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Inadequate newborn resuscitation technique and post-partum haemorrhage monitoring (07HDC08615)

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(07HDC08615, 17 September 2008)

Midwife ~ Lead maternity carer ~ Labour ~ Ambulance ~ Rural ~ Brain injury ~ Bradycardia ~ Resuscitation ~ Intubation  ~ Rights 4(1), 4(2)

A 34-year-old woman went into labour with her first baby in the early hours of the morning, and was monitored by an independent midwife (her LMC) at a rural maternity unit. When a prolonged episode of bradycardia was noted at 10.43am, the woman left the birthing bath, the LMC called for urgent assistance, and another midwife arrived to help. Shortly after arriving in the delivery room, the second midwife called for an ambulance because the baby's heartbeat was still low. A third midwife, an enrolled nurse, and a trainee midwife also arrived to assist.

The ambulance arrived at 11am. The baby's heartbeat had returned to normal, and the ambulance crew were asked to remain on standby because the birth was imminent. The baby was delivered at 11.04am, and was taken to the resuscitation table where two of the midwives provided the baby with oxygen and chest compressions. The chest compressions brought the baby's heart rate up, but this was not sustained and her heart rate dropped to 40bpm. The first attempt to intubate the baby at 11.25am was unsuccessful. At 11.27am the public hospital's Neonatal Intensive Care Unit (NICU) was notified of the situation and the retrieval team asked to attend. A second intubation at 11.35am appeared successful and the baby's heart rate stabilised but her condition did not improve. The Neonatal Retrieval Team arrived at midday.

The third midwife assumed responsibility for the woman's care while the other two midwives were resuscitating the baby. The woman haemorrhaged following delivery of the placenta and required resuscitative support. The ambulance was recalled and transferred her urgently to hospital. The baby was admitted to NICU and was found to have sustained a major brain injury presumed to have been the result of the delay in establishing effective resuscitation.

It was held that the LMC breached Right 4(1) by failing to exercise reasonable care and skill when assessing the woman's well-being, and when attempting to resuscitate the baby. She also failed to comply with professional midwifery standards in relation to her documentation of events, and breached Right 4(2). However, it was held that she did not breach Right 4(1) in relation to her postnatal care of the woman.

The second midwife was held not to have resuscitated the baby with reasonable care and skill, breaching Right 4(1). As the lead practitioner for the resuscitation, she had an obligation to comprehensively document the resuscitation provided. By failing to do so she breached Right 4(2).

It was also held that by failing to remain with the woman during the third stage of her labour when she was at risk of a postpartum haemorrhage, the third midwife did not provide midwifery services with reasonable care and skill, and breached Right 4(1).


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