A baby was stillborn after his mother was given a drug to induce labour despite a history of quick deliveries and the baby's unusual foetal position, an investigation has found.
Health and Disability Commissioner Anthony Hill today released his report into the death of the baby boy at a Lakes District Health Board (DHB) hospital.
It was his 25-year-old mother's third pregnancy, and she had a history of quick deliveries. She was admitted for induction when she was 10 days overdue and her waters broken.
When labour did not progress she was given Syntocinon by her lead maternity carer (LMC) midwife, in consultation with an unnamed registrar, despite the baby being in the "face" position.
"A short time later, the woman's uterus became hyperstimulated and there were signs of fetal distress," Mr Hill said in his report.
The Syntocinon was turned off but the baby was by then in an undeliverable brow presentation, and a Caesarean section was necessary.
"Prior to transfer to theatre, the hospital midwives assisting in preparing the woman had difficulty detecting and recording the fetal heart rate (FHR)," he said.
"This was not adequately communicated within the team, and the FHR was not monitored again on arrival in the theatre."
The mother was given a spinal block in preparation for the Caesarean and it was then the registrar realised the baby's heart rate was not being monitored. The lead midwife was unable to find one, and an ultrasound scan then confirmed there was none.
"After discussion with the parents, the registrar made the decision to perform a Caesarean section. Sadly, the baby was stillborn."
Mr Hill found the woman should not have been given Syntocinon, given her history, and that the registrar should have consulted the on-call consultant before doing so.
As well, the registrar failed to give the woman inadequate information about her options, shared responsibility for failing to monitor the FHR in theatre and failed to proceed with the Caesarean immediately when the baby's heartbeat could not be found.
Mr Hill also found the DHB did not have a system which ensured policies and procedures were followed.
"I am satisfied that the policies were available to staff. However, despite this, I am concerned that the policies were not followed by both the registrar and the LMC midwife."
Staff did not think critically, important information was not communicated effectively and the DHB had to accept some responsibility for the registrar's decision-making, he said.
Mr Hill's recommendations included that the DHB conduct an audit of all deliveries where babies presented in unusual positions and of all Caesareans carried out on women who had been induced.
The DHB said it had implemented new policies in response to the case.