Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Complaint The Commissioner received a complaint from the complainants, Mr C and Mrs B, on behalf of their daughter, Ms A, concerning midwife, Ms D. The complaint is that on 5 March 1998 Ms D:
- did not take reasonable action to diagnose that Ms A's baby was lying in a breech position.
- did not adequately monitor the labour of Ms A.
Investigation Process The complaint was received on 30 March 1998 through advocacy and an investigation was commenced on 28 April 1998. Information was obtained from:
Ms A Consumer / Complainant
Mrs B Complainant / Mother of consumer
Mr C Complainant / Father of consumer
Ms D Provider / Midwife
Ms E Midwife
Ms F Midwife
Ms G Midwife
Ms H General Manager, Crown Health Enterprises
Information Gathered During Investigation
On 21 August 1997 the consumer, Ms A, registered Ms D, midwife, as her lead maternity carer (LMC). Ms A was 12 to 14 weeks pregnant with 1 March 1998 as the estimated date of delivery. Initially Ms A had slightly elevated thyroid function levels for which Ms D consulted with Ms A's general practitioner but this soon settled to normal.
At 37 weeks pregnant Ms A had a major crisis when her brother drowned in a canoeing accident. Ms A's blood pressure became elevated but after two weeks was once more within the normal range.
Ms D stated that when examining Ms A throughout her pregnancy none of the classic indicators of breech presentation were present on palpation. Breech presentation is when the baby presents with the head up instead of the usual downward position and can sometimes lead to complications in a vaginal delivery requiring a caesarian section. Ms D stated that from 37 weeks onwards she palpated the baby's head as presenting in the latero-posterior (downwards) position.
On 5 March 1998 at 3.00pm Ms A telephoned Ms D to advise that she had been having contractions at 15-minute intervals.
Ms D stated she advised Ms A to get some rest because she would probably go into labour. Ms D had another client, a friend of Ms A's, who was in labour and had gone into hospital at 1.30pm that day. Ms D stated it seemed likely her two clients would be labouring at the same time so she therefore made calls to arrange back-up. Ms D's usual back-up midwife was about to attend a home birth and had contacted another midwife to assist her.
Ms D rang another midwife, Ms E, who was about to fly to a city. Ms E stated to Ms D that she would be available for backup after 7.30pm and could be paged at a meeting she planned to attend later that evening. Ms E said:
"After arriving back in [the city] I left from home at 7.55pm to go to my meeting, not having heard from [Ms D] and knowing I had both my cell phone and pager with me in my bag."
Ms D rang Ms A back at approximately 5.00pm to check on her progress. Ms D stated Ms A was contracting irregularly but was not in established labour. Ms D telephoned again at 6.00pm and was informed by Mr I, Ms A's partner, that the contractions were still irregular and that Ms A was most comfortable in the bath. There was discussion about coming to hospital for an assessment and Ms D stated she informed them (with Ms A's friend's permission) that Ms A's friend's baby was close to being born and that she might be occupied when they first arrived.
Ms A and Mr I arrived at the hospital at approximately 7.00pm. Ms D stated she assessed Ms A, briefly palpating the baby and thought that the lie of the baby was occipito-posterior (head down in a normal position). Ms D said she had trouble hearing the foetal heartbeat with the hospital sonicaid because the batteries were flat and therefore obtained her own instrument. Ms D stated the heart could be heard just above the symphysis pubes where it was heard the last time she listened. The rate was 135 to 145 beats per minutes and movements were felt over a wide area.
The contractions were one every seven to 10 minutes and were palpated as moderately strong. Ms D said she then suggested Ms A have a bath because this was where she felt most comfortable. At 8.00pm Mr I came to Ms D who was with her other client, saying he thought his wife's membranes had ruptured because "there was shit floating in the bath". Ms D stated she immediately expected meconium and went straight to see what was happening:
"I was relieved to see there was no meconium but there was white vernix. I explained this to [Ms A and Mr I] and checked the foetal heart rate. I suggested a vaginal examination to assess progress but [Ms A] indicated that she was not keen at this stage. Once I was assured that [Ms A] and baby were well I returned to [my other client]."
"[Ms D] did offer to do an internal, but said she'd have to go and get long gloves & that the other woman's delivery was critical. This would have been about 9pm. I felt like it would be a hassle for her and said if she was needed elsewhere she had better go."
Ms D reported that the other woman who was in labour had complications and required specialist assistance. At 8.30pm Mr I advised Ms D that Ms A was becoming sore. Ms D checked Ms A and found that contractions were still not completely regular but were generally coming once every five minutes. The heart rate was checked at regular intervals and was about 135 bpm which is within the normal range.
Ms D told Ms A that she was still not available and that she would call her back-up midwife, Ms E to come in. Ms E was phoned at home and her husband said she was at a lecture. Ms D stated she paged her three times over the next half-hour and the phone indicated that it was either switched off or outside the coverage area. Ms E reported:
"I returned home at 12.30am and heard my tracer buzzing in my bag. I had thought it was on 'audible' rather than 'vibrate' and discovered that [Ms D] had traced me at 10.30pm, 2 hours previously.
While my cellphone had been turned on during the meeting, the battery at some stage had expired."
Ms D attempted to contact another midwife but she was also unavailable. At this time Ms D was called urgently into her other client's room to assist and then Ms D returned to Ms A to check that all was well and found that Ms A was still in the bath. Ms D explained that the other client was to go to the postnatal ward and that she would be back as soon as possible. Ms D then bought in the client's baby and showed it to Ms A. Ms D was unaware that Ms A had stated to her partner that she did not wish to see her friend's baby.
Ms A said that she later found out her friend, who delivered her baby at around 9.00pm, had a specialist present during the labour and three different types of pain relief including an epidural. "Lots of attention from lots of people (including [Ms D], but [Ms D] hadn't actually assisted much with the delivery (performed by a specialist)."
Ms A stated that Ms D returned at between 9.50 and 10.00pm and performed an internal. By this time Ms A described her contractions as intensely strong and evenly spaced at three-minute intervals. Ms A said the internal revealed that she was 10cm dilated with a foot coming down.
Ms D reported that at 11.00pm, when Ms A was complaining of increasing pressure, a vaginal examination was performed showing a breech presentation. 11.00pm was also the time which Ms D recorded in the Labour Summary that the assessment was undertaken. Ms D informed Ms A and Mr I and called the hospital midwife for assistance. Ms D asked that an obstetrician be called as none were in the unit. The hospital staff set up for a breech delivery while Ms D listened to the heart rate. Ms D stated the heart rate was reactive but started having marked decelerations during contractions with good recovery.
Mr J, the obstetrician, arrived after about 20 minutes. Mr J assessed Ms A to be fully dilated and said that the baby would deliver vaginally. Ms A was placed in the lithotomy position and commenced pushing. As the feet were delivered, Ms D reported that she lost contact of the heartbeat and informed Mr J. The next contraction delivered the legs. There was a delay at the shoulders because the contractions "died off" and Mr J checked to see that he had not missed some "undilated cervix". Mr J asked Ms A to push without the contractions and he placed his hand in the vagina to assist flexion. Ms D reported these last pushes were very painful for Ms A and she cried out and this was difficult for Mr I to watch. However he remained and supported her throughout.
Mr J wrote in the labour summary:
"Called to undiagnosed breech.
[11.15pm] Small baby. Feet in vagina with rapid descent occurring. Decision to continue with vaginal breech delivery.
Assisted vaginal breech delivery. Rapid descent during contractions. Good maternal effort. Legs and trunk delivered spontaneously. Arms brought down in Maurice-Smellie-Viet manoeuvre to deliver head. Live male infant […] delivered in fairly good condition and handed to [paediatrician]. ?
The baby was delivered at 11.45pm. Ms D reported:
"[T]here was some meconium present which is not unusual with breech babies. He was pale and floppy and placed on [Ms A's] abdomen while the cord was cut and then he was given to the paediatrician. I explained to [Ms A] that he needed his airways cleared and would probably be intubated and given some oxygen. The [paediatrician] commented on his good heartbeat. [The baby] rallied well and at 10 minutes was breathing on his own and had good muscle tone. He was transferred to the [neo natal intensive care unit] because of the delay in the delivery of the head and small birth weight, but he did not develop respiratory distress. The baby was fully breast feeding on discharge and was gaining weight and appeared to be doing well."
Ms D reported that Ms A told her that she was very upset that she was not with her more during her labour and Ms D has apologised for this. Ms D stated "It is very unusual for an independent midwife to have two women labouring at the same time although it can be quite common for hospital midwives". Ms D said "it is never an ideal situation looking after two woman at one time" and regrets that Ms A has felt let down about this.
Ms D stated that medical and midwifery texts give the incidence of breech positions as occurring in 3 to 4% of babies at term, and of these 10 to 15% will be undiagnosed in labour.
Independent Advice to Commissioner
The Commissioner obtained advice from an independent midwife as follows:
My midwife advisor stated:
"[T]he intensity of the labour and the breech presentation would have been apparent at an earlier point had [Ms D] done a vaginal assessment either at admission to the hospital ?or at the spontaneous rupture of membranes at [8.00pm]. Details from this assessment would have greatly informed the development of an appropriate care plan inclusive of Obstetrician involvement and transfer to secondary care."
Late diagnosis of breech position
When questioned whether the late diagnosis of breech contributed to the baby's asphyxia, my midwife advisor stated:
"Almost certainly. By the time the breech presentation had been diagnosed [Ms A] was already fully dilated with the presenting part at station +1. As there was no Obstetrician immediately available, he [Mr J] had to come from home twenty minutes away. In his assessment at [11.15pm] [Mr J] states that there were 'feet in the vagina with rapid descent occurring. Decision to continue with vaginal breech delivery.' It was now too late to organise emergency caesarean section.
As the breech birth proceeded there was a reduction in the number of contractions necessitating [Mr J] to ask [Ms A] to push without a contraction to affect delivery of the babes head using the Maurice-Smellie-Viet manoeuvre to enhance flexion. The babe's apgar score reflect graphically the difficulty of the birth for the baby, 0 at 1 minutes, 3 at 5 minutes, 9 at 10 minutes. Active resuscitation was required and the babe did not breathe spontaneously for 6-7 minutes."
Detection of breech presentation
My midwife advisor, using data from Backe and Nakling in their population-based study: Effectiveness of Antenatal Care (1993 Brit J Obstetrics & Gynaecology 100:727-732), commented:
"The detection rate for small for gestational age was remarkably low (14%) and breech presentation only (69%). Unfortunately this sort of omission appears very common
?Given that antenatal diagnosis of breech presentation and intra uterine growth retardation are frequently missed, it would seem at least judicious to conduct a vaginal examination once labour has been determined to be established. In this situation it would have allowed for a more controlled birth experience for [Ms A] and [the baby]."
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:
Right to Services of an Appropriate Standard
2) Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.
3) Every consumer has the right to have services provided in a manner consistent with his or her needs.
5) Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
Other Relevant Standards
New Zealand College of Midwives Standards for Midwifery Practice
The Midwife collates and documents comprehensive assessments of the woman and/or baby's health and well-being.
The Midwife: ?
- documents her assessments and uses them as a basis for on-going Midwifery
Midwifery actions are prioritised and implemented appropriately with no Midwifery action or omission placing the woman at risk.
CRITERIA The Midwife ?
- plans midwifery action on the basis of current and reliable knowledge and in accordance with Acts and Regulations and relevant policies.
- ensures assessment is on-going and modifies the Midwifery plan accordingly.
The Second Decision Point in Labour
Information shared?From Examination
- assess woman's well-being, including her emotional and behavioural responses;
- check blood pressure and pulse;
- discuss need for vaginal examination;
- assess contractions, lie presentation and descent of baby;
- assess baby's well-being, including heart rate;
- if membranes have ruptured, check liquor.
Opinion: Breach - Midwife, Ms D
In my opinion midwife, Ms D, breached Rights 4(2), 4(3) and 4(5) of the Code of Health and Disability Services Consumers' Rights as follows:
Ms D did not reach acceptable professional standards in caring for the consumer, Ms A, during her labour. Her actions were contrary to the New Zealand College of Midwives Standard 6 and the Scope of Practice which states that midwifery actions are prioritised and implemented appropriately with no action or omission placing the woman at risk.
In particular, Ms D did not undertake a vaginal examination to ascertain the progress of labour until labour was well established. I accept my advisor's comment that a vaginal examination should have been performed at admission or at 8.00pm, especially when Ms D was only able to be present intermittently during Ms A's labour
. Ms D not only failed to detect the breech presentation but also did not pick up that the baby was smaller in size than usual. I accept that the statistics demonstrate this occurs frequently. However if an appropriate standard of care had been given during Ms A's labour her baby may not have faced unnecessary trauma and asphyxiation at birth.
In my view Ms D did not respond adequately to the needs of Ms A and her partner. Ms A was in labour for the first time and needed more support than Ms D gave. The delays in monitoring were unacceptable. Ms D demonstrated she was not attending fully to Ms A's needs when she showed Ms A her friend's new born baby. If she had taken time to recognise what was happening for Ms A, this insensitive action would not have occurred.
Further it was not acceptable to rely on Ms A and Mr I to signal that they required more assistance. As first time expectant parents, they should not in any way be responsible for monitoring the progress of labour and detecting possible deviations from the norm. This is the task of the midwife.
Ms D did not ensure that Ms A had continuous midwifery services. While I accept that Ms D made attempts to contact another midwife for back-up purposes, these attempts were unsuccessful and were therefore insufficient. When midwife, Ms E, did not respond to Ms D's calls, Ms D should have reviewed the situation and made attempts to find another available midwife. It was unacceptable that Ms A and her partner were not supported by a midwife during labour, particularly when this was a first pregnancy.
I recommend midwife, Ms D, takes the following actions:
Sends a written apology to the consumer, Ms A, and her partner, Mr I, for breaching the Code of Rights. This apology should be sent to the Commissioner who will forward it to Ms A and Mr I.
Ensures that all routine observations are undertaken and documented during labour, including assessing the need for vaginal examinations.
Works under the supervision of a senior midwife for a six-month period including a review of her record-keeping.
Examines her backup midwifery system so that in the event of some midwives being unavailable, cover can always be found when necessary.
A copy of this opinion will be sent to the New Zealand College of Midwives and the Nursing Council of New Zealand.