A baby tragically died during childbirth after the midwife failed to act promptly when the infant’s shoulders became stuck, a health watchdog investigation has revealed.
The Health and Disability Commission (HDC) found that the locum midwife, who was covering for the primary midwife on leave, failed to properly monitor the labor and call for medical assistance in a timely manner.
The incident occurred at a rural hospital, where Ms. A, the mother, was in labor. Her usual midwife had transferred her care to the locum midwife, the only other available independent midwife in the area. After the birth, the locum midwife also failed to recognize that the mother was suffering from sepsis.
The baby’s head was delivered around 12:30 a.m., nearly 24 hours after labor began. Ms. A’s mother later told the Coroner that she felt more should have been done at this point, as the baby’s head had been out for too long with no progress.
At 12:38 a.m., the locum midwife called for help, but the nurse who arrived was not informed of any complications. The nurse, unaware of the difficulties, was instructed to contact Ms. A’s regular midwife, Midwife C, who was at the hospital at the time.
Midwife C arrived shortly after, at 12:43 a.m., and quickly assessed the situation. She discovered the baby was stuck due to severe shoulder dystocia. Despite attempts to release the baby using maneuvers, the baby remained trapped. Midwife C requested additional help, and after further efforts, the baby’s shoulder was freed by internal rotation techniques.
The baby was delivered at 12:53 a.m., but showed no signs of life. Despite resuscitation attempts involving multiple medical staff and the administration of eight doses of adrenaline, the baby was pronounced dead at 1:47 a.m. A post-mortem confirmed the cause of death as asphyxiation following shoulder dystocia and prolonged labor.
Family’s Heartbreak
The baby’s mother expressed regret at her decision to give birth at the rural hospital, despite being reassured by her midwife that it was a safe environment. She told the HDC, “This is a decision I regret every day.”
Her mother added, “My daughter and grandchild did not get the care they deserved. We lost our moko (grandchild) and almost lost our daughter too.”
The baby’s parents-in-law said the loss had devastated the family, highlighting the need for improved medical care and communication. “We believe systemic changes need to happen to ensure all families receive the highest standard of care. Improved training, better communication, and timely escalation of care are essential to prevent families from experiencing the same preventable loss,” they said.
Midwife’s Failure to Act Promptly
Midwifery expert Isabelle Eadie, who reviewed the case for the HDC, identified several key failures in the locum midwife’s care. Eadie pointed out that there were several moments when nursing staff recognized potential problems but felt unable to question the midwife’s decisions. One nurse recalled asking why Ms. A was still in the hospital, but the midwife reassured her that everything was fine.
Eadie also criticized the lack of regular monitoring of the baby’s heart rate, a crucial part of labor care. She noted that the midwife’s monitoring was insufficient, a problem that has been recognized in ongoing efforts to improve midwifery practices in New Zealand.
Additionally, Eadie suggested that the mother’s decision to decline blood products, due to her religious beliefs as a Jehovah’s Witness, may have added complexity to the situation. Eadie emphasized the importance of guidelines for such cases.
She also noted that the locum midwife had been working for 24 hours straight, except for one hour when she was relieved by Midwife C. Eadie argued that working such long hours without adequate rest can impair critical decision-making, especially in high-pressure situations like childbirth.
Midwife Acknowledges Shortcomings
The locum midwife expressed deep regret over the tragic outcome, acknowledging her shortcomings in the care provided. She stated she should have acted differently in several areas and admitted that she breached the code of health and disability services.
Deputy Health and Disability Commissioner Rose Wall offered her condolences to the family, recognizing the difficult working conditions faced by the midwife. However, she emphasized that these challenges did not excuse the failures in care. Wall has referred the midwife to the Director of Proceedings and suggested that the Midwifery Council review her competence.
Call for Systemic Change
The family and experts alike have called for systemic changes to prevent such tragedies from happening again. The family’s statement underscored the need for timely medical intervention, better training, and improved communication in maternity care, especially in rural areas where resources are limited.
The case has raised important questions about midwifery practices, staffing shortages, and the adequacy of training, all of which need to be addressed to ensure that no other family faces a similar loss.
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