Deanna Hinde doesn't want the death of her baby son to be in vain.
Timothy Hinde was stillborn last November, just one week before he was due.
Mrs Hinde and husband Corey later found out their third son had become entangled in his umbilical cord and eventually choked, but the couple had suspected something was wrong when at 38 weeks Timothy stopped moving.
"Literally he just stopped and I remember thinking 'this is really weird'," Mrs Hinde said.
The 36-year-old Hamilton mother sent a text message to her midwife, who had just checked the baby that morning, and was told to lie down and have an ice block because temperature changes could provoke a response.
When that and lying in a bath did not work Mrs Hinde again texted her midwife, who cannot be named for legal reasons. She did not hear back.
Two days later Mrs Hinde, still concerned, visited her midwife who found the baby's foetal heartbeat.
She followed advice from the midwife to get another scan the next day, which found a healthy heartbeat but showed the baby's weight had dropped.
"I texted her on my way out and said, `the scan has come back normal, do you want to see me for a CTG on Friday?'."
A cardiotocography (CTG) recording can be used to identify signs of foetal distress and Mrs Hinde said the midwife had wanted one done.
"I never heard anything. So I took the understanding that she was confident enough with the scan results to ensure that my baby was safe."
On the Tuesday following that weekend, the midwife's colleague checked Mrs Hinde and could not find Timothy's heartbeat. At Waikato Hospital the baby's death was confirmed.
Timothy was born later that day, on November 11, and doctors estimated his death occurred some time over the weekend.
Mrs Hinde said the tragedy was impossible to describe.
"Labouring and knowing that your child has died," she said through tears. "It's incredible, so surreal. To have gone that whole journey."
When the extent of what happened sank in, the couple filed a complaint with the health and disability commissioner.
"I wanted to know why I hadn't had a CTG. And why she hadn't replied to me."
She also thought a dramatic shift in the baby's growth between 32 and 38 weeks should have been a warning when considered alongside the reduced movement.
Commissioner Ron Paterson found the midwife had breached The Code of Health and Disability Services Consumers' Rights by failing to provide appropriate care and information to Mrs Hinde.
In July he recommended she apologise to the Hindes, include in her advertising leaflet how to contact backup midwives, and attend a foetal surveillance education programme.
Mrs Hinde sought a verbal apology and met again with her midwife last week to get more answers.
She wants the midwife's new brochure to include more details on how to contact a backup midwife, their qualifications, latest training and experience, examples of urgent and non-urgent symptoms, and more focus on not using text messages to communicate with clients.
Mrs Hinde spoke out about her story in the hope her midwife and others will review their processes.
"It's about honouring our son. It's to illustrate that we need to do something to our system so my son didn't die in vain. And I need her to know that this is forever for us."
A lawyer for the midwife, Carla Humphrey, said the midwife had expressed sadness and sorrow over the death. "This is a terribly sad case and all parties involved feel deeply for the family."
However, she said the commissioner agreed care provided to Mrs Hinde was "generally appropriate" and his report did not suggest her breaches of the code contributed to the tragic outcome.
The commissioner's investigation found the midwife had not received the two text messages in question.
"On these occasions, Mrs Hinde assumed the midwife had received her text message, and the midwife assumed that Mrs Hinde had no concerns," the commissioner said.
Mrs Humphrey said the CTG was not carried out because the scan had showed a reassuring foetal movement, amniotic fluid level and umbilical arterial blood flow. It did not show evidence of growth restriction, according to a health and disability comm-issioner's midwifery expert.
However Mrs Humphrey said the midwife had now changed her practice to ensure a CTG was also carried out whenever there were concerns about fetal wellbeing, and that a follow-up plan was made with the client.
- Waikato Times