A baby was left with a brain injury caused by a lack of oxygen after a midwife failed to recognise signs of the baby's distress during labour.
The incident unfolded after a woman in her 20s went into spontaneous labour at about 38 weeks in 2020, a decision by the Health and Disability Commissioner (HDC) noted.
She had booked a self-employed midwife as her lead maternity carer. Up until the spontaneous labour the woman had had an uneventful pregnancy.
The woman was connected to a cardiotocograph (CTG) during labour at a public hospital so that the baby's heart rate could be continuously monitored. However, the midwife only made limited documentation of the recordings, the HDC said.
The woman started pushing - signalling the second stage of labour - but didn't give birth until more than three hours later.
The baby was born in very poor condition and needed resuscitation and intubation. He was transferred to the Neo-Natal Intensive Care unit, where he was diagnosed with a brain injury caused by a lack of oxygen.
The Midwifery Council of New Zealand notified the HDC of its concerns about the services provided to the woman by the midwife.
The HDC found the midwife to be in breach of the Code of Health and Disability Services Consumers' Rights for failing to recognise that the CTG showed abnormal recordings, indicating possible fetal distress. The midwife also failed to consult the obstetrics team about the abnormal CTG and lack of progress in labour.
Deputy Health and Disability Commissioner Rose Wall said that the midwife's documentation fell seriously short of acceptable standards.
"The midwife's failure to identify fetal compromise and her not seeking specialist input at various points meant the opportunity to respond to these issues in a timely manner was missed.
"Sadly, these failures appear to have resulted in the baby's hypoxic condition at birth," Wall said.
Wall also highlighted how the back-up midwife - called about eight hours after the woman arrived at hospital - inadequately interpreted the CTG recordings and failed to escalate care to the obstetrics team, but did not find them in breach of the code - she said the lead carer likely influenced these shortcomings.
"While I am critical of the shortcomings in the care provided by the backup midwife, I consider these shortcomings were influenced by the lead maternity carer.
"The lead maternity carer was the midwife primarily responsible for the woman's care. She did not present an accurate account of the labour and how it was progressing. I, therefore, do not consider that the backup midwife breached the code," Wall said.
Wall recommended that both midwives complete further documentation and fetal surveillance monitoring training.
She also suggested that the Midwifery Council of New Zealand consider a further review of the lead midwife's competence.
The midwife has provided an apology letter to the woman and her family and undergone further training.
"I am pleased to see the further training undertaken by the midwife and the changes made to her practice, which should improve her standard of care and help to prevent other women from having a similar experience in the future," Wall said.
Wall also recommended independent practitioners carry out a "fresh eyes" review of CTG, which Te Whatu Ora - Health New Zealand has incorporated.
"I note that Te Whatu Ora has now incorporated a fresh eyes approach into routine care, with education to support this. I endorse this change."
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