Failures In Care During Labour 21HDC00367

Deputy Health and Disability Commissioner Rose Wall has found the rights of a woman and her baby were breached under the Code of Health and Disability Services Consumers’ Rights (the Code), due to failures in care during labour.

The woman at the centre of the report was admitted to the Birthing Suite at Christchurch Woman’s Hospital for induction of labour, which started three days after admission.

After labour failed to progress, the woman underwent a Caesarean section (C-section). Sadly, the newborn was diagnosed with a brain injury caused by inadequate oxygen and was transferred to the neonatal ICU where he passed away.

Ms Wall found Health New Zealand | Te Whatu Ora breached the Code for failing to provide services with reasonable care and skill.

The breach covered several failures in care. The first stage of labour was prolonged and there was a delay in assessement during labour. There was a lack of appropriate escalation of care to the second on-call Senior Medical Officer. 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.

Ms Wall said, "In my view the key issue in this case is the delay in diagnosing the failure to 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."

The decision to recommend a C-section should have been made once the assessment was done, Ms Wall said.

"Given the overall clinical picture, it was clear that there was a failure to progress in labour. In my view the decision to recommend delivery of the baby by C-section should have been made at this point."

There was a final delay, of almost two hours, once the decision to undertake the C-section was taken. This was due to the operating theatre needing to be prepared and medical staff made available.

"I am concerned about the delay in the C-section commencing, particularly as I have already established that the decision to recommend delivery by C-section should have been made earlier."

Multiple systemic issues affected the care provided to the woman, Ms Wall said. "I consider that a combination of inadequate staffing and support, and a lack of safe staffing escalation processes primarily affected the care provided."

"I have taken into account the resource constraints outlined by Health New Zealand," Ms Wall said. "While I acknowledge these limitations, I remain of the view that the woman was entitled to receive services of an appropriate standard from supported staff."

Since the event, Health New Zealand has made a number of changes, which are outlined in the report, and include major changes to staffing within the Obstetrics and Gynaecology Department.

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