There were no complications with the birth and the little boy was considered healthy, with an Apgar score of 10, the maximum.
After he was born, the baby was placed on his mother’s chest for skin-to-skin contact and breastfeeding.
The mother had suffered a second-degree perineal tear during labour, which required suturing.
The midwife left the room to collect equipment, then returned and checked on the baby before she began suturing, starting when the baby was about 50 minutes old.
The mother was given nitrous oxide gas for pain relief.
From her position at the end of the bed, the midwife was unable to see the baby’s face while she was suturing.
Deputy Health and Disability Commissioner Rose Wall. Photo / Lance Lawson
She later recalled checking with the mother twice during the procedure, which lasted about 20 minutes, asking if he was warm enough and what he was doing.
The mother replied that the baby was warm, and that he was sleeping.
Action to Improve Maternity Health (AIM), an organisation that seeks to improve the maternity system, acted for the baby’s whānau before the HDC, and said the mother’s sight of the baby was obstructed by the mask she was wearing to receive the gas.
AIM also said that it was “inappropriate” for the midwife to rely on the mother’s opinion as she might have been affected by the nitrous oxide.
The baby’s father had also left the room, to make a phone call.
When the suturing was finished, the midwife went out of the room again to turn on a shower for the mother.
She returned and at about 12.30am, about an hour and a quarter after the birth, she lifted the baby to complete a full postnatal check.
The midwife realised that the baby was unresponsive and had stopped breathing. Efforts to resuscitate him were unsuccessful.
A coroner later found that the probable cause of death was accidental asphyxiation.
Guidelines require an hour of assessment
Ministry of Health guidelines state that all new mothers and their babies should receive “active and ongoing assessment” for at least an hour after the birth and should not be left alone – even for a short time.
Particular care needs to be taken during periods of skin-to-skin contact.
Deputy commissioner Rose Wall said the midwife accepted that she had breached the Code of Health and Disability Service Consumers’ Rights.
“I consider that [the midwife’s] practice departed from the Ministry of Health’s guidelines when she chose to begin suturing during the one-hour window in which active supervision was required and without ensuring that [the baby] was able to be actively monitored by herself or another suitable person,” Wall said.
“I acknowledge that, while she was suturing, [the midwife] asked [the mother] for two updates on [the baby’s] wellbeing, but I do not consider that this met the threshold for active monitoring as required by the guidelines.”
The midwife has provided a formal written apology to the baby’s family.
She also did not renew her practising certificate when it expired in March 2022.
“Noting that [the midwife] has retired and is no longer practising midwifery, I have no further recommendations,” Wall said.
Ric Stevens spent many years working for the former New Zealand Press Association news agency, including as a political reporter at Parliament, before holding senior positions at various daily newspapers. He joined NZME’s Open Justice team in 2022 and is based in Hawke’s Bay.