Multiple failures in care have been identified following the death of a newborn at Christchurch Woman’s Hospital
It included a delay in assessment during labour; a lack of appropriate escalation; a delay in diagnosing a failure to progress labour; and this leading to a decision to recommend delivery by C-section also being delayed.
There was also a delay in starting the C-section.
The infant was diagnosed with a brain injury caused by inadequate oxygen and died in neonatal ICU.
A report, released today by the Health and Disability Commissioner, discussed breaches of the rights of the woman and her baby under the Code of Health and Disability Services Consumers’ Rights.
The woman became pregnant with her first baby in 2017 following in vitro fertilisation (IVF).
Extensive monitoring and investigation were undertaken by the woman’s private midwife due to the pregnancy’s high-risk nature — designated as such because of her advanced maternal age, the fact it was an IVF pregnancy, and due to a medical history of diabetes, lupus and asthma.
These factors led to the woman being induced at 39 weeks’ gestation and she entered the first stage of labour three days after being admitted to Christchurch Woman’s Hospital.
The report said the woman was transferred to a birthing room around 5am on day four and that pain relief was given in the form of Entonox and morphine.
A plan was made at 11.30am for the woman to be given an epidural and to commence oxytocin — a natural hormone which stimulates contraction of the uterus, bringing on labour.
This commenced at 2.16pm after the anaesthetist was delayed due to several epidural requests, with the plan to increase oxytocin gradually to increase the frequency of contractions.
A vaginal examination at 3pm showed “significant moulding” of the baby’s head due to the forces of labour and that it was “deflexed” or extended backwards. However, this was not brought up in a discussion between doctors.
“Dr C does not recall being informed about any moulding or that the baby’s head was deflexed, only that there was a delay in labour and a delay in the oxytocin being commenced,” the report read.
Advice was sought from doctors regarding the lack of progress in the woman’s labour after a second vaginal examination at 5.22pm revealed similar findings to the earlier examination.
The report said they were unable to review the woman at the time as they were reviewing two other women who potentially required a C-section.
It was then discussed at 5.44pm that the findings of the next vaginal examination would be “decisive” as to whether the baby required a delivery by C-section.
The third vaginal examination took place at 9.17pm, nearly four hours on from the previous examination because “all doctors were busy in operating theatre”, according to clinical notes.
The report said a “relatively comprehensive” discussion took place during the assessment where a decision was made to continue augmenting the labour with oxytocin for a further two hours.
A junior registrar obtained the woman’s consent for a C-section at 11.15pm and oxytocin was discontinued. They noted a delay in the transfer to the operating theatre as there was another case “already in theatre” and that they then needed to wait for it to be cleaned.
The woman was transferred to the operating theatre at 12.20am, with the C-section beginning at 1.11am.
The baby’s head was found to be “very deflexed” and wedged into the woman’s pelvis after an incision was made by the junior registrar, so the senior registrar was asked to take over.
Dislodging the baby was attempted by the senior registrar and a doctor, but this was not successful. The NICU was alerted that the C-section had been upgraded to category 1, indicating “urgent delivery with immediate threat to life of the woman or fetus”.
A second incision was made by the doctor and the senior registrar, with the baby “floppy and pale” at delivery.
The doctor said they were “devastated” and “completely shocked” to see the baby born in “bad condition”. “It made me question what went wrong and how we could not foresee such an unwell fetus.”
The baby was later diagnosed with a brain injury due to having inadequate oxygen. The newborn developed brain swelling and died two days later.
The findings
Deputy Health and Disability Commissioner Rose Wall found Health NZ Te Whatu Ora breached the code for failing to provide services with reasonable care and skill.
“The first stage of labour was prolonged and there was a delay in assessment during labour. There was a lack of appropriate escalation of care to the second on-call Senior Medical Officer,” she said.
“The diagnosis of failure to progress in labour was delayed, and therefore the decision to recommend delivery by C-section was also delayed. Finally, there was a delay in actually commencing the C-section.”
Wall said the key issues were the delay in diagnosing the lack of progress in labour and the delay in recommending a delivery by C-section.
“Given the woman’s high-risk pregnancy, due to an advanced maternal age, IVF pregnancy, and her medical history … it would have been reasonable to take a more conservative approach and to assess earlier.”
Multiple systemic issues affected the care provided to the woman, she said.
“I consider that a combination of inadequate staffing and support, and a lack of safe staffing escalation processes primarily affected the care provided.”
A review was undertaken by Health New Zealand following the incident, with all but two of the 13 recommendations completed.
It said additional funding and recruitment has caused major changes to staffing within the Obstetrics and Gynaecology Department and that there is “much more reserve” in the system.
Education sessions involving the whole multidisciplinary team were also run, with at least one being a teaching session where the details of this case were outlined and discussed anonymously.
Wall said she took the “significant changes” made by Health NZ into account and recommended a formal written apology to the woman and her husband for the deficiencies of care identified in this report.