Failures In Care By Registered Midwife During Pregnancy And Birth

Deputy Health and Disability Commissioner Rose Wall has found a registered midwife breached the Code of Health and Disability Services Consumers’ Rights (the Code) for her care of a woman during pregnancy and birth.

Following a period of labour, the woman gave birth to her daughter via Caesarean section. Sadly, the baby was born in poor condition and diagnosed with severe hypoxic ischaemic encephalopathy (HIE) (a condition caused by insufficient oxygen delivery to the brain).

The registered midwife was the woman’s Lead Maternity Carer, responsible for her care until she was transferred to the care of hospital clinicians. In her report Ms Wall identified several omissions in the care the registered midwife provided, in breach of Right 4(1) of the Code, (which gives consumers the right to services provided with reasonable care and skill).

The registered midwife failed to arrange obstetric consultations for a suspected small for gestational age (SGA) foetus in scans at around 36 and 38 weeks. She also failed to recommend an obstetric referral because she did not recognise the significance of signs of static foetal growth in the final weeks of the woman’s pregnancy.

"Recognising and appropriately responding to concerning symptoms as they arise over the course of a woman’s pregnancy, including seeking input from a specialist when it is called for, is critically important to the safety and wellbeing of both the woman and their unborn child," Ms Wall said.

In addition, at the 41-week appointment the midwife did not document the content of her discussion with the woman recommending a growth scan and failed, in her referral for induction, to document the growth concerns noted in the weeks prior.

Finally, during labour when the foetal heart rate dropped, the registered midwife did not continue the cardiotocography (CTG) trace (used to monitor foetal heart rate during labour) and, when the CTG trace showed signs of foetal distress during labour, the registered midwife failed to accurately document and report this.

Ms Wall also found the registered midwife breached Right 6(2) of the Code which gives consumers the right to information a reasonable consumer in the circumstances needs to make an informed choice or give informed consent.

"I am critical that the registered midwife did not explain the implications of static foetal growth to the woman at the 41 week appointment," Ms Wall said.

"I consider that in failing to do so, she did not provide the woman with the information that a reasonable consumer in her circumstances needed to make an informed choice about whether to undergo a further growth scan."

Since the event, the registered midwife has made a number of changes to her practice, including completing relevant training and engaging in a competency programme as prescribed under section 40 of the Health Practitioners Competence Assurance Act 2003 (following a competence review by the Midwifery Council).

Considering the changes already made, Ms Wall recommended that the midwife also complete several further training programmes and undertake an audit of antenatal records to assess whether documentation comprehensively captures the discussion of options, risks, benefits, recommendations, and any other information required for the women to make an informed choice.

Health and disability service users can now access an animated video to help them understand their health and disability service rights under the Code.

Editors notes

Please only use the photo provided with this media release. For any questions about the photo, please contact the communications team.

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

Names have been removed from the report to protect privacy of the individuals involved in this case.

The Commissioner will usually name providers and public hospitals found in breach of the Code unless it would not be in the public interest or would unfairly compromise the privacy interests of an individual provider or a consumer. More information for the media, including HDC’s naming policy and why we don't comment on complaints, can be found on our website here.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

In 2022/23 HDC made 592 quality improvement recommendations to individual complaints and we have a high compliance rate of around 96%.

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