Supporting Families, Preventing Tragedies

Zara

Lost
Zara

Wednesday, 14 February 2001

My horror came after a normal birth in 1994 at North Shore Hospital.

I fell pregnant in 1998 in Wanganui. At 20 weeks I became quite ill and at 28 weeks it was discovered my baby had died from intrauterine growth retardation. Ben had been dead for 8 weeks. The midwife failed to pick up that there was no heartbeat on her visit at 24 weeks which meant I carried him for a further 4 weeks, compromising my health. One of the midwives at the birth stated to me that it was the worst birth she had attended in 25 years. She had seen lots of 20 week old baby’s and mine was definitely 20 weeks. The body had deteriorated as it had been left so long, which complicated the labour. I gave birth to Ben naturally; labour was induced which resulted in the head being delivered then the cervix closed around the neck and the rest of the body was delivered some time later. I couldn’t move throughout the labour because of the deterioration of the body. The whole process was unbelievable. I thought I was at my limit mentally throughout. I never saw my baby as the midwife suggested it would be better if I didn’t.

In 1999 I fell pregnant again. At 9 weeks I began to bleed and at 12 weeks I miscarried.

In 2000 I became pregnant again. I chose the midwife that had been involved in the last two pregnancies as I thought she would have an understanding of what I had been through and would provide good care. She had also reassured me that I would be entitled to obstetric care because of my history.

I had scans up to 37 weeks. All was fine with my baby. Then at 38 weeks I had urinary tract infection. I tried to contact the midwife and was unable to. I left messages but she didn’t get back to me. I was very upset, anxious and a bit hormonal too. I lost confidence in the midwife and got another midwife who assured me she would work with the obstetrician, and contact him if I had any concerns, even though I had only seen the obstetrician twice. At 20 weeks he discharged me to the midwife. I wasn’t happy about it but didn’t think I could do anything about it.

At 41 weeks I went to the hospital. The obstetrician saw me on his rounds and suggested he induce labour in the morning if I hadn’t already gone into labour. But the plan changed when during the night the LMC decided she would induce labour to get things going around 1am. I saw her twice in the next 5 hours as she was tired because she had done a delivery not long before I was admitted into hospital, so she spent most of her time sleeping in the nurses room. I didn’t know what to make of this as I thought she would be keeping a close eye on me due to my history and she would need to be there to reassure me and monitor the labour.

In the last half hour she appeared in the delivery room, because my husband went looking for her because he could see I was in a lot of pain, and he didn’t know what to do. As Zara was coming down the birthing canal I felt something was wrong as she just seemed to stop moving. I stated to the midwife, “something is wrong everything has stopped.” She replied “That’s enough of that carry on, just push.” Then a second midwife appeared, whom I had never met. The LMC said, “she is with the hospital,” (turns out she was an independent midwife with her own client in the hospital).

When my baby was delivered she was lifted up onto my chest. I looked down at her and thought “why isn’t she crying, and why does she look so weak with no movements?”, It was so different to my son’s birth; he was crying and thrashing about after delivery. My baby was wrapped and handed to her father. He noted she had stopped breathing and alerted the midwives to this. They didn’t respond so he said again, “My baby isn’t breathing.” The second midwife glanced over but didn’t respond, as she stated she was watching to see how the after birth was proceeding (she stated “I had a client in labour myself and was only there to assist if needed”). He then yelled “My baby isn’t breathing!” and then the second midwife said she felt the apex for a heartbeat, and then she said she would take her for some oxygen.

There was no head of midwifery in the hospital at the time so other midwives assisted. The house surgeon was called and informed Zara needed to be intubated but she decided she didn’t want to intubate even though she was trained to do the procedure. The pediatrician was called 20 minutes after she was born and arrived 10 minutes later to try to stabilize her.

Zara was flown to Wellington hospital and placed on life support. Her condition deteriorated and she died two days later from severe asphyxia combined with a delay in recognizing and treating her.

What were the concerns from the Pediatricians at Wellington hospital?

  • He was of the opinion that because of my previous difficulties, the minimal care I should have been afforded was to have a pediatric physician present as a precautionary step during labour and birth.
  • A specialist should have been contacted when my membranes were artificially ruptured and meconium was detected.
  • During labour, the baby’s heart rate was monitored by CTG. The tape on the CTG ran out at 4.12am on 14 February, and was not replaced. That meant that the last two hours of labour was not monitored, and therefore there was no recognition of the baby’s condition – it was impossible for anyone to know whether the baby was in trouble. At the time the CTG tracing ran out, the baby’s heart rate was decelerating – he advised the Coroner that the heart rate dropped by 30 % shortly before the CTG tape ran out after 4am. If the CTG had been reconnected, it may have been possible to more adequately assess the baby’s condition.
  • He assumed the Zara’s one minute AGPAR score was recorded by the LMC as 4. He noted that on that basis, resuscitation should have started immediately, and backup called.
  • Zara was in critical condition by the time she arrived in Wellington, which was aggravated by the delay in her resuscitation.
  • ABC’s (airway, breathing, circulation) were not followed when the midwife was alerted to the fact the baby wasn’t breathing.
  • He was of the option the LMC failed to recognize the severity of Zara’s condition from the time the CTG was switched off until the father recognized that Zara was not breathing and should not be practicing as a Lead Maternity Career.

My concerns:

My first and foremost concern is that my event happened 10 years ago and this is still happening today!!! Could lessons not have been learned back then?

  • The lack of obstetric care afforded.
  • Lack of knowledge and care from both midwives present.
  • No head of midwifery in the hospital, just independent midwives running the show.
  • No one prepared to do advanced resuscitation i.e. Intubate in the hospital.
  • The notes that were doctored to make the situation look better than it actually was, and that’s acceptable?
  • The lack of monitoring during labour.
  • The behavior of the LMC involved and other Good Health Wanganui midwifes at the Coroner’s inquest, i.e. Laughing together in the back row, as evidence was been read.
  • The HDC process – most of the evidence they relied on was from the independent midwife (who actually works for the college of midwives, who represent midwives). How can that be independent?
  • The HDC accepts doctored notes as evidence, even when no-one admits to writing them, and the notes don’t add up to the events.
  • The second midwife was asked to make a statement to the HDC she did so without getting it checked by the College of Midwives, in the statement she stated “the baby was not breathing, still not overly concerned”, (later when the College of Midwifes saw this statement this above bit was obviously changed). I believe if a parent was at home and there baby stopped breathing and they made this comment, they would be charged!!!
  • Lack of team work.

What was the outcome?

The Coroner made a few recommendations. I don’t believe any of them were ever implemented, and the HDC found no fault with any of the midwives or their practices.

What’s happening with me now?

I live in Dunedin and have just recently had a beautiful baby boy. He is a lovely addition to my life, but I still grieve for my lovely daughter, 10 years later. I also am 100 % behind what The Good Fight is trying to do to prevent horrible things like what happened to me and many others from happening to our babies and parents in New Zealand.

Val

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


Disclaimer:
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.