Newborn baby's death followed suboptimal care by midwife, DHB, paediatric registrar

Suboptimal care during labour which resulted in the death of a newborn baby in 2016 has seen a District Health Board, a self-employed midwife and a paediatric registrar being found in breach of the Code of Health and Disability Services Consumers’ Rights.


The woman arrived at the hospital in spontaneous labour at term with her first baby under the care of the self-employed midwife (her lead maternity carer), Deputy Health and Disability Commissioner Rose Wall said in a statement today.

It was unclear to the LMC midwife as to who was responsible for managing the labour from that time.

After several hours of labour, the woman was mistakenly assessed as having progressed to the second stage with some signs of fetal distress.

After pushing for nearly two hours, it was recognised that the vaginal wall had been mistaken for the fetal head and the woman’s cervix was only 6cm dilated.

The labour continued but further signs of fetal distress were not reported to the obstetrician, with the baby delivered by caesarean section but requiring resuscitation.

Care was found to be suboptimal in some points, with the baby dying within 24 hours of birth.

Ms Wall found a number of omissions in the woman’s care and was critical of the midwife’s lack of clarity regarding her ongoing role and the handover to secondary care.

The LMC midwife’s lack of clarity and aspects of the system in place at the DHB contributed to the omissions, Ms Wall said.

The paediatric registrar was criticised for administering an incorrect dose of midazolam to the baby. The DHB systems also came in for criticism for several aspects of sub-standard care provided to the baby.

The DHB, the midwife, and the paediatric registrar were all asked to provide written apologies to the family.

Recommendations were also made and the DHB developed guidelines that set out the transfer process from primary to secondary maternity care at the hospital.

The midwife undertook a number of actions to meet the requirements of the Midwifery Council competence programme, Ms Wall said in a statement.