Names have been removed to protect privacy (except Birthcare Huntly Ltd and the advisor). Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.

 

Birthcare Huntly Limited

Midwife, RM C

 

 

A Report by the Deputy Health and Disability Commissioner

 

 

 

Contents

Complaint and investigation

Information gathered during investigation

My opinion

Opinion: RM C — breach

Opinion: Birthcare Huntly

Changes made since events

Recommendations

Follow-up actions

Appendix A: Independent clinical advice to Commissioner

Appendix B: Timeline of labour and delivery

 

 

He hōnore he korōria ki te Atua, he maungārongo ki te whenua

He whakaaro pai ki ngā tāngata katoa

He kura i tangihia he maimai aroha

Kia rātou te hunga kua moe

Kia koe e Baby A e moe

Moe iho rā koe i roto i te ngāwaritanga o te atua

Moe mai, moe mai, moe mai rā

Paimārire

Complaint and investigation

1. The Health and Disability Commissioner (HDC) received a complaint from Mrs B about the services provided to her daughter, Ms A, by Registered Midwife (RM) C and Birthcare Huntly Limited. The following issues were identified for investigation:

• Whether Lead Maternity Carer, Registered Midwife — RM C provided Ms A with an appropriate standard of care and culturally appropriate services in 2021.

• Whether Birthcare Huntly Limited provided Ms A with an appropriate standard of care and culturally appropriate services in 2021.

2. This report is the opinion of Rose Wall, Deputy Health and Disability Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
3. The parties directly involved in the investigation were:

Ms A                                                                     Consumer

Mr A                                                                      Ms A’s partner, Baby A’s father

Mrs B                                                                    Complainant

RM C                                                                     Lead Maternity Carer

4. Further information was received from:

RM D                                                                     Birthcare Huntly midwife

RM E                                                                     Birthcare Huntly midwife

RM F                                                                     Birthcare Huntly Clinical Manager

RM G                                                                     Lead Maternity Carer (present at Birthcare at time of events)

5. Independent advice was obtained from RM Mary Wood and is included as Appendix A.

Information gathered during investigation

6. This report discusses the concerns surrounding the care provided to Ms A by RM C and Birthcare Huntly Limited (Birthcare) in 2021.[1] I thank Ms A and her whānau for taking the time to bring their concerns to HDC.

Background

7. In 2021, Ms A became pregnant with her first child.
8. At the 20-week scan, Ms A and her whānau were excited to hear that their baby was a boy.
9. In the early hours of the morning at 40 weeks and 4 days’ gestation (40+4), Ms A started to experience labour pains. As the labour pains intensified, Ms A, accompanied by Mr A and Ms A’s mother, Mrs B, transferred to Birthcare. In response to the COVID-19 pandemic, the region had implemented public health restrictions,[2] and therefore whānau support was restricted.
10. At approximately 10.30am at 40+4 weeks, Baby A was delivered stillborn.
11. In their complaint to HDC, the whānau raised concerns surrounding the antenatal care and monitoring by RM C, the delivery of Baby A at Birthcare, the postnatal care, and the communication and cultural safety.
12. A timeline of Ms A’s labour and delivery is included as Appendix B.

Ms A’s antenatal care and monitoring

Antenatal care

13. Ms A registered with RM C on the day of her first visit when she was 20 weeks + 6 days into her pregnancy. Ms A then had antenatal visits at:

• 26+3 weeks
• 35+2 weeks
• 36+2 weeks
• 37+6 weeks
• 38+5 weeks
• 39+3 weeks
• 40+3 weeks

14. Mrs B and the whānau raised concerns around the lack of documentation, with no detailed notes completed for any of the antenatal visits. They are concerned that no routine bloods were checked during the pregnancy and that there is no written record of Ms A’s birth plan.
15. RM C recorded minimal commentary in the clinical notes from any of the antenatal visits before 40+3 weeks, other than basic results such as blood pressure, urine analysis, fundal height, and presentation of the baby. For example, at 38+5 weeks the clinical narrative in RM C’s electronic notes simply states: ‘well mama.’ At 39+3 weeks it states: ‘Finally [on] maternity leave. Birthplan discussion with [Ms A, Mrs B, and Mr A] all well follow up next Tuesday.’ No detail of the birth plan is recorded.
16. RM C acknowledged that the electronic documentation could have captured discussions more thoroughly.
17. RM C also stated:

‘[Ms A] was provided with handheld notes during her initial booking, which included discussions about her diet and antenatal education. At each subsequent visit, additional information was added to her notes, and blood and scan forms were left inside the back of the notes for [Ms A] to complete. Unfortunately, [Ms A] stopped carrying these notes.’

18. Ms A refutes the statement that she stopped carrying the notes.
19. There are no blood test results in Ms A’s antenatal record. When asked whether routine blood tests were taken and what the results were, RM C told HDC that normally she requests antenatal bloods routinely. RM C said that Ms A had already completed her first set of blood tests through her GP, and she obtained a copy of the results and discussed these with Ms A.
20. No first trimester screening scan or anatomy scan is included in the antenatal notes. An ultrasound report for a growth scan was completed at 29 weeks, with no notes made in the antenatal record as to why this scan was requested.
21. The 29-week scan noted marginal cord insertion[3] and bilateral talipes.[4] When asked whether RM C considered making a referral for these conditions and whether this was discussed with Ms A, RM C told HDC:

‘If a decision is made to refer for bilateral talipes this would normally be carried out post birth not during the pregnancy. [Ms A] was aware of this decision and happy to wait until post-delivery of her baby. There was an Anatomy Scan at 29 weeks — I did not receive the results of the scan and was not aware of the marginal cord insertion.’

22. RM C also told HDC that the visit schedule for Ms A did not meet the usual standards.[5] She stated: ‘[T]he irregular schedule was because Ms A frequently cancelled and rescheduled her appointments, resulting in fragmented antenatal care.’
23. Ms A refutes this statement.
24. Mrs B and her whānau are concerned about the care Ms A received from RM C. Mrs B and the whānau told HDC that Ms A attended every antenatal appointment and took her health and the health of her baby seriously, trusting that every test and scan was being recommended and done during her pregnancy.

Fetal monitoring at 40+3 weeks

25. During the final antenatal visit at 40+3 weeks, Ms A advised RM C that she had noticed fewer movements of her baby since 10pm the previous night and had become worried.
26. RM C arranged with Ms A to go to Birthcare to carry out CTG monitoring. The CTG trace demonstrated a baseline fetal heart rate of 140bpm, which is considered within the normal range. RM C recorded in the antenatal notes that a CTG assessment had been arranged due to Ms A’s concerns of reduced fetal movements at 40+3 weeks. There is no record of what was discussed, or comments from RM C about her interpretation of the CTG.
27. RM C told HDC:

‘The findings from the CTG indicated that [Ms A] was experiencing early labour and I predicted that she would enter established labour within 24 hours. I informed her of this from my interpretation of the CTG, and she seemed to be in the early stages of labour. However, I should have recorded the results and discussion with [Ms A] and her partner. The baseline and CTG appeared to me to be within normal limits, therefore I did not consult.’

Transfer to Birthcare Huntly

28. Mrs B and the whānau referred to the birth plan and said that Ms A had made it clear that she wanted to deliver her baby at another location (Birthing Unit 2) because she knew the owner and it was closer to the public hospital in case of an emergency. In Ms A’s antenatal notes, Birthing Unit 2 is noted as the intended location of birth, and this had been included at her booking visit.
29. Mrs B and the whānau recalled that in discussions between Ms A and RM C, RM C seemed to prefer Ms A to birth at Birthcare.
30. At approximately 1.20am at 40+4 weeks, Ms A started to experience the beginnings of labour pain. Mrs B said that she was able to make contact with RM C at around 3.03am, and at 4.05am RM C arrived at Ms A’s house. An internal examination was not able to be completed, although there is no clear explanation of why, and RM C advised Ms A to move to Birthcare. Mrs B said that she was told that she could sit out on the deck at Birthcare (in response to the public health restrictions, which allowed only one support person in the birthing suite).
31. In response to the concerns around the change of birth location to Birthcare, RM C told HDC:

‘[Ms A’s] initial birthplace choice was [Birthing Unit 2]. Towards the later end of her pregnancy [Ms A] was anxious about her mother not being present at the birth due to COVID 19 restrictions and thought that a home birth might be a better option. However, this was changed [at 40+3 weeks]. I had mentioned Birthcare Huntly as an option as there was a deck outside the birth room where [Mrs B] could wait without … entering the room. [Mrs B] was happy with this plan, and this was the reason I went to Birthcare Huntly. My rationale to direct [Ms A] and her whānau to Birthcare was based on the discussion with [Mrs B] who wanted to attend her daughter’s birth. I was trying to be accommodating however in hindsight this was not best decision.’

32. Ms A stated that this is inaccurate and that they moved to Birthcare on the advice of RM C.
33. RM C said that in preparation for [Ms A’s] arrival at Birthcare:

‘On route to Birthcare Huntly I rang the core Midwife on shift to inquire if I could bring [Ms A] to birth at Birthcare. The staff midwife raised no concerns, nor did I as I believed [Ms A] was a normal, well, pregnant mama in labour. I informed the staff Midwife [Ms A] wanted a waterbirth and requested she prepare the birth pool. I called [Ms A] to advise them to use the side entrance. [Ms A] arrived and entered the room and went straight into the pool. The room was set up by the core midwife.’

Monitoring during first stage of labour

34. Mrs B and the whānau said that at approximately 5.15am she, Ms A, and Mr A arrived at Birthcare, where Ms A went straight into the birthing pool. Mrs B raised concern that upon their arrival at Birthcare, no observations were taken, and the baby’s heartbeat was not being monitored ‘very often’, and the pool temperature was not checked.
35. RM D was on duty at Birthcare and received the calls from RM C saying that she was on her way with Ms A, who was not booked with Birthcare. In RM D’s retrospective records, she noted that at 5.30am RM C arrived, and RM D had not realised that Ms A had arrived until RM C told her that she had let in Ms A through the ranch slider.
36. RM D said that at approximately 5.40am she called out to RM C to check the temperature of the birth pool, as she had not done it. RM D said that RM C replied that she had checked it, and that Ms A was in the pool.
37. In response to the concerns raised around Ms A’s monitoring and the temperature of the pool, RM C said that Birthcare’s procedure during COVID-19 was that women in labour were not permitted to enter the building at the front entrance, and they were required to enter through the ranch slider on the deck, directly into the labour and birth room, and Ms A was familiar with this entry as she had used it at 40+3 weeks. RM C said:

‘By the time I had made my way into the birth room, [Ms A] had already removed her clothing and climbed into the birth pool. Because of this, I did not have the opportunity to check the pool temperature prior to her getting in the pool. No dyno-map or thermometer was available in the room for me to use or a portable BP cuff was set up in the room. There was a BP cuff permanently attached to the wall, but it did not reach the pool.’

38. Ms A disputed that she was already in the pool by the time RM C arrived.
39. RM C’s clinical notes from arrival at 5.15am until 10.40am are written in retrospect. RM C noted: ‘[Ms A] is enjoying the pool, now using gas with good effect, feeling well. Breathing through contractions … Partner providing good support.’ There is a gap in documentation between 8.30am and 10.10am, which RM C explained was as a result of being actively involved in providing support to Ms A. RM C stated: ‘I was quite busy as I was the only person in the unit who was providing care during the labour.’
40. RM C told HDC that throughout Ms A’s labour, she was actively supporting her and coaching her through the labour pains, providing massage and cool cloths. RM C said:

‘I spent the duration of her labour providing this support while I was jotting down on the paper what the heartbeat was and actions I was taking during her labour. I was not offered any support from Birthcare staff throughout the duration of her labour and birth. This kept me quite busy as there was only myself, [Ms A] and partner in the room up until the stage where she started pushing. I could not write contemporaneous notes as I would normally do due to my taking an active role in the labour.’

41. No FHR is recorded between 5.15am and 7.10am. Several FHR recordings are noted within the retrospective notes but no times are recorded (see Appendix B). The rate slowly drops from 5.15am, when it is recorded as 142bpm, to 135bpm at 7.30am, 126bpm at 8.30am, 110bpm at 9.50am, 105bpm at 10.10am, then 102bpm.
42. Mrs B and the whānau noted in their complaint:

‘[RM C] is typing into a laptop which is up by the Ohio[6] table a lot so much so that the clicking of the keyboard was annoying to [Ms A] she wishes she was more “present” and not so focused in presumably writing her notes in her laptop.’

43. RM C told HDC that the whānau were incorrect in their assumption of her using a laptop during the labour. She stated:

‘I generally do not make electronic notes during labour as I found it challenging to support the mama and make electronic notes. I usually make written notes and transfer them electronically at a later stage. I did use my phone, however, to present a text message to other patients to cancel my day. I recognise this could have been seen as me using my iPad.’

44. RM C’s retrospective records state that Ms A was given IV fluids at 7.30am, but no rationale for this is recorded. RM C acknowledged that she should have documented a clear rationale for this action. She stated: ‘[Ms A’s] fluid intake was minimal during the labour, she had appeared tired and [I] made the assessment that IV fluids could possibly benefit.’
45. There is no record of Ms A’s heart rate being checked or recorded other than at 9.05am when it is documented as 72bpm. A comment at 9.50am notes that the heart rate was checked but the rate is not recorded.

Consideration of transfer to the public hospital from Birthcare

46. RM C’s clinical notes at 9am record that she ‘discussed going to the public hospital for help to assist with birth. Happy with progress await if not delivered by 10am to transfer to hospital.’ However, there is no further explanation as to why this was being considered.
47. In their complaint, the whānau said that at no time was RM C’s consideration of a possible transfer to the public hospital put to them as a whānau, and they were not asked to make a decision on this, and they were not happy about progress, as stated by RM C in her retrospective notes. The whānau said that they followed the advice and instructions of RM C as the professional in charge.

Care provided during final stage of labour

48. Mrs B and the whānau raised concerns around monitoring of the baby during the final stage of labour, and the lack of documentation. RM C told HDC that she disagreed with the whānau’s recollection of the baby’s monitoring. She said:

‘During labour, I monitored [Ms A’s] baby and took notes while also helping [Ms A] through the process. When [Ms A] entered the second stage of labour, I listened to the baby’s heart rate between contractions. Looking back, I should have requested assistance from the Birthcare staff to help me manage my responsibilities more effectively.’

49. The labour records note that Ms A attempted some pushes in the pool and was told by RM C to hold and wait for contractions and to push with them, not in between. An internal examination had been completed in the pool at approximately 6.15am, but it is not clear from the retrospective notes whether Ms A was fully dilated at this time, and there is no documentation of when Ms A’s membranes ruptured, but there is a note that a lip of cervix was present. RM C recorded that Ms A was advised to hold off pushing and ‘wait until the last bit of cervix [had been] removed’.
50. RM D describes hearing active pushing with some coaching between 6am and 6.55am. She quoted RM C as saying: ‘Down into your bum not into your throat.’ RM D recorded that at approximately 7.10am during handover to day staff, RM C came out of the birthing suite and reported to RM D and RM E that there was still a lip of cervix, so Ms A had been discouraged from pushing.
51. Birthcare’s delivery summary noted the time of full dilation as 9am; however, RM C recorded in retrospect that that at 7.30am Ms A was out of the pool and lying on the bed, and she was fully dilated. Between 8am and 8.30am Ms A was noted as pushing, with caput[7] and mucousy discharge noted.
52. In their complaint, Mrs B and the whānau recall that Ms A was struggling to push and was unsure what to do but was trying so hard every single time, becoming more and more exhausted. They also said that RM C was not listening to the baby very often.

Delivery and resuscitation

53. Mrs B said that when baby’s head finally pushed through, she observed baby’s poor colouring and the cone shape of his head, and she recalled RM C saying not to worry as it was just because he had been in the cervix so long. In the next big push, Ms A was able to deliver her baby. Mrs B said that RM C placed him on Ms A and he did not make a sound, then she quickly took him off her chest and cut his cord. Mrs B recalled seeing some meconium by baby’s mouth.  
54. RM C’s notes at 10.10am record:

‘The FHR is noted as 105 bpm well done. Mum helping to support [Ms A] pushing, FHR 102 bpm, good pushing baby advancing spontaneous delivery — male infant in poor condition … no response with stimulation, transferred onto ohio table — not responsive, called to staff for support.’

55. RM E documented that at approximately 10.36am there was a call from Birth Room one (Ms A’s room), the same time at which RM F said that the LMC might need a hand. RM E stated that she went into the birth room and RM C was rubbing baby to stimulate him, and she said she needed help. RM E said: ‘[RM C] said baby is not breathing, I turn the apgar monitor[8] on and asked what time was baby born, LMC responded she did not [know] …’
56. RM E said that RM C put baby onto the Ohio table and then took the oxygen bottle from under the table. RM E stated that she had to find a stethoscope then she checked for baby’s heart rate and took the oxygen blender from the cupboard and set it up. At this time, RM F was helping RM C with the resuscitation. RM E was then asked to call an ambulance. Another LMC, RM G, was at Birthcare at the time, and she was asked to assist.
57. RM C told HDC that RM F initially directed the resuscitation and administered the bag valve mask. RM C said that she commenced chest compressions and continued until the ambulance arrived. After consulting with the public hospital NICU, the core midwife on duty, RM E, administered adrenaline following instructions from RM F.
58. In their retrospective notes, RM F and RM E both noted that baby had a large caput on his head and bilateral talipes and was very white in colour. RM E also noted ‘meconium staining on baby’.
59. RM C said that she did not see any evidence of meconium staining on baby’s body. She stated:

‘However, I do agree that there was a small amount of meconium present when I suctioned baby’s mouth. This was not thick meconium. Furthermore, the placenta was not stained with meconium as reported by Birthcare midwives. I recall checking the placenta for completion. After removing placenta samples post-delivery and taking cord blood, I believe I would have noted if the placenta was stained with meconium to a degree of visibility as reported by Birthcare midwives. I returned the placenta to the whānau.’

60. RM F’s retrospective clinical records note that at 10.36am she arrived at the birth room and took over from RM C and gave baby a good rub with no response. At this time the Neopuff (infant resuscitator) was being retrieved from the back room and the oxygen still needed to be blended. RM F recorded:

‘Mask applied by myself with a c grip under the chin and 5 slow long puffs were given. No response after the 5 long inflation breaths, advised LMC to start heart compressions. Lots of thick [meconium liquor] came out of mouth and nose, LMC got suction to clear out mouth. Oxygen increased to 70%.’

61. RM C’s response to HDC acknowledged that she did not have sufficient resuscitation equipment ready in anticipation of Baby A’s birth. She stated:

‘However, I recognised [Baby A] was compromised immediately after birth and summoned for assistance. If a delay was noted between me requesting assistance to [RM E] entering the room, the delay was her response to recognise my need for urgent assistance. There is no emergency bell located in the birth rooms at Birthcare. To request emergency assistance, the Covid policy at the time was a LMC midwife must use the phone in the delivery room where calls are directed through the switchboard and then diverted to the hand-held phone the midwife holds. I used the phone installed in the room immediately and waited for assistance while continuing care. No onsite staff raised any concern about length of labour or enquired about the progress of labour.’

62. At approximately 10.40am, vitamin K was drawn up by RM E and given to baby with no response. RM F asked RM G to call NICU, and at 10.42am RM G conveyed to NICU that ongoing full neonatal resuscitation had been underway for 7 minutes with no response from baby, and she was requesting advice.
63. RM G noted that she was told that the obstetric registrar was just heading into theatre and to call the Associate Clinical Nurse Manager (ACNM) instead. RM G then phoned the NICU ACNM and was advised to administer adrenaline. RM G stayed on the phone to NICU.
64. At approximately 10.47am, RM E administered adrenaline to baby’s left leg while heart compressions and Neopuff inflations continued. However, there was no response from baby, and the oxygen was increased to 100%.
65. RM F noted that no fetal heartbeat was found, visually baby was very pale, and there was no response. The Neopuff and heart compressions continued.
66. The ambulance and fire crew arrived at Birthcare at approximately 10.50am, at which time RM F noted that she stepped aside and checked on mum and whānau.
67. RM G continued to relay information from the NICU staff, and a second dose of adrenaline was advised and administered. RM G noted that NICU advised the insertion of a UVC[9] and then transport to the public hospital while continuing resuscitation en route. The call ended at approximately 10.56am.
68. RM G noted that at approximately 11.10am the placenta was checked. She recorded:

‘[Placenta] appears complete, tissues noted gritty and greyish in colour, membranes appear complete, mild meconium staining. Two vessels were clearly identifiable in cord, third vessel uncertain.’

69. At 11.18am, RM G called the NICU ACNM to advise that the hospital no longer needed to prepare for arrival, as the advanced paramedic had determined that continued efforts to revive the neonate were not to go ahead, and the heart was in asystole.[10]

Communication with whānau following delivery and resuscitation

70. The whānau told HDC:

‘This day changed our lives forever, we will never be the same people, ever. The hurt that stemmed from this day has been ongoing. The pain of a baby being born in such a way is of course unbearable but there are key incidents that hurt our whānau and this mamae (pain) remains … When our baby was being resuscitated and worked on, on the ohio table, no one communicated to us what was happening! Not the LMC or the staff of Birthcare Huntly … nothing was said to us, we were left there to watch in horror and guess what was going on.’

71. Mrs B spoke about standing at the bedside of her daughter, holding her hand and asking twice what was happening, in a measured voice not wanting to distress her daughter, but not being given an answer. She stated:

‘[Ambulance service] staff enter the room; they use defibrillator paddles on the baby. No success. [RM F] comes over to the bed to us … still nothing said about what is happening.’

72. Mrs B said that a man came into the room and examined baby then spoke with RM C and ambulance staff. ‘Then everyone in the room moved away from baby, everybody and left him alone on the Ohio table, it was so sad.’
73. Mrs B said that she went to baby and lifted him off the Ohio table, and it was at this time that she realised that he had passed away. She told HDC:

‘No one said he was gone that they had finished trying … not one person in the room told us or verbalised to us that “sorry your baby has passed away” no one … [Ms A] is still on the bed, placenta delivered, still unaware of what has happened, asking … if her baby is alright, “Mama is he ok?” “Mum, what’s happening?”’

74. Mrs B said that because of the lack of communication to their whānau, they had no knowledge that baby had not taken a breath and did not have a heartbeat at the time of birth. Mrs B stated:

‘[B]ecause we heard his heartbeat at stages during his birth or what we thought was his heartbeat … [w]e assumed that he had lived and had then died on that Ohio Table, because no one communicated to us otherwise. We his whānau had to assume that once everyone in the room walked away from the Ohio Table and left him lying there on his own.

We did not come to understand that in fact he was born stillborn until 4 days after his birth after talking to the Head Midwife of Delivery Unit [at the hospital] who took the time to explain this to us.’

Ms A’s postnatal care

75. The whānau raised concerns around the care provided to Ms A following delivery of her baby. Following a night of pain and high temperatures, Ms A was taken to the public hospital by ambulance. The whānau were advised by the treating specialist that Ms A had a primary diagnosis of postnatal sepsis, urinary tract infection, and pregnancy-induced hypertension.[11] The clinical records also note that a second-degree tear had ‘not [been] sutured and [was] infected’.
76. RM C said that the inspection of Ms A’s perineum was done by RM F at Birthcare, and the second-degree laceration was noted. RM C stated: ‘[Ms A’s] perineum had been assessed by [RM F] who advised of a secondary tear that she assessed as not requiring suturing.’
77. The clinical notes contain no mention of an examination of Ms A’s perineum, but a tick-box in the delivery summary records it as being ‘intact’.
78. RM C told HDC that prior to Ms A’s discharge, clinical assessments she conducted following delivery included a check of Ms A’s blood pressure, heart rate, blood loss, and fundus.[12] However, these observations were not documented and Ms A’s temperature was not taken, and the time of Ms A’s discharge home from Birthcare was not recorded.
79. RM C said that following the delivery she had minimal support from Birthcare to help with postnatal care. She stated:

‘I took postnatal observations at the best opportunity. I agree I should have taken her temperature, however, after [Ms A] finished in the shower, she left the room and sat inside her vehicle with her partner … Under the circumstances I did my best to carry out [Ms A’s] postnatal observations and provide a comfortable space for the whānau …’

80. Ms A refutes this statement.
81. The whānau’s complaint noted that following their return home from Birthcare, Mrs B sent a text message to RM C asking about pain relief for Ms A, and she was advised that Ms A should take paracetamol. The following day, RM C sent a text message to Mrs B regarding a check-up for Ms A and to see whether Ms A would prefer another midwife. Mrs B confirmed that Ms A wanted to see another midwife.
82. The midwife arrived at the house at approximately 11.45am. On examining Ms A, the midwife advised Ms A that she needed to go to the public hospital, so an ambulance was called. The following day, Ms A underwent surgery to repair the perineal tear. She remained in hospital for a further four days.

Communication and cultural safety following baby’s stillbirth

83. In their complaint, the whānau spoke of the distress and disbelief not only of losing their baby, but also of navigating the process following a stillbirth. Mrs B said that after some time had passed, when everyone had left the birthing room, she had to go to find RM C to ask what would happen next. Mrs B said that she was advised that she could take baby home if she wished to, and that Mrs B could get up and have a shower and go home too.
84. Mrs B said she asked, ‘I can take a dead baby away from here?’ believing there must be some legalities around taking a deceased baby from the premises. She said that she was advised: ‘[Y]es if that’s what you wish to do.’
85. Mrs B told HDC that RM F spoke to her about whether Ms A wanted a post-mortem and advised that this could be done at the public hospital, with swabs, angel casting, and photos. Not understanding the purposes of completing a post-mortem, Ms A declined the post-mortem, stating that she did not want her baby hurt any further.
86. RM F also advised that the swabs could be done at Birthcare, and they could take a piece of baby’s placenta to send away for testing, and she would advise RM C.
87. RM C told HDC that RM F took the lead in providing information to the whānau regarding post-mortem options. RM C stated:

‘They were encouraged to take [Baby A] to [the public hospital] for appropriate swabs and a post-mortem. The whānau declined and wanted to take [Baby A] home. The whānau subsequently requested placental test and swabs from [Baby A]. I carried out the Cord Blood, placental sample. Not all swabs could be carried out as [the] unit did not have the appropriate number of swabs to carry out the full range of tests.’

88. Mrs B described the room as being left in disarray, with soiled linen left lying around, until she specifically asked for the room to be cleaned up. She stated:

‘[I] [f]ound [RM E], asked if the room could be cleaned up and dirty stained linen etc be taken away. The room was paru[13] and we were still sitting around in remnants of our baby’s traumatic event. It was depressing and distressing not to mention disrespectful.’

89. Mrs B said that several times she had to go out of the room to look for RM C. She said: ‘No one is in the room to support us, guide us and awhi us … we were alone.’
90. Mrs B told HDC that they wanted to bathe baby. She said: ‘[W]e didn’t want to take him home covered in his blood and meconium. We wanted him to have dignity restored and be loved and looked after.’ Mrs B said that again she needed to go to find a midwife so that they could arrange this.
91. Sometime afterwards, RM C came to the door and advised Mrs B and the whānau to take baby to a separate room on the other side of the adjoining bathroom/toilet. Mrs B and Mr A’s mother bathed baby. It was noted that RM C was in the room at different times.
92. Mrs B said she also needed to ask if baby could be weighed and measured, as the whānau had no idea of his weight and measurements.
93. Mrs B said that after baby had been dressed and taken back to his parents in the room:

‘We took photos of our baby with his mummy and daddy on the bed, the saddest photo shoot in the world. No one can imagine how painful this was for [Ms A] and [Mr A], no one. [Ms A] and [Mr A] went to wait in their vehicle. They didn’t want to be in that room any longer.’

94. Mrs B said that she went out to reception again to find RM C to advise that they were ready to leave. Mrs B spoke with RM F and was advised that a form needed to be filled out first, which she would bring to the room.
95. At this time, when the whānau were ready to leave, RM F gave them a ‘Transfer of body’ form to be completed and signed. Mrs B said:

‘It was hard and traumatic and distressing to do 2 hours after losing her mokopuna. The form states “full description of place where you intend to dispose of the body” — how difficult is that to read, as the grandmother of the baby who had just died in childbirth. The word dispose haunts us.’

96. In response to the concerns of the whānau, RM C said that under the circumstances she did her best to carry out Ms A’s postnatal observations and provide a comfortable space for the whānau. She stated:

‘I assisted the whānau to my best ability during a stressful event. [Mrs B] assisted [Ms A] to the shower. I recall [Mrs B] coming out of the room to request extra towels and bedding. I asked if she needed a hand, [Mrs B] declined. I later supported both [Mrs B] and [Mr A’s] mother to bathe and dress their mokopuna. I supported the whānau to take photos of [Baby A].

I do agree that I should have provided further assistance to provide a more culturally appropriate space for whānau and provide an opportunity for whānau to meet with me to debrief.’

97. In their complaint, the whānau spoke of the confusion and hurt experienced when the Certificate of Cause of fetal and neonatal death (medical certificate) was not filled out correctly. Mrs B said that they needed to pick up the medical certificate from Birthcare Huntly because RM C had not signed the form properly.
98. Mrs B said that when they read the certificate, it stated that baby was born at 10.30am and the time of death was recorded at 11.18am. The whānau were torn and confused, as what was written on the form led them to believe that their baby had lived and had died after birth, only to be advised later by RM Barnes that the certificate had been filled out incorrectly. Mrs B said:

‘This was the first time that the family had had confirmation that their baby never took a breath or that he didn’t have a heartbeat when he was born. Before this moment no one had told us that baby had been born stillborn, well no one had ever told us that baby died in the first place, we were all just left to assume, so again all new information.’

Birthcare Huntly’s internal investigation

99. Birthcare completed a root cause analysis investigation. The purpose of the investigation was to understand why Baby A had been stillborn and to identify whether anything could have been done to prevent this outcome.
100. The investigation identified seven areas of concern:

1. During the time Ms A was in labour at Birthcare, there was very little evidence of coordination and communication between RM C and Birthcare staff. The core equipment, eg, clinical notes package/room folder, the blood pressure monitor and emergency equipment were available but not sought out by RM C or actively offered by Birthcare staff.
2. The documentation record was not of an appropriate standard. Elements required by the Midwifery Council of New Zealand Standards (eg, care decisions with rationale, dates, times, a record of the narrative) are missing in the documentation.
3. From the available information, it appears that the care provided by RM C regarding the monitoring during labour and delivery, did not adhere to Birthcare policies.
4. The emergency bell was not activated, and the emergency resuscitation equipment (Neopuff and oxygen blender) was not immediately available as per policy.
5. There is limited contemporaneous documentation surrounding the resuscitation.
6. Clinical signs, including a lack of breathing effort at birth, an undetectable heart rate and the presence of meconium in the airways, suggest that Baby A was in a state of terminal apnoea at birth. This cannot be confirmed without formal investigation (eg, post-mortem).
7. Ms A and her whānau did not receive clear communication from staff during the resuscitation efforts. Sadly, even after the resuscitation effort was stood down, Baby A’s passing was not well communicated to them. It was not until some days later that they learned that he was stillborn, as they had believed that baby had been born alive but passed away shortly afterwards.

101. In response to the areas of concern identified, Birthcare Huntly’s recommendations included:

1. The Unbooked Woman Arriving at a Birthcare Facility policy should be reviewed to clarify the criteria and expectations for LMCs who want to bring a client to Birthcare at short notice. LMCs and Birthcare staff should be made aware of the registration process and ensure that the process is followed.
2. A protocol should be developed that sets out the expectations and responsibilities for communication between the LMC and Birthcare staff when a client is in labour. The unit manager or shift midwife should maintain communication with the LMC at regular intervals during the course of the labour, to ensure the LMC is adequately supported, and that unit staff are alert to any complications.
3. Future in-service education should include a neonatal resuscitation scenario to ensure that staff have the opportunity to practise their skills with their colleagues. Specifically, training should focus on communication during clinical emergencies, assigning roles during resuscitation, such as a scribe to document, as well as practical skills. This would be in addition to the mandatory emergency skills training undertaken annually. Training should include communication with clients and families, both during the resuscitation effort and in the time afterwards. Staff should be equipped with the skills to navigate these difficult conversations.
4. The Birthcare Stillbirth Policy should be reviewed to ensure that any learnings from this incident are used to inform future practice. A recommendation from Ms A and her whānau is that all women who experience a stillbirth or neonatal death are transferred to secondary care to ensure that they are counselled appropriately about the options available to them (for example, postmortem, placental tests, the bereavement service).
5. Ms A and her whānau should be offered the option of mediation with the staff involved — a service provided by the New Zealand College of Midwives Resolution Committee. This option was discussed at a meeting with Ms A and her whānau but the offer was declined.

Competency review

102. RM C underwent a competency review by the Midwifery Council of New Zealand, during which she practised under supervision. Following the process, in April 2022 the Council was reassured that RM C met the competency requirements for entry to the Register of Midwives and she was no longer required to practise under supervision. However, it was recommended that she engage in professional mentorship and practice development, specifically around documentation.

Responses to provisional opinion

103. Ms A and her whānau were given an opportunity to comment on the information gathered during the investigation section of the provisional opinion. They reiterated the impact this event has had on their lives. Mrs B stated: ‘Our lives changed forever, we will never be the same, never.’
104. RM C was given an opportunity to respond to the relevant sections of the provisional opinion. RM C acknowledged and accepted that:

1. 1. There were shortcoming in the standard of care she provided to Ms A;
   2. Aspects of her documentation could have been more detailed and completed to a higher standard; and
   3. These matters warrant criticism and RM C is prepared to accept that they amount to a breach of the Code.

105. RM C also accepted the recommendations proposed in the provisional opinion (set out below).
106. RM C provided a Tikanga response to HDC, acknowledging Ms A’s and her whānau’s grievances regarding the lack of cultural support, and expressing regret that they were not provided with the support they were right to expect. This response has been provided to the whānau.
107. Birthcare was given an opportunity to respond to the relevant sections of the provisional opinion. It noted that Birthcare Huntly is now closed, but it has no hesitation apologising to Ms A and her whānau on behalf of Birthcare.
108. Birthcare stated that previously RM C worked at Birthcare Huntly, and prior to that role she had been an LMC with an access agreement to Birthcare for many years. Birthcare stated: ‘[I]t is incomprehensible that she was any way deficient in terms of knowing anything about Birthcare Huntly.’

My opinion

109. I acknowledge the significant loss for Ms A and her whānau. I also recognise the courage of the whānau in sharing their mamae and bringing their concerns to the Commissioner.
110. My report has focused on the following areas of concern surrounding the standard of care provided to Ms A while under the care of RM C and Birthcare Huntly:

1. The standard of antenatal care provided to Ms A by RM C during her pregnancy, from 20 weeks’ gestation.
2. The management of Ms A’s labour.
3. The standard of care surrounding the resuscitation.
4. The standard of Ms A’s postnatal care.
5. The communication and cultural safety following baby’s stillbirth.

 

Opinion: RM C — breach

Antenatal care

111. Ms A registered with RM C at 20+6 weeks’ gestation. Ms A attended eight antenatal visits with RM C before her labour and delivery at Birthcare Huntly.

Documentation

112. Standard three of the New Zealand College of Midwives (NZCOM) Midwives Handbook for Practice provides that ‘[t]he midwife collates and documents comprehensive assessments of the woman and/or baby’s health and wellbeing’. The criteria include personal and family/whānau details, physical, psychological, emotional wellbeing, cultural and spiritual dimensions, physical, social and cultural environment, and that ‘[t]he midwife documents her assessments and uses them as a basis for ongoing midwifery practice’.
113. Prior to 40+3 weeks, RM C’s clinical notes from Ms A’s antenatal visits record only basic results such as blood pressure, urine analysis, fundal height, and presentation of the baby, with no detailed commentary. Only the CTG assessment at Birthcare Huntly at 40+3 weeks, following Ms A’s concerns of reported reduced fetal movements, is recorded.
114. My independent advisor, RM Mary Wood, also noted that very little family history is included in the notes, and the antenatal record does not indicate the reason for the growth scan at 29 weeks’ gestation.
115. Further, no anatomy scan report or first trimester screening scan is included in the antenatal notes. RM Wood advised that while Ms A was already 20+6 days into her pregnancy and that these scans may have been requested by another provider, either way RM Wood would have expected them to be included as a part of a comprehensive antenatal record.
116. While there is mention in the antenatal notes of where Ms A intended to give birth (Birthing Unit 2), there is no written record of Ms A’s birth plan.

Blood tests

117. There are also no blood test results in Ms A’s antenatal notes. The whānau raised concern that no routine blood tests were completed for Ms A while she was under the care of RM C. RM Wood advised:

‘While some midwives may choose not to request 36-week bloods, depending on individual circumstance, it would be very unusual in my experience for 28 week bloods not to be done. It is at this time antenatal diabetes screening is done and it is at this time when most midwives will evaluate the women’s full blood count (FBC) … I would consider this to be a moderate departure from acceptable standards of care.’

118. RM C told HDC that normally she requests antenatal bloods as a routine, but Ms A had already completed her first set of bloods, and these results were discussed with Ms A. However, the results are not included in the antenatal records.

29-week ultrasound scan

119. Ms A had a growth scan at 29 weeks. The results showed bilateral talipes and marginal cord insertion. RM C said that she did not receive the results of the scan and therefore was unaware of the marginal cord insertion. She also said that if a decision was made to make a referral regarding bilateral talipes, this would be carried out post-birth.

Frequency of visits

120. Ms A’s antenatal notes indicate that RM C saw Ms A at 26 weeks and then at 35 weeks’ gestation, after which weekly visits took place. RM Wood advised:

‘The frequency of visits increases after 28 weeks because this is from when fetal growth is monitored more closely, usually by fundal height measurements and it is also a time when monitoring for complications of pregnancy such as pre-eclampsia becomes important. The antenatal schedule of visits does not fit within the expected standard of antenatal care midwives provide and I would regard this as a moderate departure from expected standard.’

121. RM C agreed that the visit schedule for Ms A did not meet the usual standards; however, RM C said this was because Ms A frequently cancelled and rescheduled her appointments.  

Fetal monitoring at 40+3 weeks

122. When Ms A raised concern about reduced fetal movements, RM C advised her to complete CTG monitoring at Birthcare Huntly. RM Wood noted that while the trace demonstrated a baseline fetal heart rate of 140bpm, which was in the normal range, the CTG should have been continued for a longer period given the reduced variability and the possibility of decelerations at the beginning and the end, together with the fact that reduced fetal movement had been reported by Ms A.
123. RM Wood noted that she was unable to find any comments by RM C about her interpretation of the CTG, or any indication that she had any concerns about it. RM Wood considered that the failure to continue the CTG for a longer period was a mild departure from the acceptable standard of care.

Discussion — antenatal care

124. I find the standard of antenatal care provided to Ms A by RM C concerning. RM Wood was critical of the adequacy of RM C’s antenatal care and monitoring and considered this well below the expected standard of care. RM Wood advised:

‘If [RM C] did not have any discussion nor offer information sharing during [Ms A’s] pregnancy other than basic recordings I would regard this as a significant departure of care.’

125. I note that RM C explained that she did have discussions with Ms A around antenatal education and diet. However, the antenatal records are sparse and do not provide information about any discussions with Ms A. RM C acknowledged that the electronic documentation could have captured discussions more thoroughly. Further, the reasoning for requesting a scan at 29 weeks is not recorded, the earlier antenatal scan and blood test results are not included, and there is no recorded birth plan. In my view, the standard of RM C’s record-keeping fell well short of acceptable standards, including the NZCOM guidance in the Midwives Handbook for Practice. In the absence of detailed documentation, I am unable to conclude that appropriate antenatal discussions with Ms A occurred.
126. RM C had a responsibility to Ms A and her whānau to ensure that the wellbeing of Ms A and her baby was assessed adequately during Ms A’s antenatal care. Ms A trusted RM C to provide guidance and support during her pregnancy, which included education and guidance to complete relevant assessments and tests. Although RM C has said that it is her usual practice to request routine blood tests, in the absence of any evidence that she did so, I do not accept that this occurred for Ms A. I am particularly concerned that a 28-week blood test was not requested by RM C, as this was an important juncture at which to consider gestational diabetes and the woman’s full blood count.
127. The frequency of antenatal visits also did not meet the expected standards, particularly after 28 weeks, when they should have occurred fortnightly. While RM C explained that this was because of regular rescheduling and cancelling of appointments, I do not accept that a period of seven weeks (from 28–35 weeks’ gestation) is an acceptable interval between visits at this stage of pregnancy, when monitoring becomes more critical.
128. I note with significant concern RM C’s dismissive remarks (noted in paragraph 20) in which she states that she did not receive the results of the 29-week ultrasound scan and therefore was not aware of the marginal cord insertion. As the clinician responsible for ordering the scan, she was responsible for following up on the results and ensuring that appropriate action was taken. In the circumstances, I consider that the reporting of the marginal cord insertion and bilateral talipes warranted specialist follow-up with either an obstetrician or a neonatal fetal medicine specialist to ascertain the significance of the findings and, in particular, whether they represented any syndrome that may have required further investigation.
129. I am also critical that at 40+3 weeks, RM C did not undertake a longer period of fetal monitoring via CTG in the context of reduced variability and possible decelerations at the beginning and end, and that she did not document her interpretation of the CTG in the clinical records.
130. I accept RM Wood’s advice in relation to RM C’s antenatal care having fallen below the accepted standard. RM C had a responsibility, as Ms A’s midwife, to ensure that Ms A received antenatal care of an appropriate standard. For the reasons set out above, I consider that this did not occur.

Management of labour

Transfer to Birthcare Huntly

131. Ms A’s labour began in the early hours of the morning. Following a home visit, RM C advised Ms A to move to Birthcare Huntly. The whānau raised concern that Ms A’s place of birth was changed from the preferred venue to Birthcare Huntly. I acknowledge RM C’s reasoning for moving to Birthcare Huntly in response to the public health restrictions, and I consider that this was not unreasonable. However, I am concerned that there is no documentation of any discussions with Ms A or her whānau that would support Ms A having been well informed about the reasons for changing her intended place of delivery.

Maternal and fetal observations

132. When Ms A arrived at the birthing suite, she went straight into the birthing pool. There is no record of the pool temperature having been taken. In addition, no FHR is recorded between 5.15am and 7.10am, and several FHR measurements are recorded in the retrospective notes with no times noted. There is no record of the maternal heart rate having been checked or recorded other than at 9.05am, when it is noted as 72bpm, and at 9.50am, when the heart rate was said to have been checked but no rate is recorded.
133. RM Wood advised that the accepted standard of midwifery care for monitoring the wellbeing of a woman and baby during the labour process involves baseline observations of the woman, including initial blood pressure, temperature, and heart rate, and then four-hourly observations if all is normal. Further, the baby’s heart rate should be assessed immediately after a contraction every 15 to 30 minutes during the active part of the first stage of labour, then every 5 minutes or after every contraction during the second stage of labour.
134. RM Wood advised that RM C’s lack of regular monitoring and recording of the maternal heart rate during labour, especially during the second stage, was a significant departure from the acceptable standard of care.
135. RM Wood advised that during the labour, particularly the active pushing stage, there is no way of knowing whether RM C was actually listening to the baby or to the maternal pulse. RM Wood stated:

‘During the second stage of labour it can be sometimes challenging to pick up the fetal heart after every contraction. Sometimes when using a doppler through this time, just as you find the fetal heart another contraction begins so the woman may be moving which can make it challenging to locate and monitor the fetal heart rate for a reasonable length of time … The reason that monitoring of a baby through this stage is more intensive is because this is the time that the baby is most likely to show signs of becoming distressed.’

136. RM Wood also commented that RM C recorded in her retrospective notes that the fetal heart rate was auscultated approximately every 30 minutes, and she described what would seem to be some decelerations of the fetal heart rate during contractions when Ms A was pushing. RM Wood noted that this is a common occurrence during this stage of labour, but without the maternal heart rate being recorded it is not possible to know what was actually being heard.
137. The FHR was recorded as slowly dropping between 5.15am (142bpm) and 10.10am (102bpm). RM Wood advised that it was likely to have been the maternal heart rate heard just prior to the birth rather than the FHR. RM Wood stated:

‘If [RM C’s] description of her monitoring of the fetal heart rate is correct then I would regard this as a moderate departure from the expected standard of care because of the lack of maternal pulse being noted at the same time, the failure to auscultate the fetal heart rate at the generally recommended and expected intervals and the failure to notice the apparent dropping baseline fetal heart rate. There is no fetal heart rate recorded between 0515 and 0710 despite [Ms A] being in the last part of the first stage of labour and her labour being described as progressing rapidly.’

138. Having baseline information in the form of maternal observations and regular fetal monitoring is essential for safe care during labour. Regular observations are important to ensure that emerging trends in a woman and her baby’s wellbeing can be monitored. I am particularly concerned at the lack of monitoring of Ms A (in particular, the lack of temperature, blood pressure, and heart rate checks) and her baby’s wellbeing (in particular, the irregularity of the FHR auscultation) throughout the labour.

Pool temperature

139. RM Wood advised that when a woman is using a pool for pain relief and relaxation, baseline observations are to be done prior to entering the pool, and the pool temperature and maternal temperature are to be checked hourly and recorded, with the aim of maintaining the water temperature between 35.5°C and 36.5°C during the first stage of labour and increasing that to a maximum of 37°C during the second stage of labour if the intention is for the woman to birth in the water.[14] The Birthcare guidelines for water birth also note that the temperature should be measured hourly and documented on a partogram.[15]
140. I do not accept RM C’s explanation that she did not have time to check the pool temperature prior to Ms A getting into the water. In my view, RM C could have done this once Ms A had entered the pool, to ensure that it was kept at a safe temperature. If no portable equipment was available to RM C in the room, I would have expected her to request assistance to locate the equipment elsewhere at Birthcare, particularly considering RM D’s recollection that she reminded RM C to check the pool temperature. It is also concerning that according to RM D, when asked, RM C replied that she had checked the temperature of the water, which clearly was not correct.
141. RM C failed to satisfy herself that the temperature of the birthing pool for Ms A and baby was appropriate. The failure to complete pool temperature checks fell short of the appropriate standard of care.

Retrospective documentation

142. RM C’s clinical notes were written in retrospect from the time of Ms A’s arrival at Birthcare at 5.15am until 10.40am, and a gap in the documentation is noted between 8.30am and 10.10am. RM C told HDC that throughout Ms A’s labour, she was actively supporting her and coaching her through the labour pains, and the gap in documentation was a result of being actively involved in providing support to Ms A. RM C stated: ‘I was quite busy as I was the only person in the unit who was providing care during the labour.’
143. RM Wood advised that this was not in keeping with the acceptable standard of documentation and would be unusual in general midwifery practice. She stated:

‘[T]here is normally only one midwife with the woman during the labour process if everything is progressing normally so this should not be a barrier to recording the process of her labour as it unfolded in normal circumstances.’

144. Whilst I appreciate that RM C was appropriately taking time to support Ms A through her labour, it is my view that this should not have prevented her from making contemporaneous clinical records.

Omissions in documentation during labour

145. RM C noted that at 7.30am Ms A was administered IV fluids, but no rationale is documented for this. In addition, RM C did not record when the membranes ruptured, whether any membranes were felt, or the presence or lack of liquor, although a mucousy discharge was noted.
146. RM Wood advised that oligohydramnios[16] around a baby is an indication that either the membranes had ruptured at some time prior to the labour, or that the placenta was no longer functioning well (placental insufficiency). Anhydramnios (no liquor present) is a considerable risk factor and an indication for transfer of care because of the increased risk of cord compression during contractions, and because a lack of liquor may indicate a problem with the placenta. It would also warrant close continuous monitoring of the fetal heart rate during labour. RM Wood stated: ‘It would appear from the available notes and reflections that this was never considered [by RM C].’
147. The records contain no mention of meconium having been seen during the labour. RM Wood advised:

‘There is no mention of meconium being noted through the labour although it was clear from the presence of meconium coming from [Baby A’s] mouth and nose during the resuscitation that there had been meconium aspiration. Meconium staining of the placenta was noted and [Baby A] had meconium on his body at birth which was noted by the Birthcare midwives and the whānau. This scenario would be in keeping with anhydramnios as meconium is thick and sticky so the passage of meconium may be hidden if there is no liquor around the baby. If there is at least some liquor present it would most likely have been noted as meconium stained and have been observed during the second stage when active pushing is happening.’

148. Having considered the accounts of the whānau, the Birthcare midwives, and RM C, there is more evidence supporting that meconium was seen on Baby A’s body at delivery. Therefore, I find that meconium was present on Baby A’s body.
149. From the information gathered it is not clear when Ms A’s second stage of labour began. RM C’s retrospective notes describe Ms A as pushing between 8am and 8.30am. However, RM D said that between 6am and 6.55am she heard RM C encouraging active pushing.
150. I also note that Birthcare’s delivery summary includes the time of full dilation as 9am, but the retrospective clinical notes state that an anterior lip of cervix[17] was present from 6.15am until 7.30am, when full dilation was confirmed by vaginal examination.
151. RM Wood advised that a second stage longer than two hours would be considered somewhat prolonged for a woman’s first labour. Ms A’s second stage of labour appears to have been 2.5 to 3 hours in length, but she was heard to be actively pushing with encouragement as early as 6am. Based on this evidence, I consider that there had been active pushing, albeit with some breaks, for up to 4.5 hours prior to Baby A’s delivery.
152. The Referral Guidelines[18] define prolonged second stage requiring consultation (for a first labour) as being longer than two hours with no progress. In Ms A’s case there was progress, although it was slow.  
153. I accept RM Wood’s advice that Ms A’s labour was not progressing normally and should have warranted closer fetal monitoring, such as continuous CTG monitoring, especially considering the reduced variability and possible decelerations that had been evident on the CTG the previous day.
154. I also note that the whānau’s complaint mentioned that a ‘Plan B’, to consider a transfer to the public hospital, was recorded in RM C’s notes, yet there is no further documentation or explanation as to why this was being considered. RM Wood advised:

‘Closer monitoring of the baby’s heart rate especially during the second stage and the recognition of the lack of liquor may have alerted [RM C] to a significant concern with the baby’s wellbeing that would have resulted in a transfer to hospital for delivery of the baby. It is my opinion that the progress of the labour was not concerning to the point of needing to transfer but closer monitoring of the baby may well have resulted in a transfer if he had been shown to be under distress.’

155. I find it concerning that neither ‘Plan B’ nor any other options were considered further and that no reasoning was documented or discussed with Ms A and her whānau.

Discussion — management of labour

156. I have multiple concerns about the standard of RM C’s care of Ms A during her labour. In making this comment, I have considered RM Wood’s advice:

‘It is my opinion that the adequacy of the care and monitoring of both the mother and baby during this labour constituted a moderate departure from accepted standard of care and would be viewed as concerning by midwifery peers. Neither fetal nor maternal observations were done that would be considered to be of an appropriate standard of care, there was no consideration of the dropping fetal heart rate during the time [Ms A] was in labour at Birthcare and there was no recognition nor consideration given to the apparent anhydramnios.’

157. I am critical of the lack of monitoring of Ms A (in particular, the lack of temperature, blood pressure, and heart rate checks) and baby’s wellbeing (in particular, the irregularity of the FHR auscultation) throughout the labour, and that the birthing pool temperature was not checked regularly.
158. The retrospective and sparse documentation by RM C also means that I have been unable to determine the rationale for giving fluids at 7.30am, the time at which Ms A’s membranes ruptured, the presence or lack of liquor or meconium, the time at which the second stage of labour started, and the reasons for consideration of transfer to the public hospital. More fulsome documentation and recording of observations and key decision points would have provided a better overall picture of how slowly Ms A’s labour was progressing and would have assisted RM C in informed decision-making about the appropriate next steps, including consultation with a specialist and possible referral to secondary care for ongoing management.
159. In my opinion, the cumulative deficiencies in the care provided by RM C to Ms A during her labour amount to a failure to provide services with reasonable care and skill.

Management of resuscitation

160. RM C’s retrospective notes incorrectly record the spontaneous delivery of a male infant in poor condition at 10.10am. Mrs B said that RM C placed baby on Ms A and he did not make a sound, and RM C ‘quickly took him off her chest and cut his cord’. Mrs B noted that baby’s colouring was not good, and there was blood and meconium on his body and around his mouth. The Birthcare delivery summary noted that baby was delivered at 10.30am.
161. RM E documented that RM C’s call for assistance came at 10.36am. RM E said that when she entered the room, RM C was rubbing baby to stimulate him. RM E stated that she turned on the APGAR monitor and, when she asked what time baby was born, RM C responded that she did not know. RM C then moved baby to the Ohio table. RM E said that she located a stethoscope and checked for baby’s heart rate, and then set up the oxygen bottle with a blender from the cupboard.
162. RM Wood advised that in practice, midwives assess the condition of a baby as soon as they are born, particularly the colour, tone, and respiratory effort of the baby. Baby A, however, was delivered with no signs of life and APGARS of 0 and 0. When RM E entered the room at 10.36am, the baby was already six minutes old. RM Wood advised that there was a considerable delay in calling for help and commencing resuscitation other than providing stimulation, which in her opinion was a significant departure from the accepted standard of care. She advised:

‘[Baby A] did not display any reassuring signs of life and it would be my expectation that calling for help (using the emergency call bell) and commencing resuscitation would have happened within the first minute … Providing stimulation to [Baby A] was the correct initial action to take but this is something I would expect to be done for perhaps 20 to 30 seconds, 6 minutes is a very long time to be persisting with stimulation of a baby in the condition [Baby A] was described as being in.’

163. It is also clear from the description in RM E’s and RM F’s notes that there were further delays, as the resuscitation equipment needed to be gathered and assembled. RM Wood advised:

‘It has been my experience that most midwives will do this during the labour so they can be better prepared to manage an emergency such as this, as even with no risk factors or concerns babies will sometimes arrive unexpectedly “flat” and require resuscitation.’

164. RM C acknowledged that she did not have sufficient resuscitation equipment ready in anticipation of the birth of Baby A. In response to RM Wood’s concern about a delay in commencing resuscitation, she stated:

‘I recognised [Baby A] was compromised immediately after birth and summoned for assistance. If a delay was noted between me requesting assistance to [RM E] entering the room, the delay was her response to recognise my need for urgent assistance.’  

165. Notwithstanding this explanation, I note that there was a six-minute delay in receiving assistance from a Birthcare midwife, and that during that time RM C had not commenced resuscitation. I am critical of RM C’s actions surrounding the delivery and resuscitation. RM C’s delay in seeking assistance from Birthcare midwives, her delay in commencing the resuscitation, her failure to have the resuscitation equipment prepared adequately prior to the delivery, and her incorrect recording of the time of delivery did not meet the standards expected of an LMC midwife. In my view, this amounted to RM C failing to provide services with reasonable care and skill.

Conclusion — antenatal care, management of labour, and management of resuscitation

166. RM C had a responsibility to provide Ms A midwifery services with reasonable care and skill. As discussed above, on several occasions she failed to do so. I am critical of the standard of RM C’s antenatal care, her management of Ms A’s labour, and her management of the resuscitation, and therefore I find that she breached Right 4(1)[19] of the Code of Health and Disability Services Consumers’ Rights (the Code).
167. Further, RM C’s documentation of Ms A’s antenatal care, labour, and time of delivery did not meet the required standards, and therefore I find that she also breached Right 4(2)[20] of the Code.

Ms A’s postnatal care — adverse comment

168. Following Baby A’s stillbirth, RM C’s focus was on Baby A and the resuscitation.
169. According to the Birthcare Huntly internal investigation report, RM E delivered the placenta and RM G documented the inspection of the placenta at 11.10am. RM C said that the inspection of Ms A’s perineum was done by RM F and that the second-degree laceration was noted as not requiring suturing. The clinical notes contain no information about an examination of Ms A’s perineum, but the delivery summary is ticked as it being ‘intact’.
170. RM C stated that she conducted clinical assessments prior to Ms A’s discharge. However, these observations were not documented, and Ms A’s temperature was not taken.
171. It is understandable that RM C’s focus needed to be on the baby following his delivery. However, I am concerned that the common theme surrounding these events is the lack of supporting documentation. Whilst I acknowledge the distressing circumstances following Baby A’s delivery, in the absence of documentation I am unable to determine the validity of RM C’s statement that she undertook observations and assessments of Ms A prior to discharge.
172. Ms A required hospitalisation following her discharge from Birthcare Huntly to repair a perineal tear that had not been sutured and became infected. While it was very unfortunate that Ms A required medical intervention in hospital, I am unable to conclude that this was as a result of inappropriate care in relation to her perineal tear in the immediate postnatal period.
173. Following their return home from Birthcare, Mrs B sent a text message to RM C to request pain relief advice for Ms A. Ms A’s ongoing postnatal care was handed over to another LMC the following day, which was appropriate in the circumstances. RM Wood advised: ‘It is not uncommon for a woman to want a different midwife to take over the care following an unexpected outcome regardless of the circumstances so this was certainly in keeping with expected midwifery practice.’

Communication and cultural safety

Communication following stillbirth — breach

174. I accept that RM C’s initial focus needed to be on Baby A and the resuscitation following his delivery. I also acknowledge the trauma that surrounded these events and that individual midwives’ responses will vary.
175. However, RM C had a responsibility to Ms A and her whānau to ensure that they were communicated with effectively about what had happened. It is clear from the complaint by the whānau that little communication and cultural and emotional support was provided to them on the day of these events. I am critical that the whānau did not know that Baby A had been stillborn until four days after the delivery, when the Delivery Unit manager at the public hospital spent time with the whānau and explained this to them. The whānau should not have been left thinking that Baby A had been born alive and then passed away during the resuscitation.
176. Mrs B described needing to leave her daughter’s side several times to search for RM C to find out ‘what happens next’ or when they could leave. It is clear from the complaint that the whānau were left feeling abandoned and confused after this traumatic event.
177. The whānau were asked whether they wanted a post mortem. The whānau said that they did not understand the purpose of completing a post mortem, and therefore Ms A declined this because she did not want her baby to be hurt any further. I am disappointed that Ms A and her whānau were not provided with sufficient information to enable them to make an informed decision in this circumstance.
178. RM Wood advised:

‘[RM C] would have been busy with the paperwork involved when a stillbirth happens but failing to provide a culturally appropriate and comfortable space for the whānau was below the standards expected given the circumstances. [RM C] was still the LMC at this stage and I consider that it was primarily her responsibility to provide support and care and to document that care, despite the distress and upset she herself would have been experiencing.’

179. I agree with RM Wood that it was RM C’s responsibility to provide support and care and to document that care. In considering the concerns raised by the whānau, and with no supporting documentation of any discussions had, in my view RM C failed to provide effective communication to Ms A about what had happened to Baby A, what steps needed to happen next, and about the post-mortem process. Therefore, I find that RM C breached Right 6(1) of the Code — the right to information that a reasonable consumer, in that consumer’s circumstances, would expect to receive.

Cultural safety — adverse comment

180. The Māori Health Strategy|He Korowai Oranga was developed to address health inequities while delivering effective services that support Māori aspirations for health and wellbeing — pae ora.[21] RM C had an obligation to ensure that her practices were culturally safe and upheld the mana of Ms A and her cultural beliefs.
181. In te ao Māori, the level of tapu surrounding birth and death are heightened. Tikanga is practised to ensure that the rules surrounding tapu are observed. When certain practices are not observed, this can be considered a breach of tikanga. Tikanga underpins culturally safe practices. The NZCOM defines unsafe cultural practice as ‘any action that diminishes, demeans or dis-empowers the cultural identity of an individual’.[22]
182. In the complaint, the whānau describes Baby A’s whakapapa and his standing in his whānau as the first-born son and grandson, and of the mana te mātāmua[23] holds. Baby A’s arrival was much anticipated by his whānau.  
183. The way in which these events were handled continues to have traumatic ramifications for Ms A and her whānau.
184. The tikanga that surrounds the tapu of death acknowledges that te ara wairua[24] can involve reciting appropriate karakia and takutaku.[25] What is clear from the recollections of staff, and the documentation provided, is that there was no offer of karakia and/or guidance by a relevant person, eg, a kaumātua, to Ms A and her whānau. Ms A and her whānau had a right to be provided with services that took into account the needs and beliefs of their cultural practice.
185. It should not have been Mrs B’s role to seek and find support and ask for things to be done or provided to her whānau. The whānau’s perspective is that they were left to navigate the loss of their baby by themselves. In my view, as the LMC, RM C had an obligation to ensure that the whānau were comfortable and supported.
186. Mrs B spoke of the room being paru and the whānau still sitting around in remnants of the traumatic events, and she said she needed to ask for the room to be cleaned up. Blood from the delivery process is tapu and must be treated with care. It was disrespectful for Mrs B and her whānau to be expected to sit among the remnants of their baby’s trauma for a considerable time.
187. I am critical of RM C’s cultural response, and I consider that the cultural services and support were lacking for Ms A and her whānau.
188. I also draw attention to the importance of the tikanga that surrounds tangihanga. For many, tangihanga is about upholding the mana of the person who has passed and the whānau pani.[26] It is also the start of the healing process for the whānau pani. When Ms A and her whānau discovered that Baby A had passed, their tangihanga process began. While I cannot attribute fault to RM C for this, it is an unfortunate outcome that Ms A needed to be admitted to hospital for a period of five days, which had a negative impact on the whānau’s ability to manage the tangihanga process and therefore their healing process.

 

Opinion: Birthcare Huntly

Adequacy of care while at Birthcare Huntly — adverse comment

189. During Birthcare’s internal investigation, it was noted that the core equipment, including the clinical notes package/room folder, blood pressure monitor, and emergency equipment, were not sought out by RM C or actively offered by Birthcare staff.
190. In addition, RM C stated that no emergency bell was located in the Birthcare Huntly rooms, and she understood that the policy during the COVID-19 pandemic was to use the phone in the room to seek assistance. However, the Birthcare internal investigation found that the call bell in the room had not been activated. RM Wood stated:

‘The emergency bell was not used but rather the normal call bell was used, so the initial response from [RM E] was based on walking into an emergency situation that she was in no way expecting. She was also faced with the resuscitation equipment not being immediately available as it hadn’t been set up earlier.’

191. RM Wood advised that as an LMC, RM C is an independent practitioner, and the Birthcare staff would be expected to enter the birthing room only at the request of the LMC or if summoned by the woman or whānau in the absence of the LMC.
192. I agree that the role of LMC is independent. However, the omissions in this case in terms of RM C not seeking out core equipment and having a different understanding of the emergency bell process at Birthcare suggests to me that her orientation to the available resources and the emergency processes at the facility could have been strengthened.
193. I am not critical of the actions of the Birthcare staff in relation to their involvement in the resuscitation, and I note that RM Wood considers that they ‘acted completely within the expected standards of practice’. She commented that it would have been better for the APGAR timer to have been turned on earlier and an airway used when air entry was unable to be achieved, but she noted that this did not make any difference to the outcome.
194. RM Wood also commented that in her view, the documentation of the Birthcare midwives departed from acceptable standards mildly, given the situation they were dealing with. She said that this was because all the notes were made retrospectively, and it is unclear who was providing midwifery care to Ms A following delivery. RM Wood stated: ‘[I]t would seem to have been somewhat of a collective effort.’ I accept this advice, and whilst ideally more fulsome clinical records would have been kept following delivery, I acknowledge that the distressing situation faced by all involved may have prevented this.

Cultural safety — breach

195. Birthcare Huntly had an obligation to ensure that its practices were culturally safe and upheld Ms A’s mana and her cultural beliefs.
196. Birthcare Huntly’s Cultural Policy provides that Birthcare Huntly’s staff will ensure that each woman and their whānau’s cultural, spiritual, social and ethnic identities are maintained while they are clients at Birthcare Huntly. Birthcare Huntly therefore had an obligation to ensure that Ms A and her whānau’s cultural beliefs were maintained. From the documentation available, there is no mention of cultural support having been offered to Ms A and her whānau. The experience of the whānau was that they were left to navigate their loss alone, and how these events were handled continues to have traumatic ramifications for Ms A and her whānau.
197. I note that Birthcare Huntly’s Cultural Policy mentions the pivotal role of kaumātua in the organisation, including blessings. I also note that Birthcare Huntly’s Stillbirth Policy provides for support of a religious provider or kaumātua. I am disappointed that the whānau did not have this support and guidance made available to them, and that there was no offer of karakia to Ms A and her whānau. As mentioned previously, the level of tapu surrounding death is heightened. Tikanga is practised to ensure that the rules surrounding tapu are observed to provide safety, and the whānau should have been supported throughout this process. They had a right to be provided with services that took into account the needs and beliefs of their cultural practice.
198. I am also concerned that Mrs B had to ask to have the room cleaned up following the delivery. Birthcare Huntly staff needed to ensure that all cultural elements were considered in their response to the whānau, and this included the tikanga that surrounded the tapu of blood. I am concerned that the whānau were left to follow up this. I consider that it was disrespectful for Mrs B and her whānau to have been expected to sit among the remnants of their baby’s trauma for a considerable time.
199. In my view, Birthcare Huntly, as the organisation providing the facility in which Baby A was delivered, had a higher responsibility than RM C to provide culturally appropriate care. I am critical of Birthcare Huntly’s cultural response following Baby A’s delivery and consider that the cultural services and support provided to Ms A and her whānau were inadequate and a breach of Right 1(3)[27] of the Code.
200. Birthcare Huntly midwives completed Ms A’s postnatal checks. As mentioned previously, following discharge Ms A was admitted to the public hospital with a second-degree tear that had not been sutured and had become infected. While it was very unfortunate that Ms A required medical intervention in hospital, I am unable to conclude that this was as a result of inappropriate care in relation to her perineal tear in the immediate postnatal period. When Ms A and her whānau discovered that Baby A had passed, their tangihanga process had begun. Unfortunately, Ms A’s hospital admission had a negative impact on the whānau’s ability to manage the tangihanga process and therefore their healing process.

 

Changes made since events

201. Birthcare Huntly advised that after these events the following changes were made and incorporated the recommendations in the internal investigation:

1. 1. The unbooked labouring woman guideline was updated.
   2. A formal letter outlining the requirements of teamwork and effective communication was sent to all LMC midwife access holders at Birthcare facilities.
   3. The labour and delivery policy was reviewed to further strengthen expectations around communications between LMC midwives and Birthcare staff.
   4. Birthcare purchased a newborn resuscitation mannequin, and an education framework was developed to deliver regular neonatal resuscitation skills and drills training, incorporating teamwork, communication, documentation, and New Zealand Resuscitation Council guidelines.
   5. A birthcare neonatal resuscitation record was developed.

202. Birthcare Huntly closed at the end of October 2023.
203. As set out above, RM C underwent a competency review process with the Midwifery Council of New Zealand. She undertook further education in the areas of fetal surveillance, documentation, resuscitation, and navigating unexpected outcomes.
204. RM C no longer practises as a midwife.

 

Recommendations

RM C

205. Considering that RM C no longer practises as a midwife in any capacity and has undertaken further education as part of the competency review process, I consider that no further educational recommendations are necessary. However, in light of the concerns detailed in this report, I recommend that in the event RM C returns to practice, the Midwifery Council of New Zealand consider whether a further review of RM C’s competence is required, and report back to HDC.
206. I recommend that RM C provide an opportunity to Ms A and her whānau to meet and allow the whānau to speak of their experience and mamae. This meeting can be facilitated in consultation with HDC’s Director Māori|Mātāmua Māori. The purpose of the meeting would be to support the healing process for all parties involved and allow RM C the opportunity to express her apologies to Ms A and her whānau. If Ms A does not wish to proceed with a hui kanohi-ki-kanohi|face-to-face meeting, I recommend that RM C provide a written apology to Ms A and her whānau. The written apology is to be sent to HDC within three weeks of the date of this report. The apology will follow Ms A’s response to a hui in the first instance.

Birthcare Huntly

207. In the provisional opinion, I recommended that Birthcare provide a written apology to Ms A and her whānau for the issues identified in the report. The apology has been provided to HDC and will be given to Ms A and her whānau with this report.
208. I acknowledge the actions taken by Birthcare Huntly in response to the recommendations made in its internal investigation and understand that the Huntly facility is now closed. However, at the date of this report, the company is still registered, and the company’s other Birthcare facility remains operational. Birthcare did not consider that recommendations to its other facility were necessary, but it advised that it would take on board the following recommendations:

1. That Birthcare confirm whether its updated Unbooked Woman Arriving at a Birthcare Facility Policy has been communicated to LMCs with access agreements to its facility, within three months of the date of this report.
2. That Birthcare reflect on whether its orientation process for LMCs to the physical facility (including access to core and emergency equipment and the emergency call process) is sufficiently robust, in light of the issues identified in this case. If improvements are required to its process, I recommend that these are communicated to HDC within three months of the date of this report.
3. That Birthcare review its Cultural Safety policy to include, for instance, the practice of tikanga that surrounds the tapu of blood and the tapu of death, including the provision for relevant cultural leader/s or kaumātua to complete karakia and relevant cultural rituals. A copy of this updated policy should be provided to HDC within six months of the date of this report.
4. That Birthcare update its Stillbirth Policy to include tikanga considerations for tūpāpaku and whānau pani (bereaved family). A copy of the updated policy should be provided to HDC within six months of the date of this report.

 

Follow-up actions

209. In light of the significant concerns I have about RM C’s care of Ms A before, during, and after the delivery of Baby A, I will refer RM C to the Director of Proceedings in accordance with section 45(2)(f) of the Health and Disability Commissioner Act 1994 for the purpose of deciding whether any proceedings should be taken.
210. A copy of this report with details identifying the parties removed, except Birthcare Huntly Ltd and the advisor on this case, will be sent to the New Zealand Midwifery Council, and it will be advised of RM C’s name in covering correspondence.
211. A copy of this report with details identifying the parties removed, except Birthcare Huntly Ltd and the advisor on this case, will be sent to Health New Zealand│Te Whatu Ora and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

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