The maternity care received by a 19-year-old first-time mother who lost her baby girl after a botched home birth has been criticised by the Health and Disability Commissioner.
A report by the commissioner has found the expectant mother, Ms A, engaged registered midwife Ms D as her lead maternity carer and discussed with Ms D her desire to have a home birth.
Despite those discussions and Ms D's 13 antenatal visits, Ms D did not prepare a written care plan for the birth.
Both Ms D and backup midwife Ms E charted fundal height measurements through Ms A's pregnancy by week, rather than by the more specific measurement of weeks and days. The measurements record the size of the uterus.
On the day Ms A started having contractions, Ms D and another backup midwife, Ms C, arrived at Ms A's home.
When the baby was born at 7.31am, she had an umbilical cord wrapped around her neck several times and was blue.
Ms D wasn't carrying an oxygen cylinder, Ms E wasn't the backup midwife at that particular point, and Ms C hadn't brought any birthing equipment with her.
After failed attempts at resuscitation, an ambulance was called and the baby was transferred by helicopter to a neonatal intensive care unit. After the unit's assessment, the decision to withdraw ventilation to the baby was made and the baby died at 12.45pm.
The commissioner found Ms D had during the pregnancy failed to monitor Ms A with reasonable care and skill and did not advise Ms A of the risks posed to the baby if she stayed in the bath.
Ms D was also found to have breached the code for not ensuring the availability of all home-birth equipment, including an oxygen supply.
She was found to have acted in a concerning and unprofessional way after the birth.
Ms E was found to found to have failed in accurately completing the baby's antenatal growth chart, while Ms C was found to have not been adequately prepared for attending a birth.
The commissioner recommended Ms D apologise to Ms A, organise a special midwifery standards review through the New Zealand College of Midwives, undertake further training, and provide a report to the commissioner's office upon enrolling in upcoming workshops.
It was recommended that Ms E and Ms C also apologise to Ms A for their failings, as identified by the commissioner.
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