Baby dies: government-funded research finds ‘missed opportunities’ in pregnancy care

A government-funded investigation uncovered “missed opportunities” for senior physicians to intervene in the run-up to the death of a one-month-old Waikato baby.

Today, the Waikato District Board of Health has violated the Code of Rights of Consumers of Health Services and the Disabled for the care provided to a pregnant woman 30 years after losing her baby.

At 28 weeks pregnant, the woman, who cannot be identified for privacy reasons, was rushed to Waikato hospital with severe abdominal pain.

“The pain in my abdomen was unbearable and all I could do was sob,” the woman said in the HDC report.

She was evaluated by teams of obstetrics and general surgery, but they could not find the cause of the pain.

In the report, the woman said a doctor quickly examined her abdomen by pushing it down, causing significant pain that she could barely breathe between sobs, and then left the room.

“He didn’t tell me what he was thinking, what the plan was, what he thought was wrong with me … Then I was in agony for another two hours with no more vital signs being completed despite [RM F] checking on me regularly. “

The doctor said, in the report, that the clinical picture at the time was unclear and that the blood results did not demonstrate the likelihood of an intra-abdominal inflammatory cause.

The woman collapsed 17 hours later and her uterus was found to have ruptured.

Her baby initially survived but died a month later as a result of hypoxia at birth, a condition in which the baby’s brain and other organs do not receive enough oxygen and nutrients before, during, or immediately after birth.

“This whole experience has left me completely emotionally and physically drained and distrustful of the medical profession,” said the grieving mother.

The report emphasized that the rupture of a scarless uterus in a woman who was not giving birth was extremely rare, occurring in about 1 in 100,000 births, and difficult to detect.

One doctor said in the report that they had only seen one other case in their 34 years of medical practice.

Deputy Commissioner for Health and Disability Rose Wall accepted the rarity of the woman’s condition and acknowledged that “aspects of women’s care were well managed,” but criticized DHB for “missed opportunities for more senior oversight. “and” inadequate documentation “of some reviews.

“[There was] the lack of effective communication and coordination between the obstetric and general surgery teams contributed to a delay in the appropriate radiological evaluation, “said Wall.

In the report, the deputy commissioner said that DHB should also apologize to the woman and her family.

The clinical director of obstetrics, who was not named, said in the report: “I would like to send my sincere condolences to [Mrs C] and his partner for the loss of [Baby C] and for the traumatic events they experienced during their stay in[elhospitalpúblico”[thepublichospital”[elhospitalpúblico”[thepublichospital”

Wall recommended that DHB provide evidence of recent staff training on care coordination, escalation of care, and documentation.

Wall also suggested that they use this case as a basis for staff training and report on their implementation of the New Zealand National Maternity Early Warning System (Mews).