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Antenatal care of woman carrying fetus small for dates (09HDC01581)
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Obstetrician ~ Midwife ~ Public hospital ~ DHB ~ Antenatal
clinic assessments ~ Antenatal systems ~ Maternal fetal medicine ~
Intrauterine growth restriction ~ Pre-eclampsia ~ Rights 4(1),
A 21-year-old woman who was pregnant for the first time was
referred to the fetal medicine service at a DHB for investigation
and monitoring of her fetus' early onset intrauterine growth
restriction. The woman was first seen at the clinic when she was in
the 21st week of her pregnancy by a clinician who was an
obstetrician and gynaecologist specialising in maternal-fetal
medicine. The obstetrician performed an initial assessment and
arranged to see the woman again two weeks later.
When the woman was seen in the 23rd and
24th weeks of her pregnancy, her routine antenatal
screening assessments were conducted and recorded. The tests showed
that she had a trace of protein in her urine, but were otherwise
normal. The obstetrician tried to persuade the woman to have an
amniocentesis to establish the cause of the baby's growth
restriction but the woman refused.
When the woman attended the hospital maternal fetal medicine
antenatal clinic in the 25th week of her pregnancy, she
was accompanied by her mother who was concerned that her daughter
had swollen hands and feet, and says she told the obstetrician she
was concerned that her daughter might be developing toxaemia. The
obstetrician denies being advised of these concerns and again tried
to persuade the woman to consent to amniocentesis.
At this appointment, the clinic midwife, who was responsible for
conducting routine assessments (blood pressure, urinalysis and
weight) of the women attending the clinic had noted the woman's
attendance but the woman's routine antenatal assessments were not
checked. The obstetrician signed off the woman's record, which
included blanks for the uncompleted blood pressure and urinalysis
tests but did not follow up the absence of the assessments.
The next week the woman again attended the clinic. This time she
was accompanied by her partner. She had a severe headache, blurred
vision and swollen hands and these symptoms were communicated to
the obstetrician. The absence of the previous week's antenatal
assessments was noted, but again no routine antenatal assessments
were performed. Later that night, the woman returned to the
hospital by ambulance, was admitted and underwent an urgent
Caesarean section. The baby was transferred to a neonatal intensive
care unit but died a few days later.
It was held that the obstetrician breached Right 4(1) for twice
failing to adequately assess the woman or follow up the absence of
blood pressure recordings and urinalysis results. This was part of
the expected assessment of the woman and should have been carried
out as part of the consultations.
The midwife assigned to the clinic, who was not established to
have seen the woman on the two relevant visits, failed to take
steps to ensure that the woman's routine recordings were taken or
to ensure the woman was advised not to leave before the
observations were taken. However, she was not found to have
breached the Code.
By not ensuring the fetal medicine clinic had appropriate
systems in place, that roles at the clinic were clearly defined,
and that the clinic midwife was able to undertake the necessary
observations on all patients, the DHB breached Rights 4(1) and
It was recommended that the obstetrician enter into an
appropriate mentoring relationship. She was also referred her to
the Director of Proceedings. Recommendations to the DHB included
ensuring the implementation of clear pathways for the care of
patients attending the clinic.