Babies died after lack of monitoring

Inadequate foetal heart rate monitoring has been cited in the deaths of three Canterbury babies.

The deaths occurred between July 2004 and June 2005.

All are recorded as "unexpected" by the Canterbury District Health Board (CDHB) in the recent report into sentinel and serious events.

They are among about eight neo-natal deaths nationwide since 2002 in which inadequate foetal heart rate monitoring played a role.

According to the document, the first Canterbury baby was delivered after a difficult labour, and "on review, foetal distress may have been recognised earlier".

A subsequent recommendation by the CDHB to adopt National Institute of Clinical Excellence (NICE) guidelines does not appear to have averted the other two deaths.

The second baby's death highlighted a need for continuous foetal monitoring, while the third died due to difficulties with monitoring foetal well-being and complications during the delivery.

The deaths led to successive recommendations that the NICE guidelines be reviewed and that staff receive education on the practice.

CDHB chief medical officer Nigel Millar said NICE guidelines had been adopted in 2004 and staff training for the 300 or so personnel involved in childbirth had been ongoing since.

He said foetal heart rate monitoring was a valuable but "complex" practice which was subject to individual interpretation.

"Birthings are a momentous event and one that causes inherent dangers for mother and baby," Millar said. "There are always unanswerable questions. There's no certainty that if you saw something that anything could have been done."

New Zealand College of Midwives midwifery adviser Norma Campbell said the interpretation of monitoring information was not always straightforward because not all problems that developed were easily detected.

- © Fairfax NZ News