The woman was admitted to hospital after expressing concerns about reduced foetal movements and was diagnosed with pre-eclampsia the same day. (file image) Photo: RNZ /Dom Thomas
The health watchdog has criticised the care given to a woman who lost her 11-day-old son after giving birth at Palmerston North Hospital.
The boy died of a severe brain injury after being delivered by emergency Caesarean section at 33 weeks' gestation in 2018.
The woman - identified as Mrs A in the Health and Disability Commission report - had been admitted to hospital a week earlier with pre-eclampsia, a condition that causes dangerously high blood pressure, often in the later stages of pregnancy.
Deputy commissioner Rose Wall found the woman's consultant obstetrician and gynaecologist did not carry out a foetal growth assessment following the woman's diagnosis, even though it was the expected standard of care.
She has made a number of recommendations after finding both the doctor and the then-MidCentral District Health Board in breach of its consumer rights' code.
The doctor - identified as Dr B in the report - said she was very sad to learn that "Baby A" had died.
"I reiterate how very sorry I am for the loss of [Baby A] and for [Mrs A's] experience while under my care," she said.
" tragic case like this always leads one to review the care provided with a critical eye and consider whether anything was missed, or whether anything could have been done differently."
The woman was admitted to hospital after expressing concerns about reduced foetal movements and was diagnosed with pre-eclampsia the same day.
On day six of her hospital stay, a cardiotocograph (CTG) monitoring the baby's heartbeat was abnormal, so she began a course of steroids in anticipation of an early delivery.
Her obstetrician cancelled Mrs A's ultrasound, which was scheduled for the following day, because a scan three weeks earlier showed normal foetal growth and amniotic fluid and another was unlikely to change the delivery plan at 34 weeks.
Mrs A was induced on day eight because of her worsening pre-eclampsia, but the CTG showed irregular drops in the foetal heart rate and she had an emergency Caesarean section.
Baby A was stable until 39 hours after his birth, but then became unwell.
He was diagnosed with a severe brain injury, likely to have been caused by an "in-utero event", and died when he was 11 days old.
The case was reviewed by the perinatal and maternity mortality review committee under the former MidCentral District Health Board, which did not raise concerns about clinical decision-making or care.
However, Mrs A remained concerned about the standard of foetal monitoring, particularly the lack of an ultrasound or Doppler test, which measures blood flow from the foetus to the placenta.
Deputy commissioner Rose Wall found it was Dr B's responsibility to ensure that a foetal growth assessment was done when Mrs A was diagnosed with pre-eclampsia, based on guidelines and accepted clinical practice.
She said the health board's foetal monitoring guidelines were not in line with national Ministry of Health guidance recommending ultrasounds and Dopplers at the time of diagnosis.
"I consider that the lack of alignment of the MCDHB guideline with current best practice represented a missed opportunity for staff to check foetal growth and well-being, which may have influenced other decisions in Mrs A's care, such as the timing and method of delivery," her report said.
"While I acknowledge that this may not have altered the outcome, I am critical that the scan was not performed.
"I remain concerned ... that three years after these events, MCDHB's policies had still not been updated to reflect national guidance.
"MCDHB told HDC that in December 2021 it was in the process of finalising an updated version of the MCDHB guideline, to include a recommendation to order an ultrasound scan and Dopplers at diagnosis of pre-eclampsia.
"In my view, and while I accept that this has no bearing on the care Mrs A received, the three-year delay in updating its policies to reflect national practice is unacceptable."
Te Whatu Ora MidCentral had since adopted updated national Te Whatu Ora hypertension and pre-eclampsia in pregnancy guidelines, which recommended ultrasound and Dopplers at the time of diagnosis, the report said.
Dr B said she now diligently incorporated growth assessment and Doppler tests in her care of women with pre-eclampsia.
Mrs A's previous child was delivered by Caesarean section and her preference was to have a vaginal birth.
Wall also found there was a general lack of information about the risks of induction and labour to Mrs A's baby following the CTG abnormalities.
"This new risk factor needed to be discussed with Mrs A prior to the attempted induction, and I am critical that induction was attempted in the absence of this," she said.
Wall was also critical of a lack of communication with Mrs A, including her transfer from the delivery suite to maternity ward and the cancellation of the scheduled ultrasound.
She recommended Dr B give Mrs A a written apology and the Medical Council consider whether a review of the doctor's competence was warranted.
She also recommended that Te Whatu Ora MidCentral use the report as a case study for obstetric and maternity education sessions and ensure changes to planned procedures or investigations were discussed with patients and explanations provided.