The woman, who is not identified in the HDC report, went to the same midwife who delivered her first baby when she became pregnant again.<\/p>\n
However, unlike the first pregnancy, where she gained weight as expected, she \u201cvomited all day\u201d during the second and did not gain any weight at all.<\/p>\n
The midwife, who was also not identified, accepted that she did not weigh the mother but felt reassured because her abdomen was growing with each visit and scans suggested the baby was growing normally.<\/p>\n
The mother said the midwife did the \u201cbare minimum\u201d of fetal monitoring checks during eight consultations, and used a Doppler machine only once, apart from during labour.<\/p>\n
\u201c[The woman] said that, on multiple occasions, she raised that she did not think her baby was moving very much and that [the midwife] would just say that all babies are different,\u201d the HDC report said.<\/p>\n
\u201c[The woman] said that the entries in the clinical notes of reportedly normal fetal movements are inaccurate.\u201d<\/p>\n
The midwife said she offered to listen to the fetal heart rate at every appointment but that her client would not always consent.<\/p>\n
When labour started, the midwife attended the woman at home first but had her transferred to a birthing unit when she could not find a fetal heartbeat.<\/p>\n
At the birthing unit, a cardiotocography (CTG) machine was attached to monitor the fetal heart rate and uterine contractions, but was removed after six minutes.<\/p>\n
During that time, the CTG had picked up a reassuring pulse but a second attending midwife later said that the condition of the baby at birth was such that it was impossible that a heartbeat had been heard.<\/p>\n
The second midwife said the heartbeat was probably a \u201cdoubling\u201d of the mother\u2019s pulse, which sometimes happened.<\/p>\n
The HDC said there was no evidence the midwife palpated the mother\u2019s abdomen at any stage that day, nor was there any documentation of fetal movements or the regularity of contractions. <\/p>\n
The baby boy was stillborn, with the umbilical cord tightly around his neck, no heartbeat, and evidence of maceration, suggesting he had died in the uterus.<\/p>\n
An assessment of the placenta found nothing to suggest why the baby died and an autopsy was not carried out. <\/p>\n
Later, the mother commented to the HDC that everyone around her had been worried about how her pregnancy had gone.<\/p>\n
\u201cI told them my midwife wasn\u2019t worried as I felt reassured by her,\u201d the mother said.<\/p>\n
\u201cFor [the midwife] to ever say that she wasn\u2019t worried [because] I wasn\u2019t worried is a huge oversight in her care. <\/p>\n
\u201cIt was her job to properly care for me and [the baby], inform me and be aware of any risk factors that I was clearly unaware of. <\/p>\n
\u201cLooking back, they are clear as day to me.\u201d<\/p>\n
Breaches of patient rights found<\/p>\n
Deputy Health and Disability Commissioner Rose Wall said the circumstances of the case had been difficult to reconcile.<\/p>\n
This was not only because of discrepancies between the mother\u2019s complaint and the midwife\u2019s version of events, but also the \u201cpoor standard\u201d of the midwife\u2019s documentation.<\/p>\n
However, Wall said she had determined that aspects of the care provided to the mother were deficient and did not meet the required standards. <\/p>\n
Deputy Health and Disability Commissioner Rose Wall says the midwife failed to meet certain standards. Photo \/ Lance Lawson<\/p>\n
\u201c[The midwife] had a responsibility to provide midwifery services to [the woman] with reasonable care and skill,\u201d Wall said.<\/p>\n
\u201cShe failed to do so in a number of key respects.\u201d<\/p>\n
Wall said she was critical of the standard of antenatal care and the management of labour, and found that the midwife breached the code of patient rights in these regards.<\/p>\n
She said there were \u201cstark omissions\u201d in the midwifery care provided during labour. <\/p>\n
Wall also said the midwife\u2019s documentation did not meet the required standards, which was a further breach of the code.<\/p>\n
In addition to writing an apology to the mother, the midwife has told the HDC that she had introduced changes to the way she practises.<\/p>\n
These include taking scales to each appointment to monitor the mothers\u2019 weights.<\/p>\n
The Midwifery Council has since reviewed the midwife\u2019s competency and required her to complete further education on documentation and fetal surveillance. <\/p>\n
The Midwifery Council subsequently confirmed she had satisfactorily completed the competence programme.<\/p>\n
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\u2019s Open Justice team in 2022 and is based in Hawke\u2019s Bay. <\/p>\n