A newborn baby died in Christchurch Woman’s Hospital due to multiple failures in care, including a delay in assessment during labor, a lack of appropriate escalation, a delay in diagnosing a failure to progress labour, and a delay in starting the C-section.
The infant was diagnosed with a brain injury caused by inadequate oxygen and died in the neonatal ICU. A report by the Health and Disability Commissioner discussed breaches of the rights of the woman and her baby under the Code of Health and Disability Services Consumers’ Rights.
The woman became pregnant with her first baby in 2017 following in vitro fertilisation (IVF). The woman’s private midwife undertook extensive monitoring and investigation due to the pregnancy’s high-risk nature, advanced maternal age, IVF pregnancy, and medical history of diabetes, lupus, and asthma.
The woman was induced at 39 weeks gestation and entered the first stage of labour three days after being admitted to Christchurch Woman’s Hospital.
A plan was made at 11.30 am for the woman to be given an epidural and to commence oxytocin, a natural hormone that stimulates contraction of the uterus, bringing on labour.
This commenced at 2.16 pm after the anesthetist was delayed due to several epidural requests. A vaginal examination at 3 pm showed “significant molding” of the baby’s head due to the forces of labor and that it was “deflexed” or extended backward. However, this was not brought up in a discussion between doctors.
The advice was sought from doctors regarding the lack of progress in the woman’s labour after a second vaginal examination at 5.22 pm revealed similar findings to the earlier examination. The report said they were unable to review the woman at the time as they were reviewing two other women who potentially required a C-section.
A third vaginal examination took place at 9.17 pm, nearly four hours from the previous examination because “all doctors were busy in the operating theatre.” A decision was made to continue augmenting the labour with oxytocin for a further two hours. A junior registrar obtained the woman’s consent for a C-section at 11.15 pm, and oxytocin was discontinued.
from the previous examination because “all doctors were busy in the operating theatre.”
The woman was transferred to the operating theatre at 12.20 am, with the C-section beginning at 1.11 am. The baby’s head was found to be “very deflexed” and wedged into the woman’s pelvis after the junior registrar made an incision.
Dislodging the baby was attempted by the senior registrar and a doctor, but this was not successful. The NICU was alerted that the C-section had been upgraded to category 1, indicating “urgent delivery with an immediate threat to the life of the woman or fetus.”
The baby was later diagnosed with a brain injury due to having inadequate oxygen. The newborn developed brain swelling and died two days later.
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