Health and Disability Commissioner Anthony Hill today released a report finding a midwife and a District Health Board in
breach of the Code of Health and Disability Services Consumers’ Rights for the care provided to a pregnant woman with
high risk factors.
The woman had two high risk factors - a high body mass index and an inconclusive Hepatitis C status. She was under the
care of a midwife lead maternity carer (LMC) who did not advise the woman of the recommendation in the Ministry of
Health’s Guidelines for Consultation with Obstetric and Related Medical Services (Referral Guidelines) that she consult
with an obstetrician about her care. When the woman was admitted to the hospital in early labour, the senior medical
officer and the obstetric registrar were not advised of the risk factors, and the labour was augmented with syntocinon
without a full obstetric review. Later there was fetal distress and the obstetric registrar planned for a category two
Caesarean section, which is a response to fetal compromise that is not immediately life threatening. He confirmed his
plan by phone with the senior medical officer, who was conducting a clinic elsewhere in the hospital. Tragically, the
baby was stillborn.
Mr Hill found that the LMC midwife failed to advise the woman of the recommendations in the Referral Guidelines in
relation to her high body mass index and inconclusive Hepatitis C status, which was information that a reasonable
consumer would expect to receive in the woman’s circumstances. Mr Hill also found that the care provided by the DHB was
seriously compromised because the DHB did not create an environment that ensured the registrar was supervised
appropriately; the DHB’s handover practice was suboptimal; there were deficiencies in internal communication; and the
DHB policy relating to syntocinon was inappropriate.
Mr Hill recommended that the DHB review its handover process, implement daily consultant-led ward rounds, and confirm
the implementation of the associate clinical midwifery manager role, cardiotocograph (CTG) interpretation cards, and
weekly CTG meetings. Mr Hill further recommended that the midwife undertake training on informed consent and the
Referral Guidelines, and that the registrar undertake training on fetal surveillance.