Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
On 11 July 2022, the Health and Disability Commissioner (HDC) received a complaint from Ms A (aged 25 years at the time of these events) about the care she received from her lead maternity carer (LMC) registered midwife (RM) B. Ms A raised concerns that RM B failed to provide her with an appropriate standard of care between mid 2021 and early 2022 when she was pregnant with her second child, Baby A. Sadly, Baby A was delivered stillborn in early 2022. I extend my sincere condolences to Ms A and her family for the loss of Baby A.
Information gathered
Initial booking appointment
RM B1 had been Ms A’s LMC for her first pregnancy (a normal vaginal birth at 40 weeks 4 days’ gestation in 2019), and Ms A engaged her as LMC for her second pregnancy at 8 weeks’ gestation in mid 2021 via email. RM B said that, at the time she was engaged as LMC for the second pregnancy, she discussed nutrition with Ms A and referred her for an ultrasound dating scan to confirm the pregnancy and establish the estimated due date and for initial antenatal blood tests.
In 2021 (at 10+4 weeks’ gestation), Ms A had her initial appointment with RM B, where she was given an ‘information folder’ that included information about ‘warning signs’ in pregnancy, fetal movements, and common complaints during pregnancy, including morning sickness. At the time, Ms A weighed 54kg, had a normal body mass index (BMI)2 of 19.6, and was still breastfeeding her first child. The dating scan showed an estimated due date of early 2022. RM B said that the antenatal blood test results were not available for review at this appointment.
RM B visited Ms A at her home eight times throughout her pregnancy (once a month in a seven-month period between 2021 and early 2022 but with two appointments in the last month, including an appointment the day prior to birth).
Antenatal care
Weight management
Ms A told HDC that she experienced persistent vomiting throughout her pregnancy, which resulted in her not gaining any weight (compared with a weight gain of 17kg during her first pregnancy). Ms A said that she could not keep any food down and was vomiting ‘all day’ every day, making it difficult for her to care for her other child. Ms A said that RM B did not weigh her throughout her pregnancy or refer her for further investigation of this issue.
RM B accepts that she did not weigh Ms A throughout her pregnancy. RM B said she felt reassured that Ms A’s abdomen was growing each visit, she had undergone scans that showed the baby was growing normally, and the fetal movements appeared to be normal. RM B acknowledged that Ms A had gained more weight during her first pregnancy and said that she discussed this with Ms A, although this discussion was not documented.
Regarding management of Ms A’s ongoing vomiting, RM B told HDC that she did not believe that referral was necessary as Ms A did not clinically present with hyperemesis gravidarum (severe or prolonged vomiting during pregnancy that leads to weight loss and dehydration). RM B said that she was not of the understanding that vomiting was persistent or to the point that Ms A was unable to properly eat or drink. The clinical notes state that Ms A reported nausea/vomiting at her first home visit in 2021,3 her third home visit in 2021,4 and her last two home visits in 2022.5 RM B said that the information she gave to Ms A about weight gain during pregnancy included healthy eating resources and that she discussed strategies for dealing with morning sickness, including ginger, herbal tea, acupressure points, and regular small snacks. These discussions were not documented.
Fetal monitoring
Ms A said that RM B did the ‘bare minimum’ of checks antenatally and that she only used a Doppler machine6 once, aside from during labour. Ms A said that RM B would only offer to listen to the fetal heartrate at the end of her appointments but that RM B did not seem concerned so she thought it was unnecessary. In response to the provisional report, Ms A said that RM B presented any checks as ‘extra and unnecessary’, which made Ms A feel like it would be extra work for RM B if she were to request them. Ms A said that, on multiple occasions, she raised that she did not think her baby was moving very much and that RM B would just say that all babies are different. Ms A said that the entries in the clinical notes of reportedly normal fetal movements are inaccurate.
The clinical records show that on three occasions antenatally the fetal heartrate was auscultated and the abdomen was palpated.7 The clinical notes also record reported fetal movements on three occasions8 with no abnormal movements reported. The clinical records also contain a GROW chart,9 but this includes only one entry for fundal height10 (measured at 37 weeks’ gestation) and two scan entries (at 33+3 weeks’ and 36+1 weeks’ gestation).
RM B said that she offered to listen to the fetal heartrate at every appointment but that Ms A would not always consent. However, there is only one reference to palpation being declined, at the eighth home visit appointment in 2022, because Ms A was ‘happy with movements’. RM B accepts that she did not document the consenting discussions with Ms A.
In early 2022, Ms A had a scan to follow up on previously reported enlarged fetal kidneys. The scan showed that the enlarged kidneys had resolved but it also showed enlarged ventricles. RM B said that she discussed these findings with Maternal Fetal Medicine (MFM) before seeing Ms A the next day. MFM agreed to see Ms A early the following month . RM B said that during the sixth home visit, Ms A advised that she was happy with movements and, as she had had a normal scan the day before, she chose not to listen to the heartbeat. The clinical notes state: ‘I did not feel baby today as [Ms A] had scan yesterday but will feel for position next visit.’
Regarding documentation of reported fetal movements, RM B said that she always correctly documented reported fetal movements and that at no point during her pregnancy did Ms A report abnormal movements. RM B said that if reduced fetal movements had been reported at any stage, she would have taken appropriate action. RM B said that her understanding is that, following the birth, Ms A’s partner reported that movements may have been reduced.
Labour and birth
At 38+2 weeks’ gestation at 8.05am, RM B was contacted and advised that labour was establishing (ie, the cervix has started to dilate and contractions were becoming more regular and intense) so she attended Ms A’s home at around 11.50am because Ms A’s initial birthing plan had included a home birth. She reviewed Ms A and was unable to find the fetal heartrate using a Doppler machine. RM B said that she did not obtain a set of maternal observations on review of Ms A at home. This is because she usually checks the fetal heartrate first, and when she was unable to locate the fetal heartrate, her immediate reaction was to move to the Birthing Unit for support.
On review at the Birthing Unit, RM B attached the cardiotocography (CTG)11 to Ms A, but she did not attach the tocodynamometer (TOCO)12 to the CTG to record Ms A’s contractions. RM B said that she and another attending midwife, RM C, were ‘reassured’ after finding the fetal heartrate on the CTG. The CTG showed no accelerations and one to two decelerations13 (abnormal); however, the CTG was removed after six minutes of monitoring, and the fetal heartrate was not recorded again after this reading. RM C told HDC that, in hindsight, Baby A’s condition at birth means it was not possible that the fetal heartrate had been heard and that the CTG was probably doubling the maternal pulse, which can sometimes happen.
RM B said that she did not take maternal observations at the birthing unit as she presumed RM C had done so and birth appeared to be imminent. There is no evidence that RM B palpated Ms A’s abdomen at any stage on this day, nor is there any documentation of reported fetal movements or regularity of contractions in the lead up to, and during, labour. RM B said that she documented that Ms A was losing her mucous plug14 at her second visit at (38+1 weeks’ gestation), but she did not ask about regularity of contractions as Ms A had laboured quickly in her first pregnancy and she assumed this pregnancy would be the same.
Sadly, Baby A was delivered stillborn.15 RM B told HDC that the umbilical cord was wrapped tightly around his neck and he had evidence of maceration16 and no heartbeat.
Further information
RM B accepts that her documentation was insufficient during her care of Ms A. She said that this standard of documentation was not usual for her and has not occurred since. However, she also reported that her notes were sent to Ms A following each appointment, and she did not receive any feedback that they were incorrect.
Responses to provisional opinion
Ms A
Ms A was given the opportunity to comment on the ‘information gathered’ section of the provisional report. Ms A told HDC:
‘The signs were all there, but [RM B] didn’t see it. Everyone around me worried, and I told them my midwife wasn’t worried as I felt reassured by her. For [RM B] to ever say that she wasn’t worried [because] I wasn’t worried is a huge oversight in her care. It was her job to properly care for me and Baby A, inform me and be aware of any risk factors that I was clearly unaware of. Looking back, they are clear as day to me’.
RM B
RM B was given the opportunity to respond to the provisional report. RM B accepted the findings and recommendation.
Changes made
RM B told HDC that she has made the following changes to her practice since these events.
Documentation
Takes advice and feedback from colleagues on documentation standards.
Uses her laptop for note-taking at all in-home antenatal appointments.
Completed a documentation course to improve the standard of her documentation.
Sends notes from appointments to pregnant clients so they can advise if anything is incorrect or missing.
Weight management
Takes a set of scales to in-home visits and will usually conduct initial appointments at a birth centre or clinic to measure height and weight.
Has updated the information about healthy eating in pregnancy that she gives to women at the initial appointment and has specific and in-depth conversations with women around eating during pregnancy.
Plans to book a diet and nutrition course to further her knowledge.
Fetal monitoring
Completed the Fetal Surveillance Education Program (FSEP) and the Growth Assessment Protocol (GAP) training.
Seeks input from other midwives or obstetricians when she requires support and will consider referral when necessary.
Has a pulse oximeter, blood pressure measuring equipment, and a thermometer easily accessible.
She no longer offers palpation and heart rate monitoring as optional and always proceeds to obtain consent to palpate and listen to the heart rate unless expressly declined.
She now generates the GROW chart earlier in pregnancy and discusses the chart at booking for pregnant clients she has not cared for previously.
The Te Tatau o te Whare Kahu Midwifery Council (the Midwifery Council) undertook a review of RM B’s competency and required her to complete further education on documentation and fetal surveillance, including interpretation of CTGs. RM B was also required to write a reflection of her learnings and advise of any further changes to her practice. On 24 June 2025, the Midwifery Council confirmed that RM B had satisfactorily completed the competence programme.
Opinion: RM B – breach
Given the circumstances of this case, it is understandable that Ms A has concerns about the care she received from RM B. As Ms A’s LMC, RM B had a responsibility under the Code of Health and Disability Services Consumers’ Rights (the Code) to provide care of an appropriate standard to Ms A. In her complaint to HDC, Ms A raised several concerns about RM B’s management of her wellbeing during pregnancy, a lack of fetal monitoring, and the care she provided during labour.
The circumstances in the period leading up to Baby Baby A’s stillbirth have been difficult to reconcile because of not only the discrepancies between Ms A’s complaint and RM B’s version of events but also the poor standard of RM B’s documentation during her care of Ms A. I am cognisant of the advice of my in-house clinical advisor, RM Nicholette Emerson, that it is difficult to ascertain what discussions took place between RM B and Ms A regarding consent for routine midwifery practice and that the ‘sparsity of detailed documentation and differing accounts of the antenatal period has hindered clarity.’ I have taken careful note of RM Emerson’s advice, alongside the other information gathered over the course of this investigation, and I have concluded that aspects of the care RM B provided to Ms A were deficient and did not meet the required standards. These deficiencies are set out below.
Documentation
The New Zealand College of Midwives (NZCOM)17 and the Midwifery Council outline the documentation standards expected of midwives. NZCOM standards state that a midwife should comprehensively document all assessments, information, and advice shared and decisions made for the plan of care. In addition, the Midwifery Council publication ‘Documentation and Record Keeping’18 states that professional documentation should include detailed assessments and clinical findings, discussions of care and information provided to the woman, evidence of informed choice and consent, and care decisions with rationale.
RM B’s clinical records are clearly deficient. RM B saw Ms A on eight occasions antenatally, but there are only three references to reported fetal movements, fetal heartrate, and palpation; no documentation of consenting discussions about standard midwifery assessments such as palpation or fetal heartrate auscultation or reference to Ms A being offered such assessments and declining them; only one fundal height measurement and an incomplete GROW chart; and a lack of documentation of advice provided about healthy weight gain in pregnancy or management of persistent vomiting. RM B has accepted that her documentation fell below an acceptable standard.
RM Emerson considered that the standard of RM B’s documentation departed from an accepted standard to a moderate degree. I accept this advice and am extremely concerned at the paucity of information recorded by RM B. Fulsome contemporaneous documentation is essential for chronicling the provision of safe and effective care for women and is an important mechanism for monitoring the progression of the fetus over the course of the pregnancy. The failure to capture important information makes retrospective review of the care provided very difficult, as outlined by NZCOM and the Midwifery Council.
Antenatal monitoring
Management of maternal wellbeing
At the time, the Ministry of Health had published guidelines for healthy weight gain in pregnancy. The guidelines state that, for a woman with a BMI of 18.5–24.9, the recommended weight gain during pregnancy is 11–16kg. The ‘NZCOM Assessment and Promotion of Fetal Wellbeing (2021) practice points’ state that the midwife should share information about healthy nutrition and weight gain with the mother, identify the need for support in these areas, and offer the woman referral to other services if required.
The accounts of the nature and frequency of Ms A’s vomiting are conflicting, and the clinical notes only contain three references to nausea/vomiting reported by Ms A. However, I note that Ms A was still reporting vomiting at her appointment with MFM at 36 weeks’ gestation. Given that Ms A did not gain any weight during her pregnancy, I consider it more likely than not that she did experience persistent vomiting over the course of her pregnancy. I also consider that it should have been apparent to RM B that Ms A was not gaining the recommended 11–16kg.
RM Emerson advised that to gain 17kg in a previous pregnancy and none in a subsequent pregnancy warrants further investigation and that a referral to a general practitioner (GP) or dietitian to explore possible causes of the ongoing vomiting should have been considered. RM Emerson also advised that there is both a woman and a baby in pregnancy, and although the growth of the baby may have been reassuring, it should not have been considered in isolation from Ms A’s wellbeing. In conclusion, RM Emerson advised that RM B’s management of Ms A’s persistent vomiting and lack of weight gain constitutes a moderate departure from accepted standards, and I agree with this finding. In my view, the extended period of poor nutrition is likely to have had some bearing on Ms A’s maternal health. I am also critical that there is no evidence that RM B discussed healthy weight gain or nutrition with Ms A, aside from providing her with a written resource at her initial appointment.
GROW chart
The GROW chart that RM B gave to HDC contains only one entry for fundal height and two scan entries.19 RM Emerson advised that if the chart was generated contemporaneously, it has not been used appropriately as ‘it is the trajectory of fetal growth20 (a combination of fundal height measurement and scans from 26 to 28 weeks’ gestation to birth) that engenders reassurance regarding fetal growth.’ RM Emerson advised that the lack of fundal height measurements makes it difficult to assess the fetal growth trajectory and that, combined with RM B’s monitoring of Ms A’s weight gain and lack of palpation, this constitutes a moderate departure from accepted standards. I accept this advice. As I have reflected earlier, in my opinion, customised growth charts are a valuable tool for monitoring the progression of the fetus over the course of a pregnancy.
Fetal monitoring
The lack of documentation and somewhat conflicting accounts about fetal monitoring has made it difficult to establish the facts. RM B’s account is that she offered palpation and fetal heartrate auscultation but Ms A declined. Ms A’s account is that RM B did not convey the importance of such checks. If any consenting discussions occurred, they are largely undocumented. There is only one reference to palpation being declined, in 2022 at 38+1 weeks’ gestation, as Ms A was reportedly happy with the fetal movements, and one reference in the month prior to RM B not palpating as Ms A had received a scan the previous day, although it is unclear whose decision this was. Other than that, the clinical records show that palpation and fetal heartrate auscultation occurred only three times antenatally.21 RM B accepts that she did not document the consenting discussions. Taking into account the limited evidence, I find it likely that, on at least some occasions, RM B offered to complete these checks. However, I also find it likely that RM B failed to appropriately educate Ms A about the importance of completing these assessments, which RM Emerson advised are part of routine midwifery practice.22
In any event, RM Emerson advised that RM B’s failure to document her discussions with Ms A about the assessments constitutes a moderate departure from accepted standards, and I agree.
Labour and birth
When RM B attended Ms A’s home at 38+2 weeks’ gestation, she was unable to locate the fetal heartrate, so she advised Ms A to attend the birthing unit for CTG monitoring.
The CTG at the birthing unit was abnormal with no accelerations and one to two decelerations; however, it was removed after six minutes, and no further fetal heartrate monitoring was documented. RM B also did not attach the TOCO (to record contractions) to the CTG and did not take a set of maternal observations, including maternal heartrate, which she assumed had been taken by RM C. There is also no evidence that RM B palpated Ms A’s abdomen or that she recorded the regularity of contractions. RM B acknowledged that this was not acceptable midwifery care. RM B said that she documented that Ms A was losing her mucous plug at 38+1 weeks’ gestation, but she did not ask about the regularity of contractions as Ms A laboured quickly in her first pregnancy so she assumed that would be the case with this pregnancy.
RM Emerson advised that, assuming the CTG was monitoring the fetal heart (which, retrospectively, is unlikely to be correct), there were CTG features that required further investigation and the CTG should have been left in place so that monitoring could continue. Further, RM Emerson advised that, combined with the lack of palpation antenatally, there was a moderate departure from accepted standards for RM B failing to palpate Ms A during labour. Overall, RM Emerson advised that the failures in the care provided to Ms A by RM B during labour, as outlined above, constitute a moderate to severe departure from accepted standards. I concur with my advisor’s findings and consider there were stark omissions in the midwifery care RM B provided during Ms A’s labour.
Conclusion
RM B had a responsibility to provide midwifery services to Ms A with reasonable care and skill. As discussed above, she failed to do so in a number of key respects. I am critical of the standard of RM B’s antenatal care and her management of Ms A’s labour, and therefore I find that she breached Right 4(1) of the Code.
Further, RM B’s documentation of Ms A’s antenatal care and labour did not meet the required standards, and therefore I find that she also breached Right 4(2) of the Code.
Fetal movements – educational comment
Ms A said that she told RM B on multiple occasions that she did not think her baby was moving very much; she told HDC that any documentation of reported normal fetal movements was incorrect. Conversely, RM B told HDC that she correctly documented all reported fetal movements and at no stage did Ms A report abnormal movements. The clinical records show reported fetal movements on several occasions, with none reported as abnormal.
The conflicting accounts from Ms A and RM B and the contemporaneous documentation reflecting normal fetal movements mean I am unable to make a finding on whether or not Ms A reported abnormal fetal movements to RM B. I note that RM Emerson also noted that she could not verify this retrospectively and was therefore unable to comment further on that aspect of the care provided to Ms A. However, if Ms A did report abnormal fetal movements at any stage during her pregnancy, I would be very critical that RM B failed to both document this and appropriately escalate Ms A’s care.
Recommendations and follow-up actions
In my provisional report I recommended that RM B provide a written apology to Ms A for the failings identified in this report. The written apology was provided to HDC and has been forwarded to Ms A. Given the changes already made by RM B since these events, including her completion of the competence programme, I have no further recommendations to make.
A copy of the sections of the final report that relate to RM B will be sent to the Midwifery Council. I note the Midwifery Council has already reviewed RM B’s competency and, in June 2025, confirmed that RM B had satisfactorily completed its ‘competence programme’; however, I will ask that it consider whether any further action is called for on account of this investigation and my findings.
A copy of this report with details identifying the parties removed, except the name of my clinical advisor, will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.
Rose Wall
Deputy Health and Disability Commissioner