Midwife failed to monitor young woman for pre-eclampsia


Midwife failed to monitor young woman for pre-eclampsia

Health & Disability Commissioner
1 minute to Read
HDC decision 19HDC01789
Download773.27 KB

Deputy Health and Disability Commissioner Rose Wall today released a report finding a midwife in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide a young pregnant woman with services of an appropriate standard.

The woman lived in a rural area, and was outside the midwife’s practice area, but she agreed to be her lead maternity carer. The midwife did not measure the fundal height in centimetres at every antenatal visit, and she encouraged the woman to count the fetal movements, which was not consistent with current midwifery practice.

In the final weeks of her first pregnancy, the woman developed oedema, headaches, and elevated blood pressure. However, the midwife did not request a pre-eclampsia blood test at 37 weeks’ gestation when this was indicated, or perform a urine analysis at each visit.

When the woman was in labour, the midwife assessed her condition by telephone but did not recommend an in-person assessment, although it was warranted. The woman was then rushed to hospital. Tragically, her baby had died.

The Deputy Commissioner considered that cumulatively the woman showed signs of impaired health that were not recognised by her midwife, which meant that a referral to secondary care was warranted but not done.

"Had this occurred, the symptoms of pre-eclampsia, intrauterine growth restriction, and reduced fetal movements may well have been detected sooner," Ms Wall said.

The report highlights the importance of appropriate assessment of a woman’s condition, monitoring of a baby’s growth accurately, and the need for appropriate action in response to the development of clinical concerns that have the potential to affect the health of the woman and/or her baby.

Ms Wall was also critical that the midwife did not maintain accurate antenatal records, and that the arrangement for remote oversight was not suitable to detect and respond to the issues arising as the woman’s pregnancy progressed.

She recommended that the midwife provide a written apology to the woman and her whānau, undertake training on pre-eclampsia in pregnancy, and documentation and the Growth Assessment Protocol.

The full report for case 19HDC01789 is available on the HDC website.