A teenager remembers being excited while getting rushed to hospital to give birth, not knowing her precious baby girl was already dead.
“We had prepped her room and everything … we couldn’t wait to share her with our big whānau,” the grieving woman says in a Health and Disability Commission (HDC) report released today.
Two years after losing their daughter, the teen couple have today won an apology from a midwife for failing to properly monitor their daughter’s growth during pregnancy and request suitable testing.
The couple, their whānau and the midwife have not been identified in the report citing privacy reasons.
An investigation by the country’s health watchdog revealed the midwife had not measured the fundal height at every visit. The fundal height is a measure of the size of the uterus used to assess fetal growth and development during pregnancy.
In the woman’s final weeks of her pregnancy, the woman developed severe swelling, headaches and elevated blood pressure.
In this situation, a midwife is meant to request a pre-eclampsia blood test and a urine analysis at each visit, but that did not happen.
Pre-eclampsia is a late pregnancy complication involving high blood pressure causing damage to organs, most often liver and kidneys.
When the woman was in labour, the midwife assessed her condition by telephone but didn’t recommend an in-person assessment, although it was warranted, the HDC report said.
She was then rushed to hospital.
The baby was delivered more than 14 hours after a specialist confirmed she did not have a heartbeat and had died.
An obstetrician documented that his impression was that the baby had probably died several days prior because of pre-eclampsia, the HDC report said.
The midwife told HDC that in hindsight pre-eclampsia bloods would have given a better view on what was going on internally and an obstetric consultation would have been warranted.
“My actions were not proactive enough and I have considered the desire for her to homebirth may have clouded my judgment and caused my inaction … I did not believe
she had pre-eclampsia at the time,” she said.
The midwife said: “Finally, my deepest aroha for [the woman], her partner, and her whānau for the loss of baby. I regret some of my decisions, however, I will never know if
other decisions were to make a difference in saving [the baby]. I do hope they find
The grieving woman said she was still impacted by the loss of her baby and she sincerely hoped that no other hapū māmā experienced the pain she had.
Deputy Health and Disability Commissioner Rose Wall, who led the investigation, was critical of the midwife for not maintaining accurate antenatal records and an oversight to detect problems with the woman’s pregnancy.
“The report highlights the importance of appropriate assessment of a woman’s condition,
monitoring of a baby’s growth accurately, and the need for appropriate action in response to the development of clinical concerns that have the potential to affect the health of the
woman and/or her baby,” Wall said.
The deputy commissioner recommended the midwife provide a written apology to the woman and her whānau, and that she undertake training on pre-eclampsia in pregnancy.
Before the HDC investigation findings, a review of the midwife’s care was conducted by the Midwifery Council of New Zealand (MCNZ). It found that while documentation was “brief at times”, the midwife had “met her professional responsibilities”.
This tragic story comes after another couple won a major apology from HDC, after a seven-year fight, for failing to investigate the death of their daughter.
Zoe and Miguel Daza were left distraught after HDC declined to investigate their complaint about medical treatment leading to the stillbirth of their daughter in November 2013.
Commissioner Morag McDowell in May wrote to the Daza family saying she “sincerely regrets” the “unreasonably prolonged” assessment process.
And in June, the Herald told another story about a mum haunted by the sound of her precious baby dropping on a hospital floor at birth before dying 90 minutes later.
Limna Polly, 35, remembered lying down screaming for help at Auckland City Hospital’s maternity ward for three hours, knowing she was about to give birth and being told by a doctor to “shut up” instead of receiving help.
Polly said no medical staff believed she was giving birth when she’d only been pregnant for 22 weeks and no one intervened to help deliver her baby.
Auckland DHB didn’t dispute any part of the family’s complaint but said it “didn’t meet the criteria” to be reported to an independent body, Health Quality & Safety Commission (HQSC), for a review as “no issues were identified with the medical care”.
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