A woman needed blood transfusions to counter heavy blood loss after her baby was born, and surgery to remove part of the placenta that caused the haemorrhage.

She also received a severe obstetric injury in the form of a third-degree perineal tear from the use of forceps during the delivery.

In a report released today by the Health and Disability Commissioner (HDC), the woman was described as being at one point in a “highly distressed state” and unable to push, and requiring another epidural insertion after the first came out.

Health NZ Whanganui has been criticised by the HDC for failing to provide services that complied with relevant guidelines, including that the woman’s care was handed to a new graduate midwife, which the woman claimed she knew nothing about.

Deputy Health and Disability Commissioner Rose Wall included in her recommendations that Health NZ Whanganui develop and implement a process to guide midwives who were not epidural certified.

The health provider had therefore breached the health consumers’ rights code.

Deputy commissioner Rose Wall said in the report that while individual midwives were involved in the woman’s care during labour and delivery, the fault lay with Health NZ Whanganui for not ensuring that a midwife qualified to manage epidural pain relief was available.

This meant the woman’s epidural was not monitored appropriately, and she was subjected to unnecessary pain, which had a significant impact on her birth experience.

The midwife has since apologised to the woman for the negative experience, and for any part she played in that.

“This was never my intention. Every mother deserves to feel safe and cared for and most certainly does not deserve to feel negatively about her labour and birth,” she said.

Locum midwife called in to help

According to the report, the woman was admitted to a hospital maternity ward after going into labour in April 2022.

Because of an unexpected staff shortage, a request was made for help from a locum midwife and one was assigned to the woman’s care.

Based on the health board’s guidelines for pain management options in labour, the midwife was not certified to provide epidural care for the woman.

Wall acknowledged that the maternity unit at the public hospital was short-staffed, and that the core midwifery team wanted to provide the woman with good care during labour and delivery.

She also accepted there was an expectation that an epidural would be managed and monitored by an epidural-certified midwife, but this did not happen.

By mid-afternoon, the woman was using pain relief inhaled through a face mask. Wall said she became increasingly distressed and requested an epidural.

It was inserted by an anaesthetist later in the afternoon and the woman was given a patient-controlled analgesia pump which enabled her to control the level of anaesthesia from the epidural.

Just after 9pm, pain relief was stopped to encourage the woman to “push”.

Epidural ‘no longer in place’

The midwife documented that the woman was concerned that her contractions were becoming more painful, and that she felt she was unable to push.

The epidural was restarted and the midwife encouraged the woman to continue to push, but she was in too much pain.

An hour later, the midwife called the obstetrician who recommended that she continue trying to push for another hour.

She then asked the obstetrician to attend as the woman had become “very distressed”.

The specialist arrived an hour later and efforts were made to deliver the baby with forceps, but the woman was unable to tolerate the pain.

The obstetrician noted that the epidural was no longer in place.

The woman asked for it to be re-sited before continuing with the forceps delivery, and the baby was born safe and well, followed soon after by the placenta, but the woman had suffered a severe obstetric injury.

Heavy bleeding

In the days following, she began to bleed heavily and experience more pain, which was found to be caused by retained placental tissue, requiring surgery.

A review of the woman’s postpartum haemorrhage, during which she lost more than 500ml of blood, noted that the placenta and membranes were documented as “complete” but that it had an “odd shape”.

The woman received ACC cover for a treatment injury for “secondary postpartum haemorrhage” requiring surgery and blood transfusion.

Independent advice from a midwife during the claim assessment identified concerns related to the documentation of the placenta, and whether its odd shape was communicated to other staff involved in the woman’s care.

Health NZ Whanganui acknowledged the woman was not informed that her care would be handed over to someone who was a new graduate midwife and who was not epidural certified.

It said there should have been a three-way discussion between the core midwives, the lead carer, and the woman regarding the handover of her care.

The Midwifery Council did a competence review of the midwife in light of the complaint. After discussion about the support available to the midwife from her colleagues and the hospital’s obligation to support new graduates, it felt the hospital had let her down in her first year of practice.

The council also identified education opportunities and asked the midwife to complete a competence programme focusing on documentation and record-keeping.

Wall included in her recommendations that Health NZ Whanganui develop and implement a process to guide midwives who were not epidural certified.

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