When a woman who had lost a baby through stillbirth became pregnant again, she was naturally diligent about her care but was reassured by her midwife that “you can’t be struck by lightning twice”.

However, sadly, that was bad advice, as the woman’s near full-term pregnancy did end with another stillbirth.

Now her midwife and back-up midwife have come under fire for a list of failings in her antenatal care.

Today, the Health and Disability Commissioner (HDC) released a report on the case after the woman complained about the services provided to her by the two registered midwives from December 2019 to January 2020.

The names of all parties have been redacted.

According to the report, the woman lost her baby at 33 weeks of gestation after experiencing abdominal and back pain and a hard abdomen.

Her midwife was away at the time, and after speaking with the back-up midwife, there was a delay in assessing the woman.

When the woman was finally assessed at the maternity unit, a cardiotocography (CTG) trace was found to be abnormal and her temperature and blood pressure levels were raised.

She was transferred to a hospital by ambulance, where a fetal heartbeat could not be found.

It was discovered that the woman had experienced a placental abruption, which resulted in the stillbirth of her baby.

A ‘tragic loss’

In the report, Rose Wall, the Deputy Health and Disability Commissioner who investigated the woman’s complaint, expressed her condolences for the couple’s “tragic loss”.

“I acknowledge that the events at [33 weeks and four days’] gestation were traumatic and that [the woman] has sought answers to her questions about what happened and whether [the baby’s] death could have been prevented.”

Wall said the events surrounding the pregnancy, especially in the period leading up to the stillbirth, were challenging to investigate, particularly due to the different accounts provided by the midwives and the woman.

Rose Wall, Deputy Health and Disability Commissioner, investigated the woman's complaint. Photo / Health and Disability Commissioner

According to the report, in 2017, the woman lost her second baby at 22 weeks’ gestation as a result of a rare genetic condition.

In 2019, she became pregnant for the third time, and her baby was expected to be delivered in February the following year.

The report stated that the woman was diligent about her pregnancy in light of her previous loss.

No consideration of obstetric care

She told the HDC that she asked her midwife about obstetrics being involved in the pregnancy, but the midwife did not provide any information about access to, and choices of, obstetric and secondary care.

The woman said the midwife “strongly emphasised” that she should use only her midwifery services, saying that “you can’t be struck by lightning twice”.

She said the midwife advised her that they would “just have to see how we go” and did not inform her whether she met obstetric care criteria.

The midwife told the HDC that she had no recollection of the woman having requested a consultation with an obstetrician.

She said that had the woman done so, she would have submitted a referral, and there was no indication of such a need.

However, Wall found that the woman likely did request a consultation with an obstetrician but the midwife did not give due consideration to the request and failed to advise her that she could access such care privately.

The failure was a moderate departure from accepted practice and resulted in the midwife breaching the Code of Health and Disability Services Consumers’ Rights (the code).

Concerns of pre-eclamptic toxaemia

Relating to a separate breach, the woman also complained about care relating to vaginal symptoms she experienced at 16 weeks’ gestation, an inadequate response to her raised blood pressure, and not being weighed or having a urinalysis performed during the pregnancy, except for at the first appointment.

The woman was concerned about pre-eclamptic toxaemia (PET) and had pointed out a family history, and a sudden weight gain during the pregnancy, but said the midwife took no action in response.

The midwife told the HDC that she considered the woman to be at low risk of PET.

She said her blood-pressure readings were not high at any point, and she did not deem it necessary to undertake a urinalysis at every visit – a move she said she now regrets.

Conversely, the woman stated that on several occasions her blood pressure readings were at the “upper end of the normal range” and recalled that days before the stillbirth, it was “at the highest level during her pregnancy”.

However, her urine levels were never checked for protein or glucose and no other tests of her wellbeing were carried out.

The woman had concerns about pre-eclamptic toxaemia during her pregnancy.

She said she was never warned of any possible complications, such as the development of gestational hypertension and placental abruption, or what she should watch out for, like sudden abdominal pain indicating abruption.

On the issue of vaginal symptoms, the report stated the midwife gave the woman a prescription for thrush cream without investigating to ascertain whether thrush was the cause.

She told the HDC that the woman requested thrush treatment, which the woman denies, and she did not order a swab to investigate because it was her practice to provide such treatment if women were confident about their symptoms.

Wall found it was inappropriate for the midwife to have provided the cream without further investigation and was critical that she did not follow up to check whether it had resolved the symptoms.

She further concluded that while the woman did not have many classic signs of PET before 33 weeks of gestation, had the midwife conducted the urinalysis and monitored the woman’s weight, “that may have identified that [the woman] was not a low-risk woman, particularly in light of the familial history of PET”.

On those points, Wall established there was a breach of the code for failing to provide services with reasonable care and skill.

Symptoms not responded to with sufficient urgency

In relation to the back-up midwife, who was on call at the time the woman raised concerns about the pain she was experiencing, Wall also found two breaches had occurred.

That midwife had initially spoken to the woman for eight minutes over the phone, but they had different recollections about what was discussed.

The woman said she stressed that she was experiencing severe pain, while the midwife claimed she had not expressed that, nor that her stomach was unusually hard.

The midwife recalled that the woman had “tightenings” so she advised her that it would likely go away and she would phone her back in two hours.

Following an assessment, the woman was transferred to a hospital by ambulance, where a fetal heartbeat could not be found. Photo / 123rf

Wall found in favour of the woman’s recollection.

However, she accepted that the midwife likely did later conduct an abdominal examination of the woman at the maternity unit, which the woman claimed had not taken place.

The midwife said the exam had been conducted, despite there being no documentation of her findings.

Overall, Wall said the back-up midwife’s care of the woman was inadequate, particularly because during the telephone conversation, she did not respond to the symptoms the woman was describing with sufficient urgency, which resulted in a breach of the code.

She was further breached with respect to her record-keeping.

According to the HDC report, since the woman’s loss, both midwives had made several changes to how they practise.

Wall further recommended that they each provide a written apology to the woman and her husband for their failures.

She also recommended that they undertake further related learning.

Tara Shaskey is an assistant editor and reporter for the Open Justice team. She joined NZME in 2022 and has worked as a journalist since 2014.