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• A midwife attending a home birth in a remote area left for a break and returned to a stillbirth situation.
• The Deputy Health and Disability Commissioner found several concerning risk factors meant that it was unsafe for the mother to give birth at home.
• The midwife was found to have breached the health code and has apologised.

A midwife assigned to help deliver a baby at home in a remote rural area left on a lunch break and arrived back to a tragedy unfolding.

The parents claimed the baby was born “pale and floppy” just as the midwife arrived back. The midwife says the mother was in the final throes of delivery as she returned.

Either way, the baby girl was pronounced stillborn after the midwife, the baby’s father and emergency services were unable to revive her.

The cause of death was reported as hypovolemic shock following a cord rupture at the baby’s bellybutton.

The Deputy Health and Disability Commissioner, Rose Wall, said in a report released today that while she did not accept the midwife set out to compromise either the mother or her baby’s wellbeing, the mother was however placed in an unsafe situation during the labour and stillbirth.

Deputy Health and Disability Commissioner Rose Wall found that the mother was placed in an unsafe situation during the labour and stillbirth.

Wall said the circumstances leading up to the stillbirth at 43 weeks had proved “extremely difficult to investigate”, given the conflicting accounts of what happened and the lack of robust documentation.

The investigation showed that by the time the mother went into labour, it was no longer a normal pregnancy and that the “high-risk birth should have been facilitated in a hospital”.

Wall said several concerning risk factors meant that it was unsafe for her to give birth at home.

Risk factors

The family lived remotely, around a 15-minute drive from a nearby town, with no electricity, landline, cellphone coverage or internet.

Cellphone coverage was available only by driving for five minutes to the end of the road where they lived.

It was the woman’s second pregnancy, which progressed normally until 41 weeks when her waters broke.

The midwife advised her to go to the birthing unit immediately to have a cardiotocography (CTG) which measured the baby’s heart rate.

The CTG showed nothing abnormal.

The woman was advised to go to the hospital but she was concerned about how her labour might be managed.

Because her waters had broken but labour had not started, the midwife recommended augmented labour, continuous CTG monitoring and intravenous antibiotics.

The mother told the HDC that she thought having antibiotics while pregnant would harm the baby’s digestive system.

She claimed not to know how much risk of infection there was because the midwife never explained how crucial antibiotics were after the waters had been broken for a prolonged time.

The midwife advised the parents to move into the city to await the birth, to avoid a long transfer if complications arose for the baby.

The couple eventually found a motel but it was noisy and unsuitable, so they checked out and returned home.

The midwife told the mother to meet her at the birthing unit for another CTG on their way home.

The cardiotocography was reassuring and the baby’s movements were good, but the midwife was concerned about how the baby would cope in labour.

She repeated her recommendation for hospital admission and CTG in labour, but again the mother declined.

She felt that her labour would start naturally if she went home and relaxed, but said that if there were any signs of distress or infection, she would go straight to hospital.

Baby stillborn 15 hours after labour begins

Labour began around midnight and the midwife arrived at the house four hours later.

At 6.30am she called another midwife for assistance if required.

At around midday, the mother’s contractions had slowed down. She refused a vaginal examination to check dilation and declined further suggestions for checking the baby’s wellbeing including the use of a Doppler, which uses sound waves to measure the baby’s heart rate.

The midwife suggested the backup midwife could leave on a break as she did not believe that labour had fully established.

The lead midwife then left to get some lunch in town and make calls.

The mother told the HDC that she was still having contractions and in a lot of pain.

She got into the birthing pool, feeling a “very strong urge to push”.

She said she was petrified and didn’t know what to do because there was no midwife with them.

The baby started coming, and when the father saw that the baby’s head was purple and the baby was still with no movement, he knew something was wrong.

He said that he started praying loudly and then caught their baby girl as she was born.

There were conflicting opinions as to whether the midwife had just stepped inside, as the parents claimed, or whether she was present in the final moments of the delivery, as she claimed.

The midwife began resuscitation while the father assisted.

After several minutes, she told him to drive to the end of the road to call 111.

Emergency services including a rescue helicopter were sent, but resuscitation was stopped just before 3pm.

The midwife was found to have breached the consumer health code in several areas, including that she should never have left the woman unattended, after not being able to ascertain if she was in latent or established labour.

Wall said the advice of an in-house clinical adviser was that the decision to birth at home as opposed to the hospital rested with the mother, as did the nature and extent of monitoring by the midwife after labour eventually began.

However, it was essential for the midwife to provide the woman with the information she needed to make informed choices.

Evidence showed that either she did not receive this information, or, if she did, she did not understand the midwife’s advice and appreciate the significance of the choices she was making.

The midwife, who has formally apologised to the couple, has since made changes to her practice including that she plans to consult with obstetric colleagues when women decline recommendations in such complex cases.

The HDC has made a list of recommendations including that the midwife undertake additional education on person-centred care and effective communication with health consumers.

Tracy Neal is a Nelson-based Open Justice reporter at ��һ�ǿ�����. She was previously RNZ’s regional reporter in Nelson-Marlborough and has covered general news, including court and local government for the Nelson Mail.