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Response to woman’s presentation during labour (11HDC00123)
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(11HDC00123, 9 June
Lead maternity carer ~ Staff midwife ~ Birthing centre ~
Labour ~ Assessment ~ Monitoring ~ Referral to hospital ~ Transfer
~ Right 4(1)
A woman, pregnant with her first child, contacted her Lead
Maternity Carer (LMC) at 2am one morning when she was 38 weeks
pregnant and was experiencing three contractions every 10 to 20
minutes. She planned to deliver at the public hospital, but the LMC
was at a birthing centre with another client and suggested that the
woman meet her there for assessment.
The woman's friend drove her to the birthing centre at 4am. As
her LMC was still occupied with the other client, the woman was
initially assessed and monitored intermittently by two staff
midwives on duty at the birthing centre. The woman advised that she
had constant and severe pain throughout her time at the birthing
centre. However, the midwives advised that the woman was not
presenting unusually in terms of her pain.
The woman's pulse rate and the monitoring of the fetal heart
rate were not reassuring. Both midwives recorded that they advised
the LMC several times of their concerns about the woman's clinical
At 5.20am, the LMC's back-up midwife was paged and arrived at
the birthing centre at 6am. She stated that the woman was
distressed and was not in normal labour. At 6.25am, the LMC
conducted a vaginal examination and referred the woman to hospital.
The LMC instructed the woman's friend to drive the woman to
hospital, without any midwifery support.
When the woman arrived at hospital, the hospital midwife and
nurse recorded that the woman had constant and severe abdominal
pain. The woman suffered a placental abruption and required
emergency care. Sadly, her baby was stillborn.
It was held that the two staff midwives' assessment and
monitoring of the woman was fragmented and incomplete. They failed
to respond appropriately to the woman's presentation and breached
It was held that the LMC failed to take appropriate action to
assess the woman at the birth centre, in response to the concerns
that were relayed to her about the woman's presentation. In
addition, the LMC's decision to transport the woman by private car
without any midwifery support was inappropriate in the
circumstances. For these failures the LMC breached Right 4(1).
It was also held that the absence of clear policies contributed
to the delay in the actions of the staff midwives, particularly in
light of their ongoing concerns about the woman's presentation. The
birthing centre breached Right 4(1).