A recent report has highlighted several failures in the care provided at Christchurch Woman’s Hospital, which led to the death of a newborn. These failures include delays in assessing the labor, inadequate escalation of care, and delays in both diagnosing labor complications and performing a necessary C-section.
The infant, who suffered from a brain injury due to lack of oxygen, died in the neonatal intensive care unit (NICU). The Health and Disability Commissioner released the report today, detailing breaches of the rights of both the mother and the baby under the Code of Health and Disability Services Consumers’ Rights.
The mother, who became pregnant through in vitro fertilization (IVF) in 2017, was closely monitored due to the high-risk nature of her pregnancy. Factors such as advanced maternal age, IVF, and a history of diabetes, lupus, and asthma contributed to the decision to induce labor at 39 weeks.
She entered the first stage of labor three days after being admitted to the hospital. According to the report, she was moved to a birthing room around 5 a.m. on the fourth day and was given pain relief with Entonox and morphine.
By 11:30 a.m., a plan was in place for an epidural and the administration of oxytocin, a hormone to stimulate contractions. However, the epidural was delayed due to a backlog of requests, and oxytocin was started at 2:16 p.m. The dosage was to be gradually increased to enhance contraction frequency.
A vaginal examination at 3 p.m. revealed significant molding of the baby’s head and an extended position. This information was not discussed among the doctors, and Dr. C did not recall being informed about these findings, only about delays in labor and oxytocin administration.
Advice was sought about the lack of progress after a second examination at 5:22 p.m. The report notes that doctors were unavailable as they were attending to other patients. By 5:44 p.m., it was determined that the next examination’s findings would be crucial for deciding whether a C-section was needed.
The third examination, occurring at 9:17 p.m., was delayed due to the doctors being occupied in the operating theater. A discussion took place, and it was decided to continue with oxytocin for two more hours. Consent for a C-section was obtained at 11:15 p.m., but transfer to the operating theater was delayed due to another case in progress.
The woman was moved to the operating theater at 12:20 a.m., and the C-section started at 1:11 a.m. The baby was found to be very deflexed and wedged in the pelvis. Despite attempts by the senior registrar and a doctor, the baby could not be dislodged quickly. The NICU was informed of the urgent situation, and a second incision was made.
The baby, born pale and floppy, was diagnosed with a brain injury due to insufficient oxygen. Despite efforts, the baby died two days later.
Deputy Health and Disability Commissioner Rose Wall concluded that Health NZ Te Whatu Ora failed to provide care with the required skill and attention. Key issues included delays in diagnosing labor progression problems and the subsequent decision for a C-section.
Wall criticized the delays, stating that given the mother’s high-risk status, a more conservative approach should have been taken. She attributed the inadequate care to systemic issues, including insufficient staffing and poor escalation processes.
Following the incident, Health New Zealand reviewed its practices, implementing most of the 13 recommendations. The review led to increased staffing and funding, along with educational sessions for the team. Wall recommended a formal written apology to the woman and her husband for the care deficiencies.
