(12HDC00876, 17 December 2013)
Health and Disability Commissioner Anthony Hill today released a report finding a midwife in breach of the Code of Patient Rights for severe departures from the accepted standard of care.
The newly graduated midwife assessed a 31-year-old woman at a birthing centre at 4am, after the woman’s waters broke spontaneously at home and contractions started several hours earlier. It was known to the midwife that the baby was in the posterior position, the woman had experienced difficulties with the birth of her first son, and the woman was anxious and in pain.
Over the following ten and a half hours, the midwife did not adequately assess and monitor the woman and the fetal heart rate, support the woman, or document the care and treatment she provided. Following her assessment at 4am, the midwife administered pethidine to the woman and sent her home against her wishes and when it was not clinically appropriate to do so. When she reassessed the woman at home four hours later, she found the woman to be fully dilated and pushing involuntarily with her contractions. The midwife transferred the woman back to the birthing centre via ambulance. After an hour and a half of active pushing at the birthing centre with no progress, the midwife transferred the woman to the public hospital via ambulance at approximately 1pm.
Mr Hill found that the midwife did not consult a specialist and/or transfer the woman to secondary care in a timely manner, provide adequate handover information to the public hospital staff, or clarify who was responsible for the woman’s ongoing care when the woman was transferred to the public hospital.
The woman’s baby was born at the public hospital at 3pm that afternoon by emergency Caesarean section following a prolonged second stage of labour. Sadly, the baby could not be resuscitated and died shortly after birth. The woman suffered a spontaneous uterine rupture and required emergency surgery, including an abdominal hysterectomy.
In addition to referring the midwife to the Director of Proceedings to determine whether any proceedings should be taken, the Commissioner recommended that the midwife establish a three-year mentoring and continuing education plan with the Midwifery Council of New Zealand and the New Zealand College of Midwives. Mr Hill recommended that the midwife complete that plan before returning to work as a self-employed community-based midwife.
Mr Hill also found the hospital’s obstetric registrar in breach of the Code for failing to adequately assess the woman and for instigating an inappropriate treatment plan. Furthermore, Mr Hill concluded that the woman received poor midwifery care from the public hospital midwives, for which the DHB was found in breach of the Code.
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