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Names have been removed to protect privacy. Identifying
letters are assigned in alphabetical order and bear no relationship
to the person's actual name.
Midwife, Mrs B
A Rural Maternity Hospital
A Report by the Health and Disability Commissioner
At 4am on 13 January 2007, Ms A, a young woman in the 41st week
of her first pregnancy, was admitted in labour to a private rural
maternity hospital by her midwife, Mrs B.
At 10.35am, after a prolonged second stage, Mrs B arranged for Ms A
to be transferred to a public hospital by ambulance. Ms A was
admitted to the public hospital at 1.45pm. Her baby was
delivered by a difficult emergency Caesarean section at 3.15pm with
severe bruising to his brow and face, and a crush injury to his
Complaint and investigation
On 7 September 2007, the Health and Disability Commissioner
(HDC) received a complaint from Ms A about the services provided by
midwife Mrs B. The following issue was identified for
- The appropriateness of midwife Mrs B's management of Ms A's
labour and transfer to the public hospital on 13 January
An investigation was commenced on 24 September 2007. The parties
directly involved in the investigation were:
Ms A, Consumer/Complainant
Mrs B, Provider/Midwife
Ms C, Midwife
A private maternity hospital, Provider/Private
Independent advice was obtained from midwife Chris Stanbridge,
and is attached as Appendix 1. Additional advice was sought from Ms
Stanbridge and is attached as Appendix 2.
Ms A registered with LMC midwife Mrs B
on 18 September 2006 when she was in the 24th week
of her first pregnancy. Ms A attended antenatal visits on 27
December 2006 and 10 January 2007.
11 January 2007
At 3.30am on 11 January 2007, Ms A experienced contractions and
telephoned Mrs B, who told her to wait for an hour and, if she was
still contracting, to contact her again. Ms A was admitted to the
private maternity hospital by midwife Ms C at 5.50am. Mrs B arrived
at 6am. She performed a CTG and found that
labour had not yet established.
Ms A stayed at the hospital throughout the day. Mrs B did not
keep any notes on the progress of Ms A's condition during this
At 10pm, Mrs B noted that Ms A was "not in established labour"
and had been out for a long walk and a meal. Mrs B gave Ms A an
intramuscular injection of 50mg of pethidine for relief of pain,
and performed a CTG, which was satisfactory.
Mrs B stated that because Ms A was tired and very young she was
allowed to stay at the hospital. Mrs B stayed on duty to reassure
Ms A and her partner.
At 7am on 12 January, Mrs B reassessed Ms A and performed a
further CTG, which showed mild uterine contractions and a normal
fetal heart rate. Mrs B advised Ms A to go home to rest and to come
back to hospital on Monday 15 January for a CTG, if her labour had
Labour - 13 January
Ms A's labour commenced at 2am on 13 January. She was admitted
to the private maternity hospital at 4am by senior midwife Ms C. Ms
A did not bring the clinical record from her earlier admission on
On admission, Ms A was in good labour with contractions
occurring every two minutes. The fetal heart rate was noted to be
130-140 beats per minute (bpm).
Mrs B was notified that Ms A had been admitted and she arrived
at the hospital at 4.20am. On admission, Mrs B examined Ms A and
found that her cervix was 8−9cm dilated. Ms A's uterine membrane
ruptured spontaneously at 4.15am, yielding "slight meconium stained liquor".
Ms A says that her membranes did not rupture spontaneously and
that Mrs B ruptured it "purposely" with her fingernail, having told
her she was going to rupture the membrane and held up her
Mrs B recalls that the membrane bulged three times with
contractions. On one of these occasions, she thought she saw the
baby's head. She believes that when she inserted her finger to
check for the presence of the head, she may have inadvertently
ruptured the membrane. Mrs B said that when the membrane is bulging
in this manner, the slightest touch is enough to cause it to
rupture. She states that she would have told Ms A when the membrane
ruptured, but she would not have held her finger up in the manner
Ms A started pushing shortly after she was admitted. She recalls
that Mrs B told her she could push when she felt like it.
At 6.30am, Ms A was standing at the end of the bed, having
"good" contractions every one to two minutes and feeling some
pressure to push. Ms C continued to document Ms A's progress until
6.45am. At that time, Mrs B noted that Ms A was fully dilated
At 6.50am the "first peep" of the baby's head was seen, and Ms A
was noted to be "effectively pushing".
At 7.03am, Mrs B noted that although Ms A was pushing well, the
head was "not as low as first appeared" and was advancing slowly.
At 7.20am Mrs B recorded that Ms A was pushing well and the fetal
heart rate was 120bpm.
At 7.50am Mrs B noted that the fetal heart rate dipped to
80−90bpm during a contraction, but recovered immediately after the
contraction, rising to 130bpm.
At 8.15am, Mrs B performed a vaginal examination. She recorded
her impression that the baby was presenting "face to pubes", not a
good position for an easy delivery. She could also feel a "caput",
which is a collection of fluid under the scalp caused by the
prolonged pressure of the baby's head against the cervix. Mrs B
recorded placing Ms A in a variety of positions, to enhance her
ability to deliver vaginally.
Mrs B continued to observe Ms A and the baby closely. At 9.45am
she recorded that the fetal heart rate was 135bpm and that she saw
a "blister" on the baby's head.
Ms A complained that Mrs B ruptured this blister. Mrs B stated
that she would not and could not do this. At that time the baby's
head was still high in the pelvis. She did see "a little something"
but was not sure what she was seeing. It could have been a blister
or a piece of torn membrane. Mrs B stated that she was honest with
Ms A and recorded what she saw.
At 10.15am, when Ms A had failed to progress further, Mrs B
talked to her about transfer to the public hospital for the
delivery. At 10.17am, Ms C telephoned the ambulance service and Mrs
B started intravenous therapy in preparation for Ms A's
At 10.35am, Mrs B spoke to the public hospital's obstetric
registrar, who recorded that Ms A would be coming by ambulance. The
records note that Ms A was transferred to the ambulance at 10.55am,
accompanied by Mrs B and Ms A's partner.
It was noted that meconium-stained liquor was still draining at
10.55am and the fetal heart rate was recorded. The fetal heart rate
had been checked regularly between 7am and 9.55am, but had not been
checked in the hour before transfer.
Pain relief during transfer
Ms A said she was very distressed with pain, but that Mrs B
would not give her any pain relief until they were nearly at the
public hospital, when she was given some Entonox.
The notes record that Ms A was given Entonox in the ambulance at
11am, about five minutes after transferring to the ambulance.
Ms A denies that she was given Entonox about five minutes after
she was loaded into the ambulance. She clearly remembers first
being given the Entonox just before a town which is more than half
an hour by road from the private maternity hospital.
Mrs B stated that Ms A was connected to ambulance Entonox
cylinders, mask and tubing as soon as she was settled in the
ambulance. Ms A was "moving from position to position" at this
stage and may not remember events clearly.
Mrs B is sure that had Ms A been given pethidine at that time it
would have resulted in a "flat" baby, ie, the baby's respiratory
and circulatory systems would have been adversely affected by the
sedative effect of pethidine. She said, "It is very important to
have a safe baby especially for the [2½ to 3 hours] transfer
During the journey Mrs B monitored the well-being of Ms A and
her baby, who both remained stable.
The public hospital
Ms A arrived at the public hospital at 1.40pm. She was assessed
by an obstetric registrar who noted that there were fetal heart
decelerations with contractions. The
obstetric registrar connected a CTG, called an anaesthetist to
administer an epidural anaesthetic and, following discussion with a
consultant, planned to examine Ms A in theatre after her pain had
been brought under control. However, the spinal anaesthetic did not
work well and a second procedure was performed, which provided
effective anaesthesia. At 2.37pm the epidural was functioning but,
by this time, the baby was showing signs of fetal distress.
At 2.42pm a further vaginal examination was performed to assess
the progress and presentation of the baby. The consultant
determined that the baby was presenting abnormally, with a brow
presentation. It was decided to proceed with an immediate Caesarean
Delivery and resuscitation of baby
Ms A was transferred to theatre for the Caesarean section. The
hospital records indicate that the delivery was difficult and that
forceps were needed to extract his head from the birth canal. The
baby was suctioned at birth and initially attempted to breathe, but
at around 10 minutes became pale and stopped breathing.
The baby required respiratory support. He was intubated and transferred to
the Neonatal Intensive Care Unit. The baby had a large haematoma on
his forehead from the obstructed labour. He also suffered a crush
injury to his nose, thought to be caused by the forceps pulling him
from the birth canal. MRI scans have also revealed some brain
disturbances thought to be caused by "peripartum hypoxia" (lack of
oxygen during labour).
Helicopter transfer to public hospital
Ms A thought that she would have had a more comfortable transfer
by helicopter instead of an ambulance. Mrs B responded:
"On occasions helicopter transfer is
deemed necessary by both [a] Hospital specialist and the client's
LMC midwife when the mother and/or baby is at risk. Mother and baby
[in this case] had good observations on the way to [hospital]."
The Intensive Care Unit (ICU) Clinical Leader supported Mrs B's
decision to transfer Ms A by ambulance. There is often an overly
optimistic estimate of the time it takes to retrieve a patient by
helicopter. If the referring hospital is within 60 to 90 minutes'
drive, it is often quicker to travel by road.
He stated that there two criteria for helicopter retrieval:
"time-critical" (when a patient is at such risk that it is
imperative the patient receive treatment in the shortest possible
time) and "skill-critical" (the patient needs to be provided with
medical care not available at the referring centre). As well as
taking into account staff pick-up, the weather, daylight
conditions, and opportunity costs, the decision must be balanced
with the clinical situation and whether the patient's condition is
likely to deteriorate en route. It can be safer and quicker to
transfer by road because of the immediacy of the ambulance. If the
decision is made to decline air transport on clinical grounds, and
the situation worsens, the helicopter can then be dispatched to
meet the ambulance on the way. Delivering a baby in transit in a
helicopter is less than ideal and should be avoided whenever
Mrs B recorded Ms A's labour on two separate sets of notes. She
made rough contemporaneous notes and later transcribed them into a
more legible form.
Mrs B made two errors in transcribing her rough 'Notes on Labour
and Delivery' (the Notes) to the more legible form, the 'MMPO' midwifery notes. Mrs
B noted on the Notes at 7.20am that the fetal heart rate was
recorded in the "120s". In the MMPO notes she recorded that at
7.25am the fetal heart rate was in the "130s". She also failed to
transcribe into the MMPO notes a fetal heart rate, which was
recorded in the Notes as 122bpm at 7.45am. The Notes record Entonox
being given at 11am and the MMPO notes show that the Entonox was
given at 11.30am. All other aspects of the notes correspond.
Mrs B stated:
"[Ms A] and her family did not bring
the MMPO Care Notes with them at the second admission during the
time of labour. Following two requests from me to the client and/or
her family to give me the MMPO notes I was finally able to record,
after several months, the care provided based on the Facility
Ms A made a claim to ACC as a result of her baby's crush injury
and suspected brain injury. ACC sought expert advice from
independent obstetrician Dr Ngan Kee, who stated:
"[Ms A] was fully dilated and pushed
for three hours before the long transfer to [the public] Hospital
was arranged. There is general agreement amongst Obstetricians that
women should not push for more than 1-2 hours without intervention.
In my opinion 8.5 hours in the second stage and over 3 hours
pushing represents poor practice and in my judgement there has been
an error in management in not arranging the transfer at an earlier
In summary, it is my opinion that
errors in management occurred that contributed significantly to the
injuries that the baby sustained."
Ms A's claim was accepted as treatment injury on 6 June 2007.
For the purposes of determining whether a treatment injury has
occurred, or when that injury occurred, section 33 of the Injury
Prevention, Rehabilitation and Compensation Act 2001 defines
giving of treatment;
b) a diagnosis of a person's medical
c) a decision on the treatment to be
provided (including a decision not to provide treatment);
d) a failure to provide treatment, or
to provide treatment in a timely manner.
Dr Ngan Kee's comments suggest that the delay in Ms A being
transferred amounted to a failure to provide treatment in a timely
manner, which caused a treatment injury.
Responses to provisional opinion
Mrs B stated:
"I consider the report both
professional and fair. … It is not easy being an LMC midwife in a
rural environment two and a half hours from a base hospital. Your
best efforts to deliver 'Best Practice' care to client and baby are
on occasions not understood nor appreciated."
Ms A stated:
"I find it unacceptable that this
report gives little consideration to Obstetrician Dr Digby Ngan
Kee's opinion but rather places major emphasis on Midwife Chris
Stanbridge's opinion. I personally find the advice obtained by
Chris Stanbridge unconvincing as it is based on a considerable
amount of assumptions and creates in the reader's mind a sense of
uncertainty rather than providing factual information as to what
took place. This is highlighted by the regular use of phrases and
words such as 'it appears', … 'presumably'. …
Justifying [Mrs B's] actions because
she operates in a rural location is also unacceptable. The very
point I am trying to make with my complaint is that mothers and
babies living in such locations are not disadvantaged and have the
right to the very best kind of care appropriate to that location.
Clearly the standard of care my baby and I received in this
instance is unacceptable and needs to be addressed."
Dr Ngan Kee
Dr Ngan Kee reviewed the provisional opinion and advised:
"The management of labour in this
case ultimately led to a very prolonged second stage of 8.5 hours
with an undiagnosed brow presentation. … In my opinion there was
ample opportunity for much earlier intervention that might have
resulted in a better fetal outcome. The professionals looking after
[Ms A] should have also taken into account the increased transfer
time from a remote location in their decision making. … By any
first world standard, the care in this case is below what is
generally considered acceptable and I believe your decision should
reflect this opinion."
Dr Ngan Kee criticised the advice from Ms Stanbridge and Ms
Thorpe as contradictory because they both note, "with hindsight",
that the second stage of labour went on for too long but then go on
to say that the care was appropriate. However, on several occasions
in his report, Dr Ngan Kee refers to what "most obstetricians"
would do in this scenario. When he considers the New Zealand
College of Midwives standards, Dr Ngan Kee acknowledges that he is
considering these "as an obstetrician".
Dr Ngan Kee also commented:
"Several rural Obstetric units have
already closed ie Kaitaia and several provincial Obstetric
units [Wanganui, Masterton, Invercargill, Greymouth] are under
threat due to resource issues, primarily specialist staffing. It is
likely that many of these units will be closed (at times) in the
future, and will have to partner with larger neighbouring units to
accept acute transfers. Risk assessment, risk management and
clearly defined transfer protocols will be needed to ensure patient
safety. Prolonged second stage will be a frequent reason for
transfer and I think it is likely that a common criteria for the
transfer of primigravida will be a second stage length of 1−2
Discussion - key issues
There is some dispute about when Ms A started pushing but it is
not disputed that Ms A was in good labour at about 4am and was
fully dilated at 6.45am. The notes first show Ms A pushing at
Ms A believes that the baby should have been delivered sooner,
noting obstetrician Dr Ngan Kee's advice to ACC that Mrs B's delay
in deciding to transfer Ms A was an "error in management". Dr Ngan
Kee said that allowing a woman to labour 8½ hours in second stage
and push for more than three hours "represents poor practice". ACC,
in accepting that the baby sustained a treatment injury, implicitly
accepts the view that he should have been delivered sooner.
HDC's midwifery advisor agrees that Ms A laboured too long in
her second stage, but explained that this is only apparent now,
with the benefit of hindsight. Chris Stanbridge noted that
"[The baby's] outcome will have been influenced by the length of
[Ms A's] second stage of labour" and "8 hours is a long time for
second stage of labour" but that "it is easy to make retrospective
criticism about the care provided by another practitioner who works
in a totally different environment". Mrs Stanbridge's colleague,
Juliet Thorpe, who was asked to comment, stated that "with the
beauty of hindsight we can see how the length of second stage is of
Mrs Stanbridge advised that, in the past, there was a two-hour
limit set on the second stage of labour for a first birth. However,
the "medicalised approach" of trying to fit all women into a set
time framework for any stage of labour can result in unnecessary
intervention and cause harm. The role of the midwife is to support
the normal physiological process of birth, while watching the
mother and baby for any sign of deviation from normal. Mrs
Stanbridge advised that Mrs B made "reasonable decisions" about Ms
A's care, monitored her closely, and gave "close and appropriate
care" during the labour.
I accept that Ms A was in a stable condition throughout her
prolonged second stage of labour and that even after she was
transferred to the public hospital, she was allowed to labour for
another hour before the decision was made to proceed to delivery by
Mrs B noted meconium-stained liquor when Ms A's membranes
ruptured at 4.15am on 13 January 2007. The fetal heart rate was
monitored regularly between 4.15am and 9.55am. However, there is no
record of a fetal heart rate between 9.55am and 10.55am, when
meconium-stained liquor is noted for the second time.
Mrs Stanbridge advised:
"Meconium stained liquor (fluid
around baby) can be indicative of a baby that has or is
experiencing some element of stress. It can also occur in a mature
baby without necessarily indicating stress. Thin watery meconium
liquor is seen as less of an indication of stress than thick
meconium. It is generally seen as an indication to monitor the
baby's heart rate frequently."
Transfer to secondary services
The timing of Mrs B's decision to transfer is a key issue. There
was slow progress in the baby's descent through the birth canal. At
8.15am, Mrs B suspected the baby was not in a good position,
presenting "face to pubes". There was evidence of progress, albeit
slow progress, until 10.15am. At that time Mrs B discussed with Ms
A the need for her to transfer to the public hospital and
arrangements were made for transfer by ambulance.
In arriving at her decision Mrs B had to balance the
possibilities: Ms A delivering safely at the private maternity
hospital, the baby delivering in the ambulance with only Mrs B in
attendance and the baby needing resuscitating, and the chance of
arriving at the public hospital with a well mother and baby. This
is the reality of maternity services in rural New Zealand.
Mrs Stanbridge advised that the possibility of transfer is
always present when a woman labours in an outlying area. In a
remote rural setting, the practitioner is constantly aware of the
progress of the labour and the possibility that transfer to
secondary services might be required. When considering transfer,
the midwife needs to consider a number of factors, including
consent of the woman and her family, local transfer processes, and
the ongoing assessment, care and support of the woman and baby. The
decision to transfer needs to be balanced against the risk of not
moving. The majority of women do not transfer to a major
In relation to the timing of Ms A's transfer, Mrs Stanbridge
advised that Mrs B made a "reasonable decision", noting the good
condition of mother (although distressed) and baby on admission to
the public hospital. Ms Thorpe advised that a more thorough vaginal
examination in the second stage may have identified that the delay
in Ms A's labour was caused by a brow presentation. However, both
mother and baby were well during labour. The baby only exhibited
signs of distress some time (more than an hour and a half) after
admission. Ms Thorpe stated, "From the information I have read I
would have to concur with [Mrs Stanbridge] that reasonable
care was provided." In her view, the midwives "acted professionally
… and within the environment that they were working [in]".
Mrs B's 'Notes on Labour and Delivery' were a handwritten
contemporaneous record, whereas the MMPO notes were not completed
for several months, because she was unable to obtain the notes from
the family and finally transcribed from the original notes. Mrs B
failed to annotate that the MMPO records were completed
Mrs Stanbridge advised that Mrs B's notes are "adequate, [but]
fuller notes could have documented her rationale for actions and
decisions made and how she included Ms A and her family in decision
making". There are some minor disparities between the two sets of
notes, although not issues critical to the management of Ms A's
labour and transfer.
I have reached the following conclusions about this case:
- Mrs B met professional midwifery standards in her management of
Ms A's labour and the timing of the decision to transfer to the
- Noting the advice from my expert and the clinical leader from
the public hospital's ICU, I accept that the decision to travel by
road (ambulance) rather than air (helicopter) was sound. Nor do I
have any concerns about Mrs B's pain management during the trip.
Although the journey must have been very unpleasant for Ms A, there
was a risk that pethidine could endanger her baby.
- Mrs B's documentation did not meet professional standards.
Health professionals are required to keep accurate, clear and
legible clinical records. They are a record of the care provided to
the patient and clinical decisions made, and enable other health
professionals to coordinate care. I recommend that Mrs B review her
documentation practice in light of Mrs Stanbridge's
- Did Ms A receive "services of an appropriate standard", to
which she was entitled under Right 4(1) of the Code of Health and
Disability Services Consumers' Rights (the Code)? A woman in Ms A's
situation has the right to a reasonable standard of
maternity care. Mrs B was Ms A's lead maternity
carer. According to HDC's midwifery expert, Ms A received a
reasonable standard of midwifery care, and it is only with the
benefit of hindsight that we can say Ms A laboured too long in the
second stage of labour. According to ACC's independent obstetric
expert, Ms A did not receive an appropriate standard of maternity
care, because of "an error of management in not arranging the
transfer at an earlier stage".
It seems that obstetricians (who take a risk-averse,
interventionist approach) and midwives (who take a less
interventionist approach, to allow the normal physiological process
of labour to proceed) do not agree on what is reasonable care in
this type of situation.
The differing philosophy and practice is evident in the approach
to key issues in this case, including the frequency of fetal heart
monitoring (given the long labour and the presence of
meconium-stained liquor) and the timing of the decision to transfer
to secondary services. A case can certainly be made for closer
monitoring of the fetal heart rate (I note that there is no record
of it between 9.55am and 10.55am on 13 January 2007) and for
earlier transfer. It is a curious situation where ACC accepts that
the midwife's delay amounted to "poor practice", but midwifery
advisors describe the same care as "reasonable" and "close and
I hesitate to find that Ms A did not receive services of an
appropriate standard given this difference of professional opinion.
What is clear, however, is that midwives and obstetricians working
as lead maternity carers should spell out to women their own
philosophy of care in the event of delay or difficulties during
The "Statement on Stand-alone Primary Childbirth Units" (23 July
2007)" issued by the Royal Australian and New Zealand College of
Obstetricians and Gynaecologists (RNZCOG) notes that, where, by
virtue of a unit's remote location, onsite obstetric services are
not available, patients should be informed of the limitations of
services available and the implications for intrapartum and
postpartum care. In my view, the New Zealand College of Midwives
(NZCOM) should consider developing a consensus statement to cover
the same issues. At least that way women may be better informed
about possibilities and more empowered to ask for intervention at
an earlier point.
In conclusion, although the baby suffered a treatment injury
that may have been avoided by an earlier transfer, I do not
consider that a legal finding is justified that Mrs B failed to
provide services of an appropriate standard under the Code.
5.Given my conclusion that Mrs B did not breach the Code, it
follows that her employer, the private hospital, is not vicariously
liable for her conduct.
6. I endorse Dr Ngan Kee's comment that, for women labouring in
small rural maternity units under midwifery care, "risk assessment,
risk management and clearly defined transfer protocols will be
needed to ensure patients safety". I recommend that the RANZCOG and
NZCOM develop a joint statement covering these issues and that the
Ministry of Health ensure that appropriate transfer protocols are
- A copy of this report will be sent to the Accident Compensation
Corporation, the Midwifery Council of New Zealand, the New Zealand
College of Midwives, the Royal Australian and New Zealand College
of Obstetricians and Gynaecologists and the Ministry of
An anonymised copy of this report will be sent to the Maternity
Services Consumer Council, and the Federation of Women's Health
Councils Aotearoa, and placed on the Commissioner's website,
www.hdc.org.nz, for educational purposes.
Appendix 1 - Independent advice to Commissioner
The following expert advice was obtained from midwife Chris
"I have read the supporting information and believe, overall,
[Mrs B] provided reasonable midwifery care with the following
It appears the notes 'D' are a hand written copy of the [private
maternity hospital] facility notes, and the MMPO notes 'E' were
written in retrospect based on the facility notes. Neither have
been annotated as such, although [Mrs B] explains the copying
involved in her letter of 22.10.07. … It is unfortunate the
original notes were not included. However, I make the assumption
the facility notes have been accurately copied, and have treated
them as contemporaneous notes. … I received no notes of [Ms A's]
antenatal period. While [Mrs B's] notes are adequate, fuller notes
could have documented her rationale for actions and decisions made,
and how she included [Ms A] and her family in decision making.
The main standard that is applicable is that of the New Zealand
College of Midwives 'Midwives Handbook for Practice', standard six,
'Midwifery actions are
prioritised and implemented appropriately with no midwifery action
or omission placing the woman at risk' (the word 'woman' includes
The possibility of transfer is always present when caring for
women in outlying areas. The majority of women do not, in fact,
need transfer, either through pregnancy, labour, or
Brow presentation of the baby is an unusual phenomenon occurring
only in one in fifteen hundred births. Brow presentation is where
the baby's head is partially extended rather than the normal full
flexion - ie the baby's forehead is leading its descent rather than
the top back part of its head.
It is more likely to occur in a woman who has had previous
babies (and with other disorders, none of which [Ms A] had).
The indicators present on vaginal examination (being able to
feel the larger anterior fontanelle (meeting place of the bony
plates that make up the baby's skull; and possibly the ridge of the
eye brow)) are difficult to detect because of the swelling that
This swelling (like bruising; called caput) is commonly present
in many births, particularly first births, and especially with 'OP'
(occipito-posterior; baby facing the front of the mother rather
than the normal back facing position).
Babies presenting by a persistent brow position are not able to
birth vaginally (unless they are very small eg premature).
The current New Zealand midwifery text, 'Midwifery, Preparation
for Practice' explains what experienced midwives are aware of, and
research has demonstrated. The medicalised approach of trying to
fit all women in to a set time framework for any stage of labour
can end in unnecessary intervention, and at times causes harm. The
role of the midwife is to support the normal physiological process
of birth, while monitoring both mother and baby for signs of
deviation from the normal that might require appropriate
In the past there was a two hour time limit set on second stage
of labour for a first birth. This is no longer the universally
accepted imperative. Of more relevance is the consideration given
to progress, and the well being of mother and baby.
Where progress appears to be slow, or has slowed, there are a
number of options which can facilitate a normal birth. These
include the woman:
- changing position (squatting; standing; kneeling; sitting on
chair, toilet or birthing stool)
- moving around
- being upright (also maximises blood / oxygen availability to
- emptying her bladder
- emptying her bowel
- being encouraged and supported by family and midwife
- being in a familiar environment
- use of water - pool / bath or shower
- ensuring adequate hydration.
Also of account is the frequency and length of contractions.
Pushing is usually most effective at the peak of a contraction. If
the contractions are short there is often slow progress as there is
minimal effective pushing time in each contraction. Similarly, if
contractions are widely spaced, the overall time taken to progress
is longer than when the contractions are more frequent. In the
early time of pushing, the pushing urge may not be strong, nor
throughout the contraction, and this time may see minimal, if any,
progress. Further into the second stage the urge is much stronger
and pushing generally more effective.
When considering transfer there are a number of aspects to be
considered. There is a need to be familiar with the usual processes
needed to instigate transfer. This varies within different
institutions and regions, depending on the circumstances of that
institution. It includes knowledge of:
- who to consult with about the transfer (eg local base hospital
and the appropriate obstetric and midwifery staff within that)
- criteria for alternative forms of transport (eg is it
appropriate to use car, ambulance, helicopter)
- processes for calling the ambulance
- time expected for it to arrive
- expected skill levels of staffing of the ambulance
- time it takes to reach base hospital
- factors that may influence travel time (eg weather,
There is the decision making process - what is happening that
the midwife is considering transfer:
- this needs to be discussed with the woman and her family
- informed consent needs to be given
- discussion would then need to take place with the receiving
agency, and this may include advice on form of transport and
management for the transfer.
Relevant information needs to be shared with the receiving
- this is generally a verbal outline before transfer occurs
- this is normally accompanied by written referral, and usually
the woman's notes, on actual transfer.
- includes the woman's clinical details, medical and obstetric
history, test results, progress of pregnancy or labour to date, and
reason for transfer
Preparation for transfer includes:
- ongoing assessment of the woman and baby
- ongoing care and support for the woman and her family
- probable insertion of an intravenous (IV) line and attaching
tubing for administration of IV fluids
- possible insertion of a urinary catheter
- equipment to continue to monitor the woman and her baby en
- preparing equipment and medications to accompany the woman in
case birth occurs en route
- ensuring the family are aware of where to go when they arrive
at the base hospital
- arrangements for the return of the LMC who accompanies the
Once the ambulance arrives:
- introducing the woman and sharing of information with the
- the woman continues to need care and observation while moving
into the vehicle
- the gear needs to be transferred.
Transfer takes place with ongoing
- management of care.
On arrival at the base facility:
- introduction of the woman to the receiving staff
- physical handover of the woman
- handover of her documentation.
[Mrs B] has met the criteria of standard six of the NZCOM
Standards of Midwifery Practice that apply in this situation. This
- ongoing assessment and modifying the midwifery plan
- identifying deviations from the normal
- discussion with the woman
- consulting and referring appropriately
- working collaboratively with other health professionals
- referring when she had reached the limit of her expertise.
[Mrs B] appears to have given close and appropriate care to [Ms
A] during her labour. This includes working with the support and
collaboration of her midwifery colleague [Ms C], documented as
arriving (presumably at [the rural maternity hospital]) between 4am
and 5am, … and present (presumably in the room with [Ms A] and her
family, and [Mrs B]) from 6.50am. …
[Mrs B] documents seeing [Ms A] in early, non-established
labour. She monitored the baby with a CTG (cardiotocograph - used
to record a tracing of baby's heart rate running parallel to the
recording of contractions). … She settled [Ms A] for the night with
a small dose of pethidine (pain relief) and stemetil (to prevent
nausea and with some sedative effect). … In the morning she was
further assessed, including a CTG, before going home. …
[Ms A] returned at 4am the following morning 'in good labour'. …
She commenced using entonox - nitrous oxide and oxygen - a pain
relieving gas. … Her membranes appear to have ruptured
spontaneously at this stage. The fluid was clear to slight meconium
[Mrs B] performed a vaginal examination which showed bulging
forewaters, and the cervix opened 8−9cms (fully opened at 10cms). D
page 13. She does not record the level of the presenting part, or
if she assessed what the presenting part was.
[Ms A's] labour appears to be progressive at this stage with
strong contractions lasting 45 seconds recorded. … By 6.30am [Mrs
B] has recorded [Ms A] feeling 'some pressure'. The baby's heart
has been monitored. … [Mrs B] records [Ms A] being 'fully dilated'
at 6.45. She does not say if this was assessed by vaginal
examination or by the characteristics of [Ms A's] labour and her
response. … Baby's head was first thought to be seen at 6.50am. …
There was a further loss of 'good amount' of thin meconium stained
liquor noted at 7.03am. … Meconium stained liquor (fluid around
baby) can be indicative of a baby that has or is experiencing some
element of stress. It can also occur in a mature baby without
necessarily indicating stress. Thin watery meconium liquor is seen
as less of an indication of stress than thick meconium. It is
generally seen as an indication to monitor the baby's heart rate
[Mrs B] clarifies it was not baby's head seen earlier, but
bulging membranes. ... This is not an uncommon occurrence. [Mrs B]
acknowledges the 'great pushing' [Ms A] was doing. … [Mrs B]
continues to record baby's heart rate frequently. … She records
changes of position and [Ms A] moving around. … At 7.30am she
comments 'no further advance of head'.
[Mrs B] notes a slight drop in the heart rate with good recovery
at 7.40am, and subsequently documents the baby's heart rate more
frequently. … She does not record how she was listening to baby
(whether intermittently or continuously). No CTG recordings were
included in the notes I received.
[Mrs B] continues to document 5 minutely how [Ms A] is moving
around (staying active and upright), and the baby's heart rate. At
8.15 she notes 'descent slow? face to pubes'. … Five minutes later
she records 'starting to bulge' (a sign of progress) and 'caput'
(common 'bruising' seen on the presenting part of babies). … Being
able to see caput further suggests progress.
[Ms A] continues to move around, trying different positions.
[Mrs B] continues to record frequent heart rates. … At 9.45am, [Mrs
B] notes a blister on baby's head. This suggests there is
sufficient of baby's head on view to be able to see the blister.
Although blisters are not commonly seen, they can be present with
nothing untoward happening.
At 9.55am [Mrs B] catheterises (passes a fine tube into [Ms A's]
bladder) and measures and checks her urinalysis (urine test) and
blood pressure. … All are acceptable for the stage of labour. It
would seem that at this stage, [Mrs B] is beginning to think she
needs to be more actively assessing what is happening with [Ms A's]
By 10.15 [Mrs B] has recorded discussing transfer with [Ms A]. …
The assumption is this is acceptable to [Ms A] as the next entry,
at 10.55am, records [Ms A] now having an IV line with fluids
running, and in the ambulance. …
[Mrs B] writes [in response to HDC] that the decision to
transfer was made in conjunction with her colleague ([Ms C]) and
the [public hospital] registrar. The hospital notes support this
with an entry by the (presumably) registrar at 10.35am summarising
progress to date, and noting 'for ambulance Xfer' (transfer). …
Half hourly recordings during transfer show [Ms A] continued to
push, with the support of entonox, and baby's heart rate was within
the normal range. …
[Mrs B] appears to have:
- monitored [Ms A] and her baby closely throughout her
- made notes acknowledging slow progress in labour
- supported [Ms A] to mobilise to enhance progress
- worked closely with her midwifery colleague
- acted on the stalling of progress by referring
- arranged transfer
- prepared [Ms A] for transfer
- provided entonox to help [Ms A] cope with her labour
- accompanied [Ms A] to base hospital.
The midwife who received [Ms A] at [the public hospital],
records her being distressed and pushing with three contractions in
ten minutes. Her CTG had a baseline of 145 and was reactive ie was
reassuring. At this stage it is recorded [Ms A] is draining clear
liquor. Her recordings are normal. … It appears [Ms A] and her baby
were in good condition on admission to [the public hospital]. It is
to be expected [Ms A] would be finding it difficult to cope at this
The registrar records (in retrospect but shortly after delivery)
there was still some of baby's head palpable above the pelvic brim
abdominally, and that, on internal examination, s/he could not
define baby's presenting part because of caput. … There appears to
have been some difficulty in commencing a spinal anaesthetic (to
provide pain relief, to enable a better assessment of [Ms A's]
progress, and to enable assisted delivery). … Forty minutes after
admission to [the public hospital], late decelerations (a sign of
baby distress) are noted on the CTG. … An internal examination
(under spinal which allows more extensive examination) at 2.42pm
ascertained a brow presentation, and a repeat spinal anaesthetic
needed to be administered … to enable them to progress to a
Caesarean section an hour and 25 minutes after admission. …
In retrospect one could question whether too long was taken to
decide on transfer for [Ms A]. Documentation shows there was
spurious progress through the time of 7am to 10am with 'great
pushing', 'descent slow', 'starting to bulge' and baby's head on
view, implying progress. While progress (albeit slow) is being
made, and maternal and baby well being is being demonstrated, it is
appropriate to continue to work towards a normal birth.
Involved in the considerations through this time is the time
taken to transfer. [Mrs B] notes the average transfer time is 2½ to
3 hours. ... If progress is being made, and the mother and baby are
coping, it would be unwise to transfer with the possibility of
delivering en route. This would expose the birth to sub-optimal
conditions. The mother is exposed to greater risk with less freedom
to adopt a comfortable and progressive position; more difficulty
assessing both the mother and baby, both before and after birth;
less opportunity for the midwife to facilitate the birth easily. A
second midwife is not available in the ambulance to assist if the
need arises. For the baby the ideal is to have warm, static
surroundings with full resuscitation gear that may be needed easily
Weighed against this is the time it takes to transfer being
added to what has already become a longer second stage. It appears
[Mrs B] and [Ms C] made reasonable decisions for [Ms A's] care in
this situation, and both mother (although understandably
distressed) and baby appear to have been in good condition on
admission to [the public hospital].
Transfer method was discussed with the base hospital registrar …
who appears to have been supportive of road transfer. As [Mrs B]
points out, in some regions it can be almost as time consuming to
transfer by air. In this region it would appear road transfer is
the normal form of transfer unless mother or baby are unwell. ...
This is also the situation in some other areas of New Zealand.
Overall [Mrs B] (and Ms C) appears to have provided appropriate
care of a reasonable standard to [Ms A]."
Mrs Stanbridge provided additional advice in light of ACC's
treatment injury decision:
"Thank you for asking me to review the advice I gave in December
2007 on the midwifery care given by midwife [Mrs B] to [Ms A] early
in 2007, following the advice given by Dr Ngan Kee to ACC.
It is obvious [the baby's] outcome will have been influenced by
the length of [Ms A's] second stage of labour, and by the
subsequent mode of delivery. I also agree 8 hours is a long time
for second stage of labour.
However, as in my original opinion, [Mrs B]
- gave appropriate care to [Ms A] during labour, monitoring her
and her baby, recording slow but ongoing progress once pushing (the
presenting part reached +3, which is close to birthing), considered
reasons for the rate of progress (?face to pubes), supported [Ms A]
to be active to encourage progress, and worked in conjunction with
her midwifery colleague.
- consulted appropriately with her medical colleague in [the
public hospital] when it became clear birth was not going to happen
in the immediate future.
- appropriately managed the preparation for, and transfer.
The mode of transfer decision was made in conjunction with, or
by, the [public hospital] registrar.
Mother and baby were in a satisfactory condition on arrival at
[the public hospital]. More than an hour and a half passed at [the
public hospital] before [the baby] was delivered - if there was
concern for either, him or his mother (given the length of second
stage), delivery could have been expedited by a general anaesthetic
and Caesarean Section, given there were issues with establishing an
effective spinal anaesthetic. Presumably [the public hospital]
staff felt they could take the extra time to get an effective
spinal anaesthetic working for delivery.
It is easy to make retrospective criticism of care of another
practitioner who works in a totally different work environment. My
opinion is based on experience in remote rural primary care, and in
the context of what was recorded as happening at the time.
In retrospect [Ms A's] second stage of labour was unexpectedly
prolonged. In the remote rural setting there is a constant
awareness by the practitioner (in this case two practitioners) of
the progress in labour and ongoing consideration of the possibility
of the need to transfer. Transfer in itself has the potential for
difficulties, so the decision needs to be balanced against the risk
of not moving.
I believe [Mrs B] and [Ms C] appear to have been aware of this,
worked with [Ms A] to achieve what looked as if it would be a slow
but progressing birth, and instigated transfer when it became clear
progress had stalled.
I have discussed this case with my colleague, Juliet Thorpe,
another expert midwife advisor who has experience in rural primary
maternity care. She attaches her comments.
My original report was full, and explains the issues involved. I
am happy to address any further questions if there are unclear
points, or points you would like to clarify further."
Mrs Stanbridge sought additional advice from an experienced
colleague, midwife Juliet Thorpe. Ms Thorpe stated:
"I am on the NZCOM expert advisors list for the Commissioner and
am a Registered Midwife who has been in independent practice for 16
years. I work predominantly with women planning to birth at home
birth, living within both urban and rural settings.
The only documents I have read with regard to this case are
- Chris Stanbridge's original opinion.
- Your letter to Chris with regard to reviewing her original
- Dr Digby Ngan Kee's opinion
- Chris Stanbridge's subsequent review of her original
With the beauty of hindsight one can see how the length of
second stage is of concern. There is no doubt that if the baby was
born by caesarean section he may not have suffered the injuries
that he did.
A more thorough vaginal examination earlier into the second
stage may have diagnosed the brow presentation but it can be very
difficult to assess when there is swelling on the baby's head and
without the aid of effective analgesia i.e. spinal anaesthetic.
An abdominal palpation performed during the second stage may
also have helped in diagnosing a brow presentation. If there is
head palpable above the pelvis (as was found once admitted to [the
public hospital]) and head on view at the introitus (vaginal
opening) this may indicate malpresentation. This could mean a brow
or a posterior ('face to pubes') position. [Mrs B] did state that
she thought the baby may be in a posterior position.
However, as Chris has already stated, both mother and baby were
well during the labour with the baby only getting into difficulty
after some time at [the public hospital]. [Mrs B] had liaised
appropriately with medical staff at [the public hospital] and if
they had had concerns with regard to the well being of mother and
baby (knowing that [Ms A] had been in second stage for
3 hours) they would not have recommended ambulance
From the information I have read, I would have to concur with
Chris that reasonable care was provided. Within the context of a
rural setting where there is considerable time required for
transfer, the decision to make that trip is always a difficult one.
Chris outlined clearly (in her original opinion) the factors to
consider before the decision is made and it appears the midwives
involved acted professionally within the Standards of the NZCOM and
within the environment that they were working."
 Mrs B is the Charge Midwife at the
private rural maternity hospital.
 A Lead Maternity Carer refers to the
general practitioner, midwife or obstetric specialist who has been
selected by the woman to provide her complete maternity care,
including the management of her labour and birth.
 A cardiotocograph or CTG is the
external electronic monitoring of the fetal heart rate. A CTG can
indicate any abnormalities in fetal heart rhythm, which may
indicate fetal distress. The Doppler unit converts fetal heart
movements into audible beeping sounds and records this on graph
 Meconium is the first faecal
material evacuated from the fetus's or newborn's rectum, and
appears green to very dark green. It is normal for meconium to be
expelled within the first one to two days of birth. Meconium can be
present in the amniotic fluid as a green staining. Although not
always a sign of fetal distress, meconium in the amniotic fluid is
highly correlated with its occurrence. Meconium in the amniotic
fluid reveals that the fetus has had an episode of loss of
 Early decelerations are
periodic decreases in the fetal heart rate resulting from pressure
on the fetal head during contractions. The deceleration follows the
pattern of the contraction, beginning when the contraction begins
and ending when the contraction ends. The tracing of the
deceleration wave shows the lowest point of the deceleration
occurring at the peak of the contraction. The rate rarely falls
below 100 bpm and returns quickly to between 120 and 160bpm at the
end of the contraction.
Late decelerations are delayed until 30 to 40 seconds
after the onset of the contraction and continue beyond the end of
the contraction. This is an ominous pattern in labour because it
suggests placental insufficiency or decreased blood flow through
the uterus during contractions. The lowest point of the
deceleration occurs near the end of the contraction (instead of at
A tube is inserted through the mouth
into the trachea to maintain an airway.
 Maternity and Midwifery Provider