Supporting Families, Preventing Tragedies


Near Miss


 Wednesday, 12 September 2007

I wanted to share with you my story, which I believe was a “near miss” to being a much more serious situation, and I thank the stars every day that Lisa recovered from a very poorly managed entry into the world. I believe there may be hundreds of stories like mine with the current overcrowding/under resourcing of maternity hospitals.

This labour went beautifully as a second child, waters broke at home 3.15pm, contractions from 5.30pm in hospital at Chch Womens. I had advised my midwife there was very thick meconium in the waters, it looked like pea soup. I was managing on just gas quite well.

My midwife advised I was nearly fully dilated at 10.30pm-ish with a wee lip of cervix left, so after trying to hold off the natural pushing sensations for a while, she told me to go ahead and push to see if we could move the last bit. Baby however was consistently ROP slightly side on and appeared to be face first, so we were told emergency c-section was necessary, at this point I opted for an epidural! I remember quite clearly having been given the epidural and waiting to go into theatre before midnight, watching the clock closely as I was in labour on Sept 11 and was hoping we didn’t go into theatre until Sept 12 to have a nicer birthdate.

We were told another baby was in more distress than ours and had to go first so expected to wait a bit, my baby’s heart rate was strong. After a while I became concerned, my midwife kept disappearing, I was examined again by 2 people and we just kept waiting.

We ended up waiting nearly 5 hours to go into theatre – this with a baby who was jammed hard in the pelvis, heavy meconium and evidence of high heart rate at times (ie distress). When born, doctors were concerned at the level of meconium, she took time to breathe, they gave her extra suction and her first AGPAR was 3. Her blood gas level at birth was below normal and my midwife seemed concerned, but thankfully my baby breathed normally after a while and recovered well. (She was also a 4.7kg baby).

My issue here is we should never have had to wait nearly 5 hours for an emergency C-section. I complained to Chch Womens Hospital about this and they said according to notes I was asked to try pushing again on the bed at 2am – this is factually incorrect as my husband and I know I did not once push on the bed after I had the epidural, and I was completely aware and able to watch the clock after this pain relief had been administered. They record my waiting for C-section time as 2 hours and 50 minutes, which they admit is over the 45-60 minute standard they try to achieve.

I watched my baby for months after this experience, to see if the lack of oxygen had affected her responses or development. She is now a beautiful normal 21 month old and I am thankful every day that having to wait so long with a baby that needed to be born did not have the dire consequences faced by some of your mothers. The system needs to improve – all we had was the hospital blaming the midwife and everyone seeming unsure of who was actually responsible once the doctor decided an emergency C section was necessary.


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


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