Supporting Families, Preventing Tragedies


Near Miss


Wednesday, 23 May 2007

I currently have no faith in the maternity care offered to women in New Zealand both by obstetricians and by midwives; I have been failed by both.

My first pregnancy with my son was troubled by hyperemesis throughout and then at the end my placenta stopped functioning and my son was starved. I cannot fault my maternity care with my son. I had a fantastic obstetrician who was awesome and gave me the best care possible. I wished he was still practicing when I got pregnant with my daughter 5 years later because then I would not have had the traumatic birth I did. But unfortunately he got sick and had to retire. For the reasons of my failed placenta I was referred to a specialist at the hospital as there was concern that it would happen again. I went to my GP and he referred me to the specialist high risk team at the hospital.

The specialist was my lead maternity carer (LMC). Even though he was my LMC I only saw him about 5 times during my entire pregnancy. When I went to my clinic visits I was always seen by trainee doctors who would always ask “why are you here?” (I so wanted to scream at them, “why do you think I’m here, because I’m pregnant!”) By the end of my pregnancy I was getting sick of hearing this, they should have known why I was there. They had my file in their hands and had read it before seeing me! I was there because I was considered a high risk pregnancy and was there to check that both me and baby were OK. Although I was high risk I certainly was never treated as high risk. I still don’t understand why I wasn’t seen by the specialist each time instead of trainee doctors. Looking back now this is a concern, but at the time I didn’t question it as they were the professionals not me – this is a decision I now seriously regret. The trainee doctors would go back and forth to the specialist asking him questions and advice and bring it back to me; it was like the specialist was too lazy to get out of his office and see me.

In summary what I am trying to say is that I did receive adequate care during the initial stages of my pregnancy, especially during my many admissions to hospital for hypermesis that I also had with my son. Apart from not seeing the specialist and having trainee doctors, the care during the last part of my pregnancy – from when I started having bleeding episodes and other problems – was far from adequate. I strongly believe that I should have had the C-section at 30 weeks that they were going to do when I had major bleeding issues and I do strongly believe that although my daughter would have been premature she wouldn’t have the problems she now has had she been delivered then.

More that anything though after the decision was made to carry the pregnancy to full term I am even more disappointed and frustrated with the care I received from both the hospital and the specialist both on the day before I had Marion and on the day that she was born. The medical professionals knew that my pregnancy was high risk and yet they made a conscious decision to allow me to go to full term. They therefore had a responsibility to be alert to any subsequent happenings. The fact that they sent me home from the delivery suite the day before I had my daughter despite acknowledging that I was in early labour, bleeding and had high blood pressure was a fundamentally bad decision. If they had left me there they would have seen earlier that things were going wrong and they would have had time to get her out quickly and what happened to her would not have happened.

I am very upset and angry at the care I received from the hospital the day Marion was born, I believe I was not treated fairly and just being put in a room and left for half an hour despite having contractions less than a minute is not acceptable. I don’t understand why I was treated like this. I want changes made so that no one else has to go through what I went through. I want people to take responsibility for what happened to me and my daughter.

In my fight with ACC for justice for my daughter ACC have stated that this would be a very expensive case for them. I want to state that this case is not about money as no amount of money can change what happened to my daughter. This case is about not receiving adequate care which resulted in my daughter’s traumatic birth and her fight for life afterwards. This is about Marion getting what she is entitled to following her unnecessarily traumatic delivery. It was not Marion’s fault nor was it mine that this happened to her, yet Marion is going to suffer for the rest of her life because of it.

This is about Marion’s future. I have no problems with Marion’s care after her birth – in fact everyone has been fantastic. I can not fault her antenatal care they worked so hard to save her life. The fault is with the care I received during my pregnancy and especially during delivery.

I had a clinic visit the day before Marion was born. The trainee doctor thought I was in early labour and discovered I had problems with my blood pressure so sent me to the antenatal day until for investigation. They said that I was 2cm dilated I was starting to get worried so asked for my sister who was my birth partner to come up and support me. They did the usual tests blood, urine and a ctg. I could feel the baby moving and was having contractions but they were not worried. The doctor sent a midwife in to do a fingerseep to speed things up which was very painful and resulted in quite bit of bleeding. Then the doctor came back in and said, “you are only 2cm dilated so go home and don’t come back till you are in full labour.” I was not happy about being sent home as I had no transport or landline phone and lived in Fielding, a good 20 minutes drive from the hospital. Looking back now I should have put my foot down and said, “no I want to stay,” and refused to go home but they were the professionals so didn’t question them. I strongly believe that they should have never sent me home. If they had kept me there they would have picked up that things were going wrong and they would have been able to intervene and prevent things from turning out as they did.

When I got home I slept through the night. When I woke at 7am my contractions were two minutes apart and when I went to the toilet I noticed a lot of blood which really scared me. On the way over to Palmerston North in the car my contractions sped up to a minute apart. My sister rang the hospital and told them I was coming in with contractions less than a minute apart. When we got there they did not know who we were or that we were on our way up so we were taken to a room and just left there for half an hour. No one came near us despite my contractions intensifying even more and speeding up to around 50 seconds apart. I was leaning over a chair for a good half an hour before anyone came in. In my hospital notes it says they did the obs but no one came near me and my mum was with me the entire time to verify this. After half an hour a care assistant came into the room noticed things were not good and went for help this is when the midwife came in and felt my tummy during a contraction, then asked me a few questions, then put me on the bed to put the CTG on. This is when they realised all was not well. The CTG had just been put on when my waters broke and I wanted to push and it was all on.

I was in a lot of discomfort and feeling really scared at this stage. The pain got really bad and the midwife called for help. Another midwife came in and they were having problems getting Marion’s heartbeat. It was getting dangerously low when they finally found it. They took the CTG off and put me into another position. By this stage the charge midwife came in as things were getting serious. The two midwives working on getting Marion delivered were concerned so called the registrar in for help. I was petrified by all the people in the room and all the equipment they were using – it was very scary. They called the specialist and asked him to come ASAP. He casually walked into the room during a contraction in a manner I found very upsetting, as he was joking around by saying, “Oh, who’s that under thre? Oh, its you,” etc. Looking back it was not funny at all but at the time didn’t think too much of it.

We were asked why we waited so long to come in and I was shocked as we did what we were told to do the night before one doctor says don’t come in and another says why did you leave it so long it was so frustrating. I was having problems getting Marion out and her heart rate was dangerously low so they used the ventuse to get her out in a hurry when she did come out she was grey and not crying and I was so scared and in shock and shaking and kept asking why is she not crying why is she not crying I glanced over at the paediatrician working on her and it was hard to see because there were so many people there but it was really terrifying and I was so worried after all I had been though similar with my son he was taken away when he came out as well as he was not breathing then taken to the neonatal unit. They were working on Marion while I was being stitched up after 20 mins they finally spoke to me and said she was having problems breathing problems and they had to take her away she had a tube shoved down her throat and was being ventilated and looked terrible but I got a quick hello and a kiss on her head before they took her away to the neonatal intensive care unit.

They asked me if I wanted to keep my placenta and I was not sure and they asked me if they could take it away for testing as Marion had a true knot in the cord and I’m so glad I said yes now otherwise I would have never learnt how damaged and unhealthy it was. I felt they must have known when they saw it as because it was that bad. By now I was well and truly in shock and had so many questions but couldn’t ask them so had a shower and went and saw my baby properly for the first time. We had to wait though as were told that they were still working on her so we waited and waited when we finally got to see her it was so hard, she was covered in tubes and wires and she was pounding her head because she was in so much pain. I still cant get that image out of my head almost 4 years later. It has really traumatised me. I couldn’t even touch her because it upset her so much. I could only stand there and look at her. That was so damn hard. The doctors explained what had happened and spent some time with us before we left and went back to the delivery suite where I was later transferred to a ward.

Marion had in her first few days of life two strokes, loss of oxygen that resulted in brain damage. The spastic cerebral palsy and neonatal seizures were so bad they had to give her the highest dose of medication they could to stop them and that medication put her in a coma for almost two weeks. They have recored in her notes that she has severe perinatal hypoxia and ischemic encephalopathy.

I can’t help but speculate that had I been treated properly the day before I had her or had the c section at 30 weeks like they were going to do that she would have had a better outcome and would be a normal healthy little girl now. I thank God every day for my miracle girl who has proved the doctors wrong so many times with her amazing progress, doing the things they thought she wouldn’t do like walking, not being blind and deaf. The fact that she is still here with us today is a miracle in itself that I strongly believe was her Great grandmother who she is named after watching over her. It could so easily – in fact it nearly did – go the other way and we nearly did lose her. My little miracle girl. Her pediatrician has repeatedly said on visits that she is not supposed to be this good. She’s beaten the odds and he himself has also called her his little miracle girl. I constantly ask myself though, why do the doctors keep lying about what happened? Why did my hospital notes go missing? Luckily I got to them before they had a chance to alter them and take things out – funny how they do that! The doctor involved at Palmerston North Hospital still denies any wrong doing, and we have proved to ACC that he has lied and covered things up. Yet they still declined our claim. When are these doctors and nurses and midwives all going to be held responsible for their actions because my daughter nearly died at their hands, yet they still get away with it and continue to practice. I don’t want it to have to take a baby or mother dying – or worse still both dying – before they are held responsible for their actions. They can do this much damage to our children and get off scott free. Its not fair. We are the ones that suffer.

Thank you, good fight, for the wonderful work you are doing. I am not going to stop fighting until I get justice, not just for me and my daughter, but for all other mums out there so that they do not have to go through what we have been through.

Sue, Jessie and Marion

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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