Health Practitioners Disciplinary Tribunal 1199/Mid21/508D (18 October 2021)
The Director filed a charge against registered midwife (“RM”) Helen Bakker in the Health Practitioners Disciplinary Tribunal (“the Tribunal”) concerning her decision to mislead her patient (“Ms A”) by administering normal saline instead of pethidine[1] during Ms A’s labour, despite being aware of Ms A’s request to receive pethidine during labour.
In early 2018 RM Bakker was engaged as the LMC for Ms A. At a subsequent appointment, the options for pain relief during labour were discussed, including the risks and benefits associated with the use of pethidine. Ms A was also given a pamphlet about pain relief in labour. At a later appointment, Ms A’s birth plan was recorded, which showed that Ms A planned to use gas and pethidine if needed. Ms A had chosen RM Bakker as her midwife because RM Bakker had agreed that Ms A could use pethidine for pain relief during labour. During her first labour, Ms A had been refused pain relief by her midwife.
When Ms A went into labour she attended Whakatane Hospital. RM Bakker arrived at the hospital at approximately 8am, shortly after Ms A had arrived. Throughout Ms A’s labour RM Bakker was accompanied by a student midwife who was observing and assisting. By 9am that morning, Ms A was asking for stronger pain relief than the gas. Ms A asked the student midwife for pethidine. The student midwife passed this request on to RM Bakker. On RM Bakker’s instruction, the student midwife inserted an intravenous (“IV”) luer into Ms A’s arm, for the purpose of administering the requested pethidine.
After the IV luer was inserted, RM Bakker and the student midwife went to the dispensary to obtain the requested pethidine. In the dispensary, RM Bakker told the student midwife that she intended to give Ms A a placebo, being normal saline,[2] and that she would tell Ms A that it was pethidine. RM Bakker explained to the student midwife her belief in the “placebo effect”. When asked by the student midwife whether she told the women about the use of placebo afterwards, RM Bakker said she did not, save for if they were a good friend, and could laugh about it afterwards.
On instruction from RM Bakker, the student midwife administered 10ml of normal saline to Ms A. RM Bakker told Ms A that she was being given pethidine. Ms A’s labour progressed slowly, and on several occasions between 9.30am and 12.35pm Ms A told RM Bakker and the student midwife that her back hurt. During that period, RM Bakker instructed the student midwife to go back to the dispensary to get more “pethidine” (meaning more normal saline). In total, the student midwife, on instruction from RM Bakker, administered four 10ml syringes of normal saline to Ms A, three of which were given in “half doses” (i.e., 5ml at a time) as Ms A had requested that the pethidine be given to her in half doses because she was concerned that it might harm her baby. At all times, Ms A was led to believe she was receiving pethidine.
Despite her requests, Ms A was not given pethidine at any time between 9.30am and 1.15pm. By 12.35pm, a consultant obstetrician at the hospital became involved, and at 1.15pm, following the consultant’s assessment and recommendation, RM Bakker administered 50mg of pethidine to Ms A intramuscularly (“IM”). Ms A’s baby was delivered safely via a ventouse delivery performed by the consultant at 4.54pm.
After Ms A was discharged from hospital, RM Bakker advised her that she had not given her IV pethidine when requested, and had instead given her saline. However, RM Bakker did not communicate to Ms A sufficiently that she had received pethidine by way of IM injection after pethidine had been recommended by the obstetrician. As a result, Ms A initially believed that she had not been given any pethidine during her labour.
The charge before the Tribunal included eight particulars, all of which RM Bakker admitted and accepted amounted to professional misconduct warranting disciplinary sanction. The Tribunal found that the entire charge against RM Bakker was established and amounted to professional misconduct. In reaching this decision, it said that RM Bakker’s conduct in relation to the patient fell seriously short of that which might be considered acceptable. It considered that it was not a negligent mistake but that it reflected a deliberate, unjustified, and unethical approach to the practitioner’s care of the patient.
In determining penalty, the Tribunal noted that this case involved a deliberate element of deception, which the Tribunal found “troubling”. The Tribunal made orders requiring an annual Midwifery Standards Review of RM Bakker’s practice for a period of two years by a committee of practitioners not from RM Bakker’s region, and prohibiting RM Bakker from supervising student midwives for a period of one year. The Tribunal also censured RM Bakker and ordered her to pay a fine of $3,500, plus costs. RM Bakker did not seek permanent name suppression.
A copy of the Tribunal’s decision can be found here: Decision Mid21/508D
[1] Pethidine is a synthetic opioid analgesic that is frequently used in labour, but it has some small risk that it can cross the placenta, and adversely impact the baby.
[2] A sterile solution of 9% (9.0 grams per litre) sodium chloride in water.