A baby suffered serious health complications after failures by two midwives and Nelson Marlborough DHB, a new report has revealed.
The incident occurred during a teenage woman's induced birth at Wairau Hospital in 2019.
The mother "had a complex mental health history including bipolar affective disorder and anxiety", the Health and Disability Commissioner's (HDC) decision noted.
She had a growth scan at 33 weeks and three days' gestation, which found the baby was large for its gestational age.
An obstetrician recommended the pregnancy not go beyond 41 weeks, the HDC said — and at 40 weeks and a day, when the woman was in her tenth month of pregnancy, the birth was induced.
"During the labour, a recording of the fetal heart rate showed possible fetal distress," a statement from the HDC said. "The two midwives caring for the woman did not recognise the signs of fetal distress for an hour and a half.
"Specialist support was then sought and one of the midwives attempted to deliver the baby, whose shoulders were stuck."
The baby was born in "poor condition", requiring resuscitation, after the obstetrician arrived and took over.
"Baby A took her first breath at 14 minutes of age," the HDC decision noted.
The baby was diagnosed with a brain injury caused by insufficient oxygen flow to the brain.
The injury, severe HIE (hypoxic ischaemic encephalopathy), can cause serious complications.
"This was a young woman having her first baby, and she relied on her care team to monitor her baby's well-being adequately, to collaborate effectively, and to escalate care promptly when indicated," Deputy Commissioner Rose Wall said.
"Unfortunately, this did not occur and, as a result, the baby suffered serious complications, which potentially will have a profound impact on her future well-being."
Wall found the two registered midwives and the DHB failed to provide appropriate maternity services, breaching the Code of Health and Disability Services Consumers' Rights.
Staff at the hospital felt "stressed and unsupported" as a result of the hospital's environment, she added.
"There were a number of concerning features in the way the woman was cared for by multiple staff at Wairau Hospital."
Since the incident, changes have been made to the DHB's staffing and support systems, with its fetal monitoring guidelines also updated.
Wall recommended both midwives and the DHB provide a written apology to the mother, and that the DHB "conduct a review of the effectiveness of the changes made".
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