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Abnormalities missed during labour (07HDC15908)
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(07HDC15908, 5 December 2008)
Midwife ~ District health board ~ Maternity care ~
Labour ~ Cardiotocograph ~ Fetal distress ~ Delivery ~
Communication ~ Rights 4(2), 4(5)
A man complained about the care his wife received during labour.
The woman did not progress into natural labour on her estimated
delivery date. A date for induction was subsequently made, but the
woman chose to delay this for a few days. The independent LMC
midwife identified no concerns during this period.
The labour started naturally, but progressed slowly, and the
woman was transferred to the delivery unit at the hospital because
she was becoming distressed. The midwife and clinical staff agreed
that the woman should be managed as a high-risk patient because she
was post-mature. An epidural and Syntocinon were subsequently
commenced on agreement by the clinical team, but the care was not
handed over to the clinical team.
Throughout the day the midwife noted some decelerations on the
cardiotocograph (CTG), used to measure the fetal heart rate, but
considered that these were normal. The obstetric registrar later
reviewed the CTG and noted some abnormalities. An emergency
delivery was subsequently performed but the baby was born
unresponsive and was declared dead.
It was held that the midwife failed to provide services in
accordance with professional standards by not carrying out a
continuous CTG trace prior to inserting an epidural, by failing to
appropriately interpret the CTG, and by failing to adequately
document her discussions with the obstetric team. In all these
circumstances, the midwife breached Right 4(2). She also breached
Right 4(5) by failing to refer the woman's care to the secondary
It was also held that the obstetric team was not adequately
informed of any abnormalities in the woman's labour, and therefore
had no obligation to initiate a three-way discussion under the
referral guidelines. Accordingly, the district health board did not
breach the Code.
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