A first-time mother whose newborn died after a delayed delivery wants a “safer Aotearoa for future mothers and pēpi”. The woman, who was 29 at the time and pregnant for the first time through in vitro fertilisation, twice visited Tauranga Hospital in the months leading up to delivery in April 2022, because of reduced fetal movements. She then requested labour be induced because she was concerned that she could not monitor fetal movements while experiencing severe migraines. Her baby was eventually born in a poor condition and died 22 hours after a caesarean delivery - something that should have happened sooner than it did. An initial Health NZ report started if the caesarean occurred within an hour of the mother presenting to hospital it would have “significantly improved the outcome for (her baby) and may have prevented his death”. Now a new decision released today by the Health & Disability Commissioner has backed that finding that the delivery should havhappened sooner than it did. HDC commissioner Rose Wall said delayed responses to what was a critical situation, as opposed to any lapse in care, were largely to blame. The mother was taken to theatre and the baby born mid afternoon, “covered in blood” and in a critical condition, requiring him to be placed in the neonatal high dependency unit. Photo / 123rf “I express my sincerest condolences to Mrs A and her husband, Mr A, for their profound loss.” She fully supported the mother’s sentiment over wanting a safer environment, and agreed that lessons must be taken from the family’s tragic experience, and acted on to remedy the shortcomings in care. Mother raised concerns leading up to delivery The baby was 40 weeks and one day gestation when the mother asked to be induced. She called her midwife, concerned about the absence of fetal movements and intermittent pain, again the following day. The midwife in charge of her care was attending another patient, and advised the mother that her back-up, midwife would meet her at the hospital. Following admission she was checked, with observations “normal”, but cardiotocography (CTG) monitoring showed an abnormal finding. The midwife requested a medical review from the obstetrics and gynaecology registrar, then performed a procedure called a “stretch and sweep” used to induce labour. She repositioned the mother to help improve the CTG, but the variability did not improve. The registrar assessed the mother, made a plan for further monitoring and review, then called the Senior Medical Officer (SMO), who agreed with the plan. The CTG trace was not shown to the SMO, nor did she request to see it, Wall said. The hospital’s adverse event report later found that the CTG had been misinterpreted, and that it indicated fetal distress, which should have triggered “immediate management or urgent delivery”. Deputy Health & Disability Commissioner, Rose Wall, has expressed her sincerest condolences to the parents for their profound loss. Staff had been missing the weekly CTG education sessions because of reduced staff availability, the HDC found. Despite a plan to review the mother within 30 minutes, the registrar did not return because she was attending an emergency. Health NZ said there were three emergencies that day, two staff members had called in sick, and the maternity service was short by nine full-time midwives. (New Zealand was still in the grip of the Covid-19 epidemic at that time). However, the adverse event report found the obstetrics and gynaecology team did not call for additional support, when an option existed to do this. The mother said the midwife caring for her left the room “many times” to try and get help. It was not known if the midwife was aware of the escalation pathway at the time, Wall said. ‘Very concerning’ find by second registrar By the time she handed over care to another midwife, another obstetrics and gynaecology registrar was involved, who found the CTG “very concerning”. After carrying out further...