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A girl died after a difficult pregnancy that was not recorded by her midwife and DHB (file photo).
A new mother lost her newborn baby after the midwife failed to register her severe morning sickness and weight loss that restricted her baby’s growth.
The investigation into the incident by Deputy Commissioner for Health and Disability Rose Wall found that the Bay of Plenty District Health Board violated the Health and Disability Services Consumers’ Rights Code for a series of failures in caring for a woman and her baby. .
The woman, whose name is not mentioned, was 20 years old and had a difficult pregnancy in 2017.
She lost weight and required multiple hospitalizations for severe morning sickness and her baby’s growth was restricted, according to the report.
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However, her midwife did not record the woman’s weight or fundus height at each prenatal evaluation.
It was found that while the midwife continued to check on the woman while she was with the OB team, she did not document when she formally handed over care to the team.
When the woman was in the care of DHB, there was no formal management plan and no clear guidelines for staff on managing severe morning sickness and malnutrition.
When the baby was born, she was recognized as “at risk” due to her low birth weight.
However, the baby’s blood glucose level was not monitored in a timely manner and a pediatric check-up was not requested.
In addition, he was given a higher than recommended dose of phenobarbitone, a barbiturate used to prevent seizures.
Christel Yardley / Stuff
The woman was hospitalized several times during her pregnancy, but the lack of documentation by the midwife and DHB has been criticized (file photo).
The girl’s condition deteriorated and she was admitted to the neonatal intensive care unit, where she died.
The woman’s whānau said in the report that the baby never had a chance to grow and mature.
“They say that time heals all wounds, but I can say that the whānau will never ‘get over’ the step of [their baby]. “
The whānau at no point wanted to blame people and acknowledged that there were some incredible health professionals involved.
“The whānau would like to reiterate that it was a lack of proper resources and procedures that caused this, and we, as whānau, would like to be assured that this will not be the case for expectant mothers in that position.”
Wall was critical because the transfer of the midwife to the OB team was unclear and a formal management plan was not documented.
Also, the deviation from DHB’s policy on pediatric screening and blood glucose monitoring.
Wall criticized that the dose of phenobarbitone given to the baby was not consistent with the guidelines.
And that the opportunity to seek specialist advice on a baby who was significantly small for gestational age was missed.
“Although it is not possible to determine if the outcome could have changed, I am critical that the DHB failed to ensure that staff were supported with adequate systems to guide and provide appropriate care, including the requirement to develop comprehensive management plans in situations such complex cases, “said Wall.
It recommended that the DHB provide an update on the implementation of the guidelines for nausea and vomiting in pregnancy.
Wall also recommended that the DHB consider developing guidelines when consultation with a multidisciplinary team is required and developing a formal plan for a ‘significantly small for gestational age’ baby or a woman with severe symptoms.
And for when a woman with a small-for-gestational-age fetus requires referral to a fetal medical specialist or a larger facility.
Wall recommended that the midwife provide an update on the competency order issued by the New Zealand Council of Midwifery.
