ms R also raised concerns about Ms F’s antenatal care and drug use.

259.          On 22 Month1, Ms R discussed her concerns again with RM P, who advised that she had concerns about Ms F ‘and her ability to parent a child safely’.

260.          Ms R also followed up with Ms F on this day and documented in the clinical records:

‘[Ms F] said she is working with a social worker at … (though could not give detail on what this was) and does not have [Oranga Tamariki] involvement. I discussed my concerns briefly about the lack of support she appears to have … I will follow up with [social services] to ascertain what supports she is currently receiving.’

261.          On 23 Month1, Ms R discussed Ms F with another social worker at the hospital, who agreed to follow up with Ms F and Oranga Tamariki.

262.          On 27 Month1, Ms F contacted Ms R and advised that she had been given the number of another LMC. Ms R documented in the clinical records: ‘I let [Ms F] know that I had made a referral to [Oranga Tamariki] as I was concerned about her and baby which she appeared understanding of.’

Booking with new LMC

263.          On 13 Month2, Ms F had a booking visit with her new LMC, RM S, and a care plan was completed. The additional notes in the care plan state that she was to birth at the public hospital and ‘home for postnatal’, ‘for [third] trimester scans (smoking and no palpations)’, and ‘needle phobic’.

264.          RM A said that, at this point, RM T (another midwife at her practice) was Ms F’s back-up LMC.

Hui a-whānau

265.          On 21 Month3, Ms F, her partner, and their whānau attended a hui a-whānau at Oranga Tamariki. Oranga Tamariki provided HDC with a copy of the hui minutes.

266.          Oranga Tamariki had several concerns, which were shared with Ms F and discussed during the hui. Oranga Tamariki said that due to these concerns, it was agreed that a robust safety plan was needed when the baby was born.

267.          The hui notes state that Ms F wanted to stay with her mother for a couple of days after the birth of the baby but that this was dependent on the birth, and then Ms F, her partner, and their baby would move to Ms F’s partner’s mother’s home, where they had set up a spare room for the baby.

268.          The hui minutes state:

‘There still needs to be a robust plan put in place for the safety of the unborn pēpi. Whānau will monitor baby safety when in the homes. Regular contact with external providers and midwife to monitor and check on baby. Family Start will engage and provide parenting course.’

Maternity booking form

269.          On 21 Month3, Ms F was booked for birth and labour at the public hospital. The maternity booking form was completed by RM S and noted Oranga Tamariki’s involvement. The maternity booking form states:

‘Do you have any child or family agencies working with your family? Yes

If yes, who are they? Oranga Tamariki, Social work’

Final antenatal appointment

270.          On 28 Month3, Ms F had her last antenatal appointment with RM S. RM S documented in the clinical records: ‘[Oranga Tamariki] meeting last week reported to have gone well. They will update me if any plans are made.’

271.          RM A said that this was the only note of Oranga Tamariki involvement contained in RM S’s MIS[44] notes.

Labour and birth

2 Month4

272.          On 2 Month4, Ms F started to experience irregular tightenings, with increased intensity in the evening. RM S reviewed Ms F at the public hospital at 11.50pm. On vaginal examination, RM S noted that the baby’s head was at fetal station -1.

273.          At 11.50pm, RM S documented in the clinical records that she was unable to get hold of the back-up LMC. RM S also documented that there was ‘[Oranga Tamariki] involvement’. The clinical records contain no details of Oranga Tamariki’s plan following the birth of the baby.

3 Month4

274.          At 12.32am on 3 Month4, RM S’s plan was for Ms F to be discharged home, and for the back-up midwife to assess Ms F at her home, prior to Ms F returning to the hospital.

275.          At 2.30am on 3 Month4, Ms F returned to the hospital in active labour.

276.          RM A said that at that time, she was providing labour cares to another woman at the public hospital. RM A stated that, as the back-up LMC (RM T) was unable to be contacted and her client had birthed, she agreed to assist with labour cares for Ms F once she ‘wrapped up’ with her client. The hospital midwifery staff provided Ms F with labour cares until RM A’s arrival to assist at 3.28am.

277.          There were no complications during labour, and Baby F was born at 4.58am.

278.          RM A said that the Acting Charge Midwife Manager was kind enough to assign a core midwife to help her with the postnatal cares and paperwork. Following Baby F’s birth, RM A handed over care of Ms F and Baby F to the hospital staff. There is no documentation as to what was handed over or when this occurred, although RM A’s last entry is made at 7.50am, and staff midwife documentation continued at 7.53am.

279.          After Ms F was transferred to the maternity ward, the clinical notes for the morning shift record Ms F’s progress, and that a meeting on the ward with Oranga Tamariki had been arranged for the following day.

Oranga Tamariki’s safety plan

280.          On the morning of 4 Month4, Ms F and her partner met with Oranga Tamariki and a social worker.

281.          Oranga Tamariki told HDC:

‘On [4 Month4] it is recorded that a safety plan was organised where [Ms F] and baby were to be discharged from hospital and into the care of [Ms F’s mother] who would provide 24/7 supervision.’

Review of events

282.          Following the events, Health NZ completed an incident report. The incident report states:

‘Handover by back-up LMC. Back-up LMC did not provide all relevant information (none) regarding significant [Oranga Tamariki] and social work concerns which affected the providing of care to mum and her baby. Only when curious about the [Oranga Tamariki] flag on [electronic whiteboard] did it become clear that there was a lot of information not provided — particularly regarding the need for a sitter during the postnatal stay. This was subsequently difficult to arrange at such short notice … Back-up LMC handed over no [information] at all regarding [Oranga Tamariki] and appeared to not know anything about it.’

RM A’s response

283.          RM A told the Midwifery Council that she was unaware of Oranga Tamariki’s safety plan when care of Ms F was handed over. RM A said:

‘When I handed over to the postnatal midwife, I did not know anything about needing a sitter during the postnatal stay and from the MIS and hospital notes, it would appear that [RM S] did not know either. The only documentation was that [Ms F] would go home postnatally.’

284.          RM A also said that the birth care plan is not in the MIS notes and so she did not have access to it, and the only note of Oranga Tamariki involvement in the MIS notes was the record on 28 Month3.

285.          RM A told HDC:

‘I did have time to read the MIS notes while attending my own labouring woman. I was also aware of [Ms F’s] history from discussions at our weekly midwifery practice meetings that [RM S] occasionally attended.’

My opinion

286.          Oranga Tamariki’s involvement in Ms F’s pregnancy was noted in the maternity booking form completed by RM S dated 21 Month3.

287.          On 28 Month3, RM S documented in the clinical records that Oranga Tamariki would provide her with an update if any plans were made for Ms F and Baby F, but there was no further mention of Oranga Tamariki in the clinical notes. On 2 Month4, when RM S assessed Ms F in early labour, Oranga Tamariki’s involvement was documented in the hospital clinical records, but no details of Oranga Tamariki’s plan are included.

288.          I am unable to determine with certainty when Oranga Tamariki’s plan for a postnatal sitter was made. It appears that Oranga Tamariki’s safety plan was put in place the day after Baby F’s birth.

289.          RM Emerson noted that there did not appear to be a formal handover in the clinical notes, although staff midwife documentation followed RM A’s previous documentation. RM Emerson advised:

‘If it is accepted that [RM A] was not the intended back up and stepped in an hour and a half prior to [Ms F] birthing, then there is a moderate departure in accepted practice [in not] documenting a thorough [handover] to the staff.’

290.          I accept RM Emerson’s advice. I am concerned that RM A did not document her handover. However, I acknowledge that there were other health professionals involved in Ms F’s care and that RM A had limited information about Oranga Tamariki’s involvement when care of Ms F was handed over.

291.          In addition, while I acknowledge Health NZ’s concerns, the need for a sitter was not documented anywhere in the clinical records that RM A had access to at the time. I am therefore not critical that RM A did not document this information in her own clinical records.

292.          In the circumstances I accept that RM A’s management of Ms F and her baby postnatally was significantly hampered by her late involvement in their care. I acknowledge that RM A was not the intended back-up LMC for Ms F, and that RM A provided assistance with Ms F’s labour at short notice because the back-up LMC was unavailable. In my view, these are mitigating factors, and therefore I am not critical of the care provided by RM A and I consider that she did not breach the Code in relation to her handover.

Care provided to Ms H — breach

Introduction

293.          In 2020, Ms H registered with RM O as her LMC midwife. RM A provided Ms H with back-up LMC care during labour.

294.          Health NZ raised concern about RM A’s monitoring of the fetal heartbeat during labour, and that RM A did not act promptly when she was having difficulty hearing the fetal heartbeat. Sadly, Ms H’s baby was stillborn at term.

Labour

295.          Ms H planned on having a water birth at her home.

296.          Ms H was 40+2 weeks’ gestation when she went into early labour. At 1.23pm, Ms H sent a text message to RM A advising that she was in early labour. RM A went to see Ms H after completing a postnatal visit for another client.

297.          RM A documented that on arrival at 2.55pm, she performed maternal baseline observations. RM A also performed palpation and listened to the fetal heartbeat. RM A documented in the clinical records:

‘Was tricky to hear baby’s [heartbeat] as heard [mum’s] at 94–112, but did finally hear it around 140.[45] Did feel and see a movement in process too. Heard best centrally above pubic bone.’

298.          RM A noted that Ms H was coping well. RM A left Ms H’s home and advised that Ms H should call her when the contractions continued for longer than a minute, for at least an hour.

299.          RM A documented that she returned to Ms H’s home at 6.03pm as the contractions were consistently longer than a minute for over an hour.

300.          On her arrival at Ms H’s home, RM A documented that the fetal heartbeat was ‘still difficult to hear but eventually got it’.

301.          RM A documented in the clinical records that the fetal heart rate was 138bpm at 6.06pm, 144bpm at 6.56pm, and 115bpm at 7.07pm (which were all normal). No maternal heart rate was documented at any of these times.

302.          At 7.09pm, Ms H entered the birthing pool. At 7.49pm, RM A documented in the clinical records: ‘Tried to hear baby’s [heartbeat] between a few contraction[s]. Heard it momentarily a couple of times but not long enough to get a read out.’

303.          At approximately 8.30pm, RM A contacted RM T, another back-up LMC, for assistance. RM A sent RM T a text message that said:

‘[Ms H] said she is feeling a bit of pressure. I’m stressed as the heartbeat is really hard to get. I’m probably just tired and they have techno music playing which [is] probably increasing my heart rate. Could you please come over …’

304.          RM A said that usually she would wait until ‘effective pushing is established’ to call a second midwife for a birth but, because she was tired, she called RM T early as she ‘sought support and another pair of eyes’.

305.          At 8.37pm, RM A documented that the fetal heart rate was 120bpm (normal). No maternal heart rate was documented.

306.          RM T arrived at Ms H’s home at 9.13pm.

307.          There are inconsistencies between RM T’s recollection of the events and RM A’s documentation about the fetal heartbeat.

308.          RM A documented that RM T was able to hear the fetal heartbeat. At 9.32pm, RM A documented in the clinical records: ‘[RM T] tried listening to [heartbeat]. Heard faintly at about 120 with [Ms H] standing.’

309.          RM T has a different recollection of the events and said that she never heard the fetal heartbeat. RM T stated:

‘I asked [RM A] when she thought she last heard the fetal heartbeat, she said she wasn’t sure. I look[ed] through the notes and could only see 3–4 times [within] the last few hours that [RM A] had check[ed] for the fetal heartbeat and the last couple that had been documented she was not 100 percent as she commented to me. I picked up the doppler and went over to [Ms H] and asked her if I could please try to listen to [the] baby’s heartbeat. She said yes. I tried but it was different as [Ms H] was in the pool and working hard. I then explained after the next contraction if she could get out of the pool to try, please. She said she would try. I then spoke to [RM A] and said when was the last time she felt confident about getting the heartbeat. She did not have time to answer as [Ms H’s husband] then asked what was happening should we be concerned. I explained that [RM A] had been finding it difficult to pick up the fetal heartbeat and I would really like [Ms H] to get out of the pool for me to try again. [Ms H] got out of the pool after the next contraction and lay down on the couch. I was still not able to locate a fetal heartbeat. [Ms H] then needed to stand up due to the pain of the contraction. The conversation was had about doing a vaginal exam to see if we could stimulate [the] baby or work out a position in case we were not listening in the correct location. [RM A] declined the vaginal exam and asked me to complete it [as] she said she is not very good at working out position. I looked at her and said I am a new grad midwife so am no good at working out if the baby is posterior or anterior yet however, I performed the vaginal exam with [Ms H’s] consent and was easily able to locate the baby’s head and [Ms H] was 9cm dilated. I once again tried to hear a fetal heartbeat for where we should hear it know[ing] where the baby’s head is located and unfortunately, I could still not hear a fetal heartbeat. [Ms H] then had to stand for another contraction, I then looked up at her and said I am so sorry I cannot get a fetal heartbeat and we need to go to [the hospital] as soon as possible.’

310.          At 9.52pm, RM A documented in the clinical records that Ms H was ‘out of the pool due to not being able to hear [fetal] heartbeat’. A vaginal examination and palpation were performed. RM A documented that the baby’s head was at fetal station -1 and that Ms H’s cervix was 8cm dilated.

311.          As no fetal heartbeat could be heard, Ms H was transferred to hospital.

Admission to hospital

312.          Ms H was admitted to the public hospital at 10.14pm.

313.          On admission, no fetal heartbeat could be seen or heard. The ACMM documented in the clinical records that RM A had reported difficulty hearing the fetal heartbeat throughout the day, and following assessment by the ACMM, a registrar, and an obstetrics consultant, it was confirmed that no fetal heartbeat was present, and condolences were given. The ACMM documented that she suggested that RM A and RM T head home, as care was now with tertiary services.

314.          Sadly, the baby was stillborn.

Postmortem report

315.          The postmortem report concluded that the baby had died ‘in association with placental pathology’. The postmortem report found that the placenta had ‘mild acute chorioamnionitis[46] with a fetal inflammatory response’ and ‘severe (high grade) chronic villitis of unknown aetiology[47]’.

Health NZ

316.          Health NZ told the Midwifery Council:

‘[T]here seemed to be a lack of realisation from [RM A] about the severity of struggling to hear the [fetal heart rate] “all day” and no reflection of the need in such a situation to conduct a full assessment to feel confident about hearing the fetal heart rate and then to act earlier if there were concerns.’

Concerns raised by Ms H

317.          Ms H provided HDC with further information about her concerns with RM A’s care. Ms H said that it was important to note that what happened to her baby was a combination of ‘a major issue with the placenta’ (which meant that the baby did not get the oxygen she required during labour), as well as RM A’s practice.

318.          Ms H said that prior to her labour, RM A had been busy with other births, and that RM A was ‘very tired’. Ms H believes that RM A should have called someone else to attend to her labour and birth.

319.          Ms H said that RM A incorrectly attributed her difficulty finding a consistent heartbeat to the position of the baby. Ms H stated:

‘This meant that action was not taken early enough (going to the hospital), and faint or inconsistent heartbeats were accepted by [RM A] as normal for many hours during the labour. [RM A] also did not check the heartbeat as regularly as she should have (especially given the inconsistent results she was getting), with up to an hour in between checks at times. We were subsequently told by our hospital obstetrician that we should have come to the hospital as soon as there were any concerns regarding heart rates.’

320.          Ms H said that RM A advised her that she had called the back-up midwife (RM T) earlier than usual because she was tired and wanted support. Ms H stated:

‘The backup midwife was a new grad and when she arrived, [RM A] asked her to do an internal examination. We subsequently were told that this was unacceptable for an experienced midwife to ask a new midwife to do this and that [RM A] should have been taking the lead.’

321.          Ms H also raised concerns about RM A’s documentation. Ms H said:

‘Following [the baby’s] death, we spent time looking over [RM A’s] notes and found several errors, including noting down heart rates at times where it was not assessed. This was extremely frustrating and distressing to me, particularly [given my profession], as correct note taking is vital and there should not be errors regarding basic facts such as times and heart rate results.’

RM A’s response

322.          RM A told the Midwifery Council that she listened to the fetal heart rate at least every 30 minutes but that she documented it only when she ‘clearly heard and could count the baby’s heartbeat’. RM A said:

‘The [District Heath Board] guidelines on Fetal Heart Monitoring suggest listening every 15–30 minutes in active labour. During [Ms H’s] labour I realise that, despite listening in at least every 30 minutes I only documented when I clearly heard and could count the baby’s heartbeat. [Ms H’s] contractions were coming so fast and furiously that it was difficult to locate the precise spot to hear the baby’s heartbeat clearly in the time available. I omitted to document every time I could not clearly do so and even though I listened to the fetal heart frequently, comparing it with [Ms H’s] pulse if it was unclear, I did not record those attempts. That is a fault in my record keeping which I will never allow to happen again.’

323.          RM A also said:

‘Throughout [Ms H’s] labour, including immediately prior to transfer, I was always hearing either maternal and/or baby’s heartbeat … It is true that I struggled to hear clearly, but always did, in fact, hear a good and regular heartbeat, which I documented. There was no “concern” because I always did hear the heartbeat, it was just not easy to locate it. I was therefore stunned when there was no heartbeat on the scan at the public hospital and was subsequently in profound shock.’

324.          In response to the provisional opinion, Ms H said:

‘… I struggle to understand [RM A’s] comments of not having any concerns about finding a heartbeat, even prior to transferring to the hospital. This doesn’t make sense because the reason I got out of the pool and the reason we went to the hospital was because they couldn’t find a heartbeat. Our experience matches more with [RM T’s] report …’

Policies and guidelines

Fetal heart monitoring

325.          Health NZ’s guidelines on fetal heart monitoring[48] (Fetal Heart Guidelines) state that during the first stage of labour, the fetal heart rate should be monitored using intermittent auscultation every 15 to 30 minutes. The Fetal Heart Guidelines state that the monitoring should commence toward the end of a contraction and last for 30 to 60 seconds afterwards.

326.          The Fetal Heart Guidelines state that a normal fetal heart rate is between 110–160bpm.

327.          The Fetal Heart Guidelines state that both intermittent auscultation and continuous electronic fetal monitoring require careful documentation, and that the timing and duration is to be documented, as well as the equipment used to listen to the fetal heart.

328.          The Fetal Heart Guidelines state that fetal monitoring training is mandatory for all health professionals undertaking any aspect of electronic fetal monitoring, and is a strong recommendation for all self-employed LMCs, with no charge to attend.

My opinion

Fetal monitoring

329.          The RANZCOG Clinical Guideline on Intrapartum Fetal Surveillance[49] (the Fetal Surveillance Guideline) states that it is recommended that intermittent auscultation be undertaken and documented every 15–30 minutes in the active phase of the first stage of labour.

330.          Health NZ’s Fetal Heart Guidelines are consistent with RANZCOG’s Fetal Surveillance Guideline, and also state that the fetal heartbeat should be monitored every 15–30 minutes. Under the Access Agreement, all Health NZ’s clinical policies and procedures formed the basis of primary maternity care provided in the facilities. While the birth did not take place in Health NZ’s facility, as an LMC who regularly worked in Health NZ’s facilities, RM A would have been aware of Health NZ’s Fetal Heart Guidelines, and she would have been required to follow these guidelines in Health NZ’s facility.

331.          Between 6.06pm and 9.32pm (the last time when the fetal heartbeat was documented as being heard), RM A documented the fetal heart rate on five occasions,[50] and it was documented as a normal rate. No maternal heart rate was documented by RM A after 2.55pm. In addition, there are inconsistencies between RM A’s documentation and RM T’s recollection of the events for the final recording at 9.32pm.

332.          RM A documented that the fetal heartbeat was heard ‘faintly’ by RM T at 9.32pm, and that the fetal heart rate was normal. RM T denied this and said that she never heard the fetal heartbeat. It is evident that an attempt to hear the fetal heartbeat occurred at this time but given that RM T used a Doppler and RM A did not listen herself, I am inclined to accept RM T’s recollection of events that the fetal heartbeat was not heard at 9.32pm.

333.          There are also inconsistencies between RM A’s and Ms H’s recollection of the events. RM A said that she listened to the fetal heartbeat at least every 30 minutes but that she documented it only when she could hear it clearly and was able to ‘count the baby’s heartbeat’. On the other hand, Ms H said that RM A did not listen to the fetal heartbeat as regularly as she should have, with up to an hour in between checks at times.

334.          I note that in the five documented recordings of fetal heart rate, apart from the 11 minutes between the 6.56pm and 7.07pm recording, the other recordings do represent gaps of 50 minutes to 1.5 hours, which appears more consistent with Ms H’s recollection. While RM A said that she documented only when she could hear the fetal heart rate clearly, I note that RM A did document on one occasion (at 7.49pm) that she tried to hear the fetal heart rate and, while she heard it momentarily, she could not hear it for long enough to determine the rate.

335.          Having considered RM A’s documentation and the differing statements presented by RM A and Ms H, and for the reasons outlined above, including the additional feedback Ms H has offered in response to the provisional opinion, I consider that it is more likely than not that RM A listened to the fetal heartbeat on only five[51] occasions (and recorded the fetal heart rate on four of these) between 6.06pm and 8.37pm, as set out in her clinical records.

336.          RM Emerson advised:

‘If it is accepted that the fetal heart was not heard a minimum of every 30 minutes in the first stage of labour and the notes do not adequately represent the difficulty or do not document a differentiated maternal heart rate and additional confirmation and support was not sought in a timely manner, this represents a moderate to severe departure from accepted midwifery practice in both midwifery care and documentation.’

337.          I accept RM Emerson’s advice. I am critical that RM A failed to monitor the fetal heartbeat every 15 to 30 minutes. This was contrary to RANZCOG’s Fetal Surveillance Guideline, and contrary to accepted practice.

338.          RM A should have monitored the fetal heartbeat at least every 30 minutes. I find it concerning that RM A left Ms H unassessed for extended periods of time, with almost an hour of no fetal surveillance at certain points. Given the concerns RM A had around hearing the fetal heartbeat clearly, I would have expected her to monitor Ms H more closely, and to listen to the fetal heartbeat more frequently.

339.          In addition, given the difficulty RM A had with hearing the fetal heartbeat, I am critical that she did not seek support earlier. The Midwifery Council Competencies for Practice clause 2.6 states:

‘The midwife identifies factors in the woman/wāhine or her baby/tamaiti during labour and birth which indicate the necessity for consultation with, or referral to, another midwife or a specialist medical practitioner.’

340.          In my view, RM A should have sought support from another midwife or specialist medical practitioner at 7.49pm. By that time, RM A had already been having difficulty hearing the fetal heartbeat and could no longer be reassured that she was hearing it clearly.

341.          In addition, I am critical that RM A did not record a maternal heartbeat at all after 2.55pm. It is important to differentiate between a maternal and fetal heartbeat, especially in circumstances where the practitioner is finding it difficult to hear the fetal heartbeat. RM A’s documentation does not adequately represent the difficulty she was having with hearing the fetal heartbeat clearly. In addition, RM A did not record the assessments accurately as she documented that a fetal heartbeat was heard by RM T at 9.32pm, when that was not the case. However, I acknowledge that this error could have occurred because of a misunderstanding or miscommunication with RM T.

342.          Maternal and fetal monitoring require careful documentation. The importance of diligently and accurately documenting maternal and fetal wellbeing cannot be overstated.

343.          Standard Two of the NZCOM’s Standard of Practice states:

‘The midwife provides accurate and timely written progress notes and relevant documented evidence of all decisions made and midwifery care offered and provided.’

Conclusion

344.          By failing to monitor the fetal heart rate adequately, including documented differentiation of this from the maternal heart rate, and failing to escalate her concerns about fetal heart rate in a timely manner, I find that RM A failed to provide services to Ms H with reasonable care and skill, in breach of Right 4(1) of the Code.

345.          In addition, I find that RM A’s documentation was poor and does not meet the standard required by the Midwifery Council, in breach of Right 4(2) of the Code.

Summary

346.          RM Emerson advised that from her review of the information gathered, there are emerging themes in the care provided by RM A, which include:

‘·     Documentation that does not meet the accepted midwifery standard.

·      There is a lack of record of consultation with and handover to secondary care.

·      There is a lack of documented discussion both by text or phone and a sparsity of documentation regarding assessment.

·      There is a sparsity of history review and consideration at the onset of care episodes.

·      Lack of baseline observations to determine fetal and maternal wellbeing at critical stages of labour, a lack of palpation, and evaluation of history at the commencement of labour.’

347.          I accept RM Emerson’s advice. The numerous failures by RM A represent a pattern of poor care and, overall, the care provided by RM A was not in keeping with the standard reasonably expected of a midwife. In summary, I have found that RM A:

·     Breached Right 6(1)(b)[52] of the Code for failing to provide the appropriate information that could reasonably have been expected to be received.

·     Breached Right 4(1)[53] of the Code for:

—     Failing to recognise a condition that necessitated consultation with, or referral to, another medical practitioner;

—     Failing to perform palpation and maternal baseline observations;

—     Failing to monitor both maternal and fetal wellbeing and failing to perform ongoing observations at critical stages of labour; and

—     Failing to respond with timely and appropriate intervention when there were indications of difficulty.

·     Breached Right 4(2)[54] of the Code for failing to keep adequate and accurate records.

Recommendations

348.          As RM A is no longer practising as a midwife, I recommend that RM A:

a)   Provide written apologies to Ms B, Ms C, Ms D, Ms E, Ms G, Ms H, and their whānau for the deficiencies in care outlined in this report. The apologies are to be sent to HDC, for forwarding to each of the women and their whānau, within three weeks of the date of this report.

b)   Should she decide to return to midwifery practice, undertake a full return-to-practice programme to update her midwifery knowledge, skills, and competencies to practise, as recommended by the Midwifery Council.

Follow-up actions

349.          A copy of this report will be provided to Health NZ|Te Whatu Ora.

350.          A copy of this report with details identifying the parties removed, except the advisor on this case, will be sent to the Midwifery Council, and it will be advised of RM A’s name.

351.          A copy of this report with details identifying the parties removed, except the advisor on this case, will be sent to Te Kāreti o Nga Kaiwhakawhanau Ki Aotearoa│New Zealand College of Midwives and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

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