A Health and Disability Commission investigation has found that a baby who died from severe brain injury should have been delivered hours earlier by cesarean section. The tragic case occurred after the baby’s head became stuck during labor.
Born at 1:11 a.m., the baby was pale and floppy and required immediate resuscitation. Despite being transferred to the neonatal intensive care unit, he later died.
Deputy Commissioner Rose Wall’s report criticizes Christchurch Women’s Hospital for serious lapses in care during the mother’s prolonged labor. The issues included inadequate assessment, failure to seek additional help, delays in deciding to perform a cesarean section, and further delays in executing it.
Wall noted that the mother’s high-risk pregnancy—due to her age, IVF conception, and medical history—warranted a more cautious approach. Once the decision was made to perform a cesarean, there was an additional delay of nearly two hours due to preparations and staff availability. When the procedure began, the baby’s head was stuck in the mother’s pelvis, requiring a second incision to free him.
The baby was delivered within minutes but required CPR for 38 minutes. Dr. C, the consultant overseeing the procedure, expressed shock at the baby’s condition, given that the CTG monitor showed normal heart rates.
An ACC-commissioned obstetrician reviewed the case and suggested that labor progress issues should have been identified by 3 p.m., and the baby should have been delivered 5 to 7 hours earlier. The obstetrician believed that the prolonged labor had worsened the baby’s condition, making delivery increasingly difficult.
By 9:17 p.m., when a senior doctor finally assessed the mother, she had been in active labor for 14 hours. The independent assessor noted that a vaginal delivery had become very unlikely.
Dr. Sikhar Sircar, another expert, highlighted several serious failures, including the lack of timely assessment and the delayed cesarean.
The coroner’s report revealed that the baby suffered a severe brain bleed and oxygen deprivation due to the awkward position in the mother’s pelvis, which disrupted blood flow to the brain. Although the CTG showed normal heart rates, the reduced variability and variable decelerations should have alerted the staff to potential issues.
Wall attributed the failures to “multiple systemic issues,” including inadequate staffing, support, and safe escalation processes.
In response to the findings, Health New Zealand acknowledged that, in hindsight, the baby’s delivery should have occurred earlier. However, they noted that resource constraints and staffing limitations at the time impacted the decision-making process. They also mentioned that greater funding for senior medical officers might have improved the situation.
Health New Zealand disagreed with the experts’ recommendation for a cesarean at 5:22 p.m., stating that this was not supported by international clinical guidelines.
Since the incident, Health New Zealand has made several changes to its Obstetrics and Gynaecology Department. These include hiring more doctors, enhancing training, acquiring new equipment, and updating procedures for monitoring labor and escalating clinical concerns. Health New Zealand now ensures three consultants are rostered for weekends, improving availability and response times.
The agency and involved doctors have extended their sincere condolences to the family and assured them that improvements have been made in the care of women and babies.
