Christchurch Women's Hospital has been criticised for serious failures in the care of a woman in labour. (File photo) Photo: RNZ / Diego Opatowski
A baby who died from a catastrophic brain injury after his head got stuck during labour should have been delivered hours earlier by caesarean section, an investigation by the Health and Disability Commission has found.
The large baby was born at 1.11am, pale and floppy, and needed to be resuscitated.
He was transferred to the neonatal intensive care unit, where he later died.
In a just-released report, deputy commissioner Rose Wall has criticised Christchurch Women's Hospital for serious failures in care during his mother's prolonged labour after she was induced, including a lack of assessment, failure to call for back-up, delays in making the decision to do a C-section and then the delay to carry it out.
"Given the woman's high-risk pregnancy, due to an advanced maternal age, IVF pregnancy, and her medical history … it would have been reasonable to take a more conservative approach," Wall said.
Once the decision to deliver the baby by C-section was made, there was a final delay of almost two hours, due to the operating theatre needing to be prepared and medical staff to become available and the need to juggle other urgent cases.
Two registrars started to do the C-section under the observation of a senior consultant, but it was quickly realised the baby's head was "impacted" inside the mother's pelvis and attempts to free it from "above and below" were not successful.
The consultant quickly made the decision to deliver the baby feet-first and a second incision was needed to free his head.
The baby was born within two to four minutes of the procedure starting, but needed CPR for 38 minutes.
The consultant, Dr C, said he was "completely shocked" the baby was born in such a bad condition, given the CTG monitor of the foetal heart rate in the delivery suite had been normal and reassuring.
"It made me question what went wrong and how we could not foresee such an unwell foetus."
An obstetrician commissioned by ACC to review the case said it would have been possible to diagnose the labour was not progressing by 3pm and the baby should have been delivered five to seven hours earlier.
"So many contractions over so many hours are likely to have wedged the head into the pelvis more and more as time progressed.
"This in turn caused the great difficulty in delivery … My view is that the delay in the [C-section] delivery has caused [the baby's] head to become impacted (jammed) into the pelvis and therefore very difficult to deliver."
By the time the woman was assessed by a senior doctor at 9.17pm, she had already been in "active labour" for 14 hours, by which point "the writing was very much on the wall that a vaginal delivery was very, very unlikely" the independent assessor told ACC.
Another obstetrician who gave expert evidence to the HDC, Dr Sikhar Sircar, said there were several "severe departures" from accepted practice, including not having an earlier assessment and the failure to deliver the baby by C-section "at or by 9.17pm".
The coroner's report found the baby had suffered a huge bleed in his brain and oxygen deprivation due to the awkward position in the mother's pelvis, which cut off the blood supply to his brain during the lengthy labour.
While the CTG of the baby's heart-rate during labour did not show the typical pattern that would indicate low oxygen, there were a number of instances where the "reduced variability and variable decelerations" should have alerted staff to a potential problem.
Wall said "multiple systemic issues" were to blame, including a combination of inadequate staffing and support, and a lack of safe staffing escalation processes.
In response to the HDC's provisional finding, Health New Zealand agreed that "when applying a hindsight lens to the events that occurred, Baby A's delivery should have occurred earlier".
However, considering what information and resources were available to staff at the time, it was not possible to say whether it was reasonable to have expected staff to have done things differently, it said.
"Resource constraints" prevented the staff from calling a second on-call consultant, as it was a Sunday and that doctor had already been on call for the preceding 24 hours and was expected back at work the next day.
"Health NZ said that if Health NZ Waitaha Canterbury had had greater funding to allow for the employment of more full-time senior medical officers [SMO], there could have been greater availability of a second on-call SMO."
The delay in the C-section was also due to available resources, which meant this woman, who had a reassuring CTG at that time, was overtaken in terms of priority by other cases that appeared to be more urgent.
Health New Zealand also disagreed with the experts' views that a decision should have been made to deliver the baby by C-section at 5.22pm - when the midwife discussed lack of progress with two doctors - as that was not supported by international clinical guidelines.
Since the event, Health New Zealand has made several changes within the Obstetrics and Gynaecology Department, including employing more doctors, staffing training, new equipment and updating its procedures for monitoring labour and escalating clinical concerns.
Health NZ stated that effectively there are now three consultants rostered to cover the weekend, ensuring "much more reserve in the system".
"An important part of its communication about this rostering change has been to emphasise that consultants on duty should have no reservations about calling for additional help, and the second on-call person can expect to be called without concerns about their potential exhaustion."
The agency and the individual doctors involved in this case have extended their "sincere condolences for the loss of their precious son".
'We can reassure [the baby's] family that improvements have been made to the way we care for women and babies."