![\"No](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/05\/4LSIN28_copyright_image_292894.jpeg\")
<\/p>\n<\/p>\n
\nThe baby died in August 2019.
\nPhoto: 123rf\n<\/p>\n
A minutes-old baby, who died on his mother’s chest while she was sutured up following his birth, should have been checked more regularly by the midwife tasked with their care, the Health and Disability Commissioner has found.<\/p>\n
According to a decision released on Monday by deputy commissioner Rose Wall, the midwife in question breached protocol by failing to check the baby – known as Baby A throughout the report – herself in the hour after his birth.<\/p>\n
The incident occurred in August 2019, when the mother – known in the report as Ms A – gave birth at 38 weeks to Baby A at 11.16am with no complications. Baby A was healthy, and placed on his mother’s chest for breastfeeding and skin-to-skin contact.<\/p>\n
But Ms A had sustained a second-degree perineal tear during labour, which required suturing. The midwife who had been assisting during labour, Midwife A, left the room following the birth of the placenta, and Ms A’s partner also left the room to make a phone call.<\/p>\n
Ms A said the second midwife, Midwife B, also briefly left the room to collect equipment for suturing, returned, and checked Baby A before she began perineal suturing.<\/p>\n
Suturing began at 12.05pm, and the midwife estimated that the procedure was finished within 20 minutes.<\/p>\n
Ms A was provided nitrous oxide gas for pain relief, and Baby A lay skin-to-skin with Ms A throughout.<\/p>\n
The commissioner notes from Midwife B’s position at the end of the bed, she was unable to see Baby A’s face while she was suturing.<\/p>\n
She said she recalled checking with Ms A twice during the procedure about Baby A’s condition – if he was warm enough and what he was doing – to which Ms A replied that he was warm and that he was sleeping.<\/p>\n
When suturing was completed, the midwife briefly left the room to turn on the shower for the mother, and at 12.30pm, she lifted Baby A up to complete a full postnatal check.<\/p>\n
But upon picking him up, Midwife B realised he was unresponsive and had stopped breathing.<\/p>\n
Resuscitation efforts were unsuccessful. The Coronial post-mortem report found that the probable cause of Baby A’s death was accidental asphyxiation.<\/p>\n
A group called Action to Improve Maternity, in advice to the commissioner, said the midwife should have made her own observations of Baby A’s condition, and it was inappropriate to rely on Ms A’s opinion as she may have been experiencing side effects from the nitrous oxide gas.<\/p>\n
Ministry of Health’s guidelines say all mothers and their babies must receive “active and ongoing assessment in the immediate postnatal period” and “the mother and baby should not be left alone – even for a short time” within the hour after birth.<\/p>\n
The commissioner finds: “It would have been appropriate for RM B to remove Baby A from skin-to-skin contact for the duration of the procedure or to delay the suturing until another person was available to appropriately monitor him. I am therefore critical of RM B’s failure to adhere to the guidelines for supervision of mother and baby following birth.”<\/p>\n
The midwife told the commissioner she accepted she had breached protocol, and provided a letter of apology for forwarding to Baby A’s wh\u0101nau.<\/p>\n
She had since retired from midwifery practice, and the Council had confirmed she did not renew her practising certificate when it expired on 21 March 2022.<\/p>\n