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An investigation into the care of a woman and her identical twin babies found that there were systemic problems within a district health board.
Photo: 123RF
The woman underwent an ultrasound when she was 28 weeks pregnant. While the sonographer noted the problems, the radiologist did not document them in his report or take any follow-up action.
Three days later, the woman required an urgent cesarean section, after arriving at the hospital with abdominal pain.
He was found to have twin-twin transfusion syndrome, a prenatal condition in which twins share unequal amounts of the placental blood supply.
Various difficulties arose while the woman was giving birth.
The theater staff did not know that they were going to deliver two babies and were in a small operating room where they had to locate a second resuscitator.
The first twin was born limp with no heartbeat and required immediate resuscitation. Three attempts were made to intubate the first twin, but only on the third attempt did they realize that the oxygen cylinder was off.
Then when the cylinder was turned on, the baby’s oxygen saturations did not rise to the expected level. This was because the endotracheal tube (the tube that is put through the mouth into the windpipe) that was used was too small for the baby.
When the tube was changed, the baby’s oxygen saturations rose to the expected level.
Deputy Commissioner for Health and Disability Rose Wall criticized the radiologist’s initial report, as well as the failure of a pediatric consultant to immediately intervene for an urgent or emergency delivery.
“I believe that at the time of the incident, [the DHB] it had several systemic problems, “Wall said.
“This affected the care provided to [the woman] Y [twin 1]. “
Since these events, DHB has commissioned an external review of its maternity services and has taken a number of steps to improve its systems.
The DHB apologized to the woman and took steps including increasing staffing, reviewing equipment, and implementing Maternity Care Capacity Demand Management.
