Supporting Families, Preventing Tragedies




Sunday, 15 July 2007

Like many first babies Alana was two weeks late and on the Thursday before the birth we completed our final scan. It was our understanding that the results from the scan were all healthy and our baby was estimated to be 10.2 lbs, with a good consistent heartbeat and the appropriate rhythm of the umbilical cord. That same day we attended a midwife appointment at the local hospital. Although we did not have the results from the scan available we discussed the indications with the midwife. She was able to go through routine procedures and checked the foetal heartbeat, temperature, pulse, blood pressure and did some pulping of the abdomen. While on the CTG we found small contractions spaced at 2/10, these contractions were only first stage and not very intense. The midwife was also able to stretch and sweep the membrane to help encourage the birthing process. Everything until this point was routine for any birth and deemed appropriate. The only exception was that we knew Alana was going to be a large baby potentially 10.2 lb, but no indication or urgency was given by the midwife that we should be showing concern with the only comment being was a throw away remark that the “scan estimates are always wrong and the baby is probably 1kg lighter than the estimate”.

Due to availability at Wellington Hospital we could only choose between Sunday or Wednesday for induction dates. Alana was to be the minimum allowed 10 days on Sunday. We were able to book Saturday night at Wellington Hospital for overnight with Prostaglandins to start the induction. The midwife told us that it would not be necessary to contact her unless the contractions were 3/10; 1 minute long and so strong I was having trouble talking. Thursday night they were so regular (still 2/10) and intense that we arranged for family and friends who were going to be involved in the birth to stay. Not being informed on how long this stage of the birthing will continue we were sure the baby was due in the next 24 hours.

The midwife said she would call Friday night before she went to bed but again she stipulated that it was not necessary to contact her unless the contractions were 3/10 and I was unable to talk during 1 minute long contractions. At no time did the midwife explain that the labour contractions I was having could last for many days.

The next contact was the routine call on Friday evening about 7pm; the situation was still the same from both parties.

Saturday after lunch the contractions got more and more intense. The midwife contacted after 2pm and discussed the timings for the night ahead. The midwife pointed out that she had been assisting with another midwife’s birth during the day and that she was going home for a rest because she thought she may be back in with our birth later that night. My husband and I went to Wellington Hospital a bit earlier than the scheduled 6pm appointment as I was concerned the contractions were getting heavier. Our midwife said we could go earlier if we wanted but she also mentioned as she had a dinner party she and would not be available for the checks and beginning of the induction, instead another midwife would be available for us.

Because we had wanted to go early we arrived at the Hospital after 5pm. At the Maternity Ward we were told that beds were going to be scarce that night and that there were 3 ladies looking for beds. To help them organise the beds we were ushered into the waiting room with 2 waiting fathers with their 4 kids, here my wife felt uncomfortable. Not far through the 6pm news we were shifted into one of the 4 bedrooms with mothers who seemed to be at an earlier stage than myself with much stronger contractions. We believed that since I was having such large contractions and our midwife knew this then the hospital staff should have reacted with more urgency and the appropriate tests should have begun immediately. At about 6.30 we were sent down to the Delivery Suite to meet the midwife.

Because our midwife was at her dinner party her colleague met us. After nearly 10 months of carrying a baby the mother (and father) should expect a level of health care that would understand the importance of these final hours before the birth of the child. We saw this midwife swap as yet another calamity of events that continued to unfold during our midwife care.

The new midwife had obviously not talked to our midwife as we had to explain the last few days over again. This lack of communication was apparent and again at this crucial time we should not have to repeat our notes to the next care provider. We are not health care professionals and how could we be sure we had covered all important factors. The midwife mentioned that she had a similar patient in the Delivery Suite who had been having contractions since Tuesday, so long labour contractions were normal.

With the help of a student present in the room the midwife conducted routine testing and questioning. She definitely did blood pressure, pulse and pulping of the abdomen, but due to reasons unknown no foetal heartbeat or CTG was taken at all. This was our final chance to catch any signals of distress from our baby. We later found out that the midwife believes she felt movement from our baby girl during these checks. Sometime 24 hours prior to the birth on Sunday night our baby daughter died from a compressed umbilical cord. The compression occurs during the contraction and movement of baby into birthing position. The contractions had become more and more intense during that afternoon on Saturday. Therefore it is very likely that we would have seen our baby in distress from heart rate changes, especially in relation to contractions. We now believe our baby could have been saved.

The situation of my intense contractions was discussed with the midwife. The midwife found that my cervix was posterior and would require the contractions overnight to move into position. She recommended not getting prostinglandins as this may make the uterus hypertonic and also cause hyperactive contractions that could be detrimental to the birth. The midwife informed the resident doctor of the situation and he agreed under these circumstances it was better to let nature take its course overnight through spontaneous labour and then if necessary augment the following morning. We agreed we would prefer the natural labour and therefore would go home, but now know that if we had stayed in hospital we would have increased the chances of survival of our baby because we would have been monitored throughout the night.

We were told that the spontaneous labour could continue at home and if we were 3/10 by the morning we would be best to go to Kenepuri. We were always intending on having the baby at Kenepuri so we believed that this would be more suited. If we had not reached 3/10 contractions we would be back in Wellington Hospital Delivery Suite at 8am.

I was given some optional sleeping pills for later and we were then sent home soon after 7pm. That night I got little or no sleep. Although the contractions continued to be hard they did not increase in frequency and we returned to Wellington Hospital Delivery Suite at 8am.

Although we were expecting to see our midwife a completely different midwife once again met us. This midwife was once again ill informed from the previous midwife and relied on us to explain what was discovered in the previous appointments. She asked us which way the baby had been laying when the heart beat was last taken on Thursday. I was discovered to be 2cm dilated on Saturday night but my husband believed the midwife may have been referring to the frequency of the contractions being 2/10. This is the confusion we create when the health care providers rely on the patients for updates and notes.

This time all appropriate tests were carried out. But when the baby’s heartbeat could not be found through the CTG equipment another resident doctor attempted a scan. Our baby was announced dead soon after.

Our midwife LMC arrived at the hospital after the news of the death of Alana.

We believe that our midwife not being available at critical moments was one of the biggest failures from our LMC. Due to the lack of urgency and no emphasis of the risk on the birth at this stage we lost our window of opportunity to save our daughter. Other areas of failure include the Saturday night late changes of midwife due to social reasons, being sent home with only light sleeping tablets, no foetal heartbeat test taken during critical stages, LMC not available Sunday morning for birth, lack of communication between midwives, no emphasis on risks to mother by LMC and general incompetency’s by all independent midwives involved. We put our complete faith in the health system and believed that both mother and daughter would not only have competent care but exceptional and thorough assistance. By placing our trust in our LMC we were sure any problems would be resolved quickly and professionally but what we found was a series of preventable actions from complacent and incompetent independent midwives that contributed to our baby’s death.

Over the course of the next 13 hours I gave birth to our beautiful daughter, Alana, who had no heartbeat. We will never have our baby Alana to love and cherish. She was lost through a series of events on a Saturday and Sunday in July 2007. It was not until we talked with the Pathologist on the Monday did we learn how many big babies cause problems and how it is a common misinterpretation that a big baby is always going to result with a healthy baby. Alana was born 9.35 lb and 55cm in length, this is a large baby and as the Pathologist stated the size of Alana was a contributing factor towards the compressed cord.

For the next 1 ½ years we pursued a Health and Disabilities Commission investigation, as we believed the LMC and other midwives involved should not continue to practice. We wanted answers on how our LMC could not be there during the crucial times of the pregnancy and why we were not told of the potential danger during these times? Why wasn’t our baby’s heartbeat taken when it is standard procedure to do this? What checks does the hospital have to prevent this occurring? Why was such a big baby treated with such complacency? Why were basic midwifery skills lacking from so many of the staff we encountered during the final hours of Alana’s life? Why our notes and communication are not passed between the midwives and why should a patient be the one to inform the many staff who we were in contact on the status of the pregnancy?

After a drawn out 1 ½ year HDC investigation we received two short apology letters from midwives involved (one without signature) and a reference in the report about some small code breaches. No further action could be taken against the parties involved except the midwives had an option to seek more training, if they wanted.

Two years since the tragedy we are now due with a new baby and we are this time in the safest hands available. It is a true indictment on our system that you have to suffer a tragedy before you can be guaranteed of this. The care we received during the pregnancy of our 1st child, Alana, was below average and many of the warning signs that, in hindsight, pointed towards incompetent and incapable care by our midwife were missed because we previously believed in the health care system. The lack of accountability by the midwives and any professional organisation they are aligned with was apparent during our fight for any justice for our daughter. We believe that the system is fundamentally flawed and that the maternity system is in dire need for a major overhaul, which is why we too are supporting AIM.

Grantham and Megan

Red Flags

        RED FLAGS

  • Lack of monitoring
  • “Normalising” the abnormal
  • Lack of action/delay in getting emergency care
  • Going over due date
  • Failure to progress in labour
  • Meconium-stained liquor (waters)
  • Lengthy handover during emergency
  • Inconsistent reporting and documentation
  • Your concerns being ignored

    Click here to read more about common warning signs


The content of this website is offered for information purposes only and is not intended in any way to be a substitute for medical advice. It should not be used for diagnosing or treating a health problem. Always check with your medical practitioner if you have concerns about your condition or treatment. AIM is not responsible or liable, directly or indirectly, for any form of damages whatsoever resulting from the use (or misuse) of information contained in or implied by the information on this site.

This website contains links to websites operated by third parties. Such links are provided for reference only. AIM does not control such websites and is therefore not responsible for their content.