Now, the Health and Disability Commissioner (HDC) has criticised the healthcare provider and midwives for “unacceptable” care provided to the new mum in a recently released decision.
The woman, identified as Ms B, was 41 weeks and two days gestation when she was visited by a lead maternity carer in her home after experiencing pains, vaginal discharge and vomiting. She had a planned induction labour set for two days later.
The carer recorded Ms B’s blood pressure as high and she was taken to Tauranga Hospital’s maternity unit around 9pm.
A doctor saw Ms B and her blood pressure was recorded as normal. The doctor decided Ms B should be seen every four hours for overnight observations.
However, Ms B told the HDC that she was monitored for approximately two hours and she was given pain relief. She was due to give birth the next morning.
“[I was] advised to rest and if I woke in the night to call my bell so my [blood pressure] could be done. I was left unattended all night with high [blood pressure],’” she said.
At 11.30pm Ms B was given pain medication and encouraged to sleep. She was also told to call staff if she needed them.
Ms B rang the bell at 2.40am for a blood pressure check and was seen by a midwife who documented it as normal. The midwife noted that Ms B was reporting irregular contractions, which is not established labour.
The midwife said if Ms B’s labour was increasing in severity, this was not communicated to her and she would have acted on it if it was.
The midwife was off the floor from around 3.30am and at 6am, documented in Ms B’s notes that she had been left undisturbed as she hadn’t heard from her.
However, Ms B told the HDC the documentation that she remained settled overnight was incorrect and that she was in “excruciating pain” in the early hours of the morning and rang the bell around 5am.
She said an orderly attended to her but she was told that no midwives were available as they were busy attending an emergency.
Ms B said about an hour later a nurse came in and commenced CTG monitoring and said she would be back in ten minutes but did not return until roughly 30 minutes had passed.
Another midwife who had been called into work early assessed Ms B as being “tired, exhausted and sore” and that her blood pressure taken at 6.30am was borderline/high.
The midwife was then called away to assist with another birth, at which she remained for most of the morning.
Ms B’s observations are documented as being taken at 6.30am, and the CTG recorded a fetal heart deceleration at approximately 6.32am. It is unclear whether the midwife was in the room when the deceleration occurred.
The CTG trace was not read and reviewed until approximately 7.20am. Once this was identified, a midwife activated the emergency bell and Ms B was transferred to the delivery suite where it was discovered Ms B’s membranes were artificially ruptured after a vaginal examination, indicating fetal stress.
An emergency Caesarean section was commenced, and the baby was born in poor condition and required resuscitation and transfer to the Special Care Baby Unit (SCBU) for meconium aspiration syndrome.
The baby remained in hospital for specialist care for several weeks.
Ms B told HDC that this was a “traumatic experience”.
She was concerned she had high blood pressure overnight and if her baby had been delivered by a Caesarean section during the night she would have been able to bring them home sooner to spend time with a family member who died a few weeks after the baby was born.
Te Whatu Ora Hauora a Toi Bay of Plenty told the HDC that the overnight shift during Ms B’s labour was an “unusually busy shift” with six births in seven hours, not including Ms B’s.
Although the healthcare provider acknowledged that the documentation of Ms B’s clinical care over the night shift was not comprehensive and timely.
Te Whatu Ora Hauora a Toi Bay of Plenty acknowledged and apologised for the impact this event had on the whānau concerned.
“It acknowledges that the delay in the recognition of an abnormal CTG trace meant the baby’s distress was not identified and acted upon at the earliest possible time,” a spokesperson said.
The healthcare provider also made a formal written apology to the family.
While HDC Deputy Commissioner Rose Wall was satisfied that the woman’s blood pressure was monitored appropriately overnight in line with Ministry of Health guidelines, she found that the delay between commencing the CTG and reviewing the trace was “unacceptable”.
Wall was critical of the midwife responsible for commencing the CTG and handing over any concerns, as well as the core midwife who asked for CTG monitoring to be commenced but did not follow up on the outcome.
Wall was also critical of another midwife who failed to bring an abnormal test result to the attention of the doctor caring for the woman overnight.
Te Whatu Ora Hauora a Toi Bay of Plenty has made a number of changes since this event relating to the monitoring of fetal wellbeing. The hospital has also put measures in place to better support staff when the labour ward is exceptionally busy.
Wall also made recommendations for the healthcare provider such as writing the woman an apology letter and reporting back to the HDC on the impact the changes have had on patient care.
By Emily Moorhouse
Open Justice multimedia journalist
