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Delayed post-dates induction of labour and inadequate assessment of risks (11HDC00515)

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(11HDC00515, 11 July 2013)

Midwife ~ Obstetrician ~ District health board ~ Risk factors ~ Decreased fetal movements ~ Appropriateness of care ~ Right 4(1)

During a woman's first pregnancy she was reviewed by an obstetrician at 40 weeks and six days' gestation and was diagnosed with oligohydramnios. The woman delivered her baby by emergency Caesarean section following a failed induction. During the delivery, the fetal heart showed at least three episodes of bradycardia. However, the baby was born healthy and was not identified as being growth restricted.

During the woman's second pregnancy her Body Mass Index was 36, which indicated maternal obesity. The woman's Lead Maternity Carer (LMC) was a hospital midwife, who referred the woman to an obstetrician. At 31 weeks and two days' gestation the obstetrician assessed the woman and noted the complications in her first pregnancy.

At 40 weeks and one day gestation the woman reported decreased fetal movements to her LMC. The following day, the woman repeated her concerns to the obstetrician. The obstetrician conducted a bedside ultrasound scan and cardiotocograph (CTG) monitoring. At that time the woman had respiratory symptoms, so the obstetrician decided to delay an elective Caesarean section until the woman's symptoms had cleared. At 41 weeks and one day gestation the woman was admitted to hospital for a pre-admission check, and ultrasound scans confirmed intrauterine fetal death. The following day the woman delivered her stillborn baby by induction. Poor communication contributed to the LMC not being present at the birth. The post-mortem report states that the baby was small for gestation, as was the woman's first child.

The Commissioner found that the obstetrician should have taken a more cautious approach to the management of the woman's second pregnancy. At the woman's initial consultation the obstetrician should have considered whether serial ultrasound growth assessments were warranted. When the woman reported decreased fetal movements two days post term, the obstetrician should have carefully considered the woman's risk factors and either assessed her or delivered the baby on or before 40 weeks and six days' gestation. To delay the Caesarean section until 41 weeks and two days' gestation, without earlier assessment, was suboptimal. The obstetrician was held to have breached Right 4(1).

DHB staff should have recognised that the woman's delivery would be distressing and ensured that she had appropriate support, particularly from her LMC.

The LMC was initially unclear about the nature and extent of her responsibilities. The LMC had a duty to ensure she was clear about her clinical responsibilities and to make those responsibilities clear to the woman. If there is any ambiguity, a discussion between a woman and her LMC should take place.

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