Medical staff worked for nearly an hour to try and revive a baby boy who was partially trapped in his mother’s cervix by his shoulder during a prolonged labour and delivery.

But, despite staff administering eight doses of adrenaline to restart his heart, resuscitation attempts were unsuccessful and the boy was declared dead 54 minutes later.

A coronial inquiry later found the baby died from intrapartum death - which is after the onset of labour but before they are born - as a result of prolonged first and second stages of labour complicated by shoulder dystocia.

Now a report has been released by Health and Disability Commissioner Rose Wall listing a series of failures by a locum midwife who was caring for the mother, who is only identified as Ms A.

Wall said the locum’s practice on that day “did not comply with midwifery competency”.

“During the labour, (the midwife) did not undertake regular maternal observations, she did not always follow recommended practice regarding fetal heart auscultation and monitoring and she did not assess the progress of Ms A’s labour in an appropriate and timely manner.”

She said that although the locum called for assistance when preparing to deliver the baby, once help arrived no one was made aware of any problems.

Wall said the failure by the locum in not recognising that shoulder dystocia had occurred ultimately led to the baby being born “showing no signs of life”, while the mother went on to develop sepsis which she later recovered from.

She said the mother felt her baby “deserved much better care than was provided” adding that midwife made her believe the hospital she was in was safe to birth.

“This is a decision I regret every day,” the mother told the HDC during the investigation.

Ms A’s mother told HDC that her daughter “and my moko did not get the care they deserved”.

“Because of this we lost our moko and almost lost our daughter too. In this day and age, a healthy mum with a healthy baby should have the best care and our moko should not have died.”

‘All is well’

Wall said Ms A, a Jehovah’s Witness, experienced an “uncomplicated pregnancy” under the care of her lead midwife.

However, that midwife went on leave and handed care over to a locum midwife who was on when the mother went into labour and called to say she was having contractions about three minutes apart at about 1am

She was told to wait a little longer before the locum received a second call at 3.30am requesting to go to the birthing centre in the small rural town.

After arriving at 4.15am, the mother was around 5cm dilated with her contractions increasing in regularity, mobilising well, and “showing no reason for concern”.

Her next, and last noted, dilation record was at 10.55am at 8cm but by mid-afternoon a doctor asked the locum how the labour was progressing, because of concerns raised by “multiple independent staff about the labour”.

He was told it was slow but “the baby was perfect”.

At 2.26pm, the locum began messaging other midwives to discuss a care plan, and her original midwife noticed a missed call from her so went to the hospital at 4.30pm to take over while the locum rested for a few hours.

At 6pm a senior nurse suggested that the woman be transferred to a bigger hospital for tertiary-level care but it never happened.

The next vaginal exam happened at 9.01pm which showed the top of the cervix had swollen causing the anterior portion to come in front of the baby’s head.

The locum noted she did not have any concerns at this point and by 10.12pm the mother began pushing.

However, she said she took full ownership of her lapse in clinical judgment in not doing four-hourly maternal observations during labour and birth.

A nurse who started the late shift questioned the locum at 11pm about why the labouring mother was still at the hospital but was reassured that “all was well”.

There’s a discrepancy around exactly what time the baby was born, either 12.30am or 12.38am, but the mother’s partner was asked by the locum to press the emergency bell.

The original midwife arrived at 12.43am and asked what help was needed and was told, “to help deliver the baby” but the locum did not say why she needed help.

When she examined the mother she discovered the baby was suffering “severe shoulder dystocia and was trapped by Ms A’s pubic bone”.

The baby was eventually delivered at 12.53am “showing no signs of life”.

In her findings, Wall said overall she found the locum’s labour documentation “inadequate”, her maternal observations were not taken and findings from vaginal examinations were incomplete and documentation of the fetal heart did not consistently align with recommended practice.

There was also an absence of documented discussions and “plans” made with the mother A about progress, and options for ongoing management.

“Consequently, it is not apparent what (her)s interpretation of the labour was, or Ms A’s involvement in any decision-making.”

Wall said she initially assumed the locum recognised the baby’s shoulder was stuck at 12.30am, however given there were no notes to say why she requested the original midwife to come “and nor was this crucial piece of information passed on to another nurse who said she was not asked to stay and help or made aware of any problem.”

“It is difficult to ascertain with any certainty if (she) did or did not recognise the shoulder dystocia.

“If she did not, this is very worrying, and represents a significant deficit in knowledge. But if she did, this is arguably more concerning as she failed to undertake the most basic measures such as calling for help and this represents a significant departure from expected practice and I disagree with her comment that there ‘was no delay in … requesting multidisciplinary assistance'."

‘I am deeply and sincerely remorseful’

In the coronial inquiry the locum offered her “deepest apologies and sincere remorse” for the couple’s loss of their baby, and the “deep grief and trauma of the loss of family memories”.

“I have acknowledged fault for my role in your labour and birth. I am deeply and sincerely remorseful.”

She added she had “never experienced anything like this outcome in her long professional career”.

Wall asked the locum to provide a written apology to the woman for multiple breaches of the midwifery code, undertake further training, and recommended that the Midwifery Council of New Zealand “consider whether a further review of (her) competence is warranted, in light of the findings of this report”.

The locum was referred to the director of proceedings, to consider disciplinary action, but no further action was taken.

Belinda Feek is an Open Justice reporter based in Waikato. She has worked at NZME for nine years and has been a journalist for 20.