Charge

Ms Bala Naidu, (the midwife), registered midwife of Auckland, was charged with professional misconduct by the Director of Proceedings.

The charge related to the care and documenting of care given to a patient, before and after the birth of her stillborn baby.  The fact that the baby was stillborn was not an element of the charge.

The charge alleged that in particular:

1. On or about 8 August 2005 between 2.30am and 6.16pm the midwife failed to:
   1. Record her client's blood pressure; and/or
   2. adequately assess and/or monitor:
      1. her client's pulse; and/or
      2. the nature of her client's pain;
2. Between 2 August and 15 August 2005 the midwife inaccurately recorded assessments on the partogram and/or recorded assessments on the partogram which had not been undertaken.
3. On 8 August 2005, at or about 12.30pm, when the midwife's client's membranes ruptured and when she had administered 100mg pethidine (25mg intravenously and 75mg Intramuscularly) at or about 12.00 midday, she discharge her client from hospital without first monitoring or recording:
   1. her client's pulse; and/or
   2. her client's blood pressure; and/or
   3. the fetal heart rate.
4. Between 8 August 2005 and 15 August 2005 after the midwife had delivered her client's baby she made a number of alterations and/or additions to her client's clinical records in the Maternity Information Booklet, without noting they were made retrospectively.  In particular:

4.1  In the page entitled "Maternity Record" the midwife:

• added an estimated date for delivery based on the results of her client's scan;
• added her client's weight (60); and/or
• added inforamtion to indicate that her client had no allergies; and/or
• crossed out "primp" and added "TOP 2003 2nd Pregnancy"; and/or
  4.2  On the pages entitled "Antenatal Visit Information Record" the midwife;
  • recorded appointments and/or blood pressure and/or weight for 7 February 2005 and/or 20 February 2005 when no appointments had taken place on or around those dates; and/or
  • recorded additional clinical notes to indicate the position and descent of her client's baby for the appointment that occurred on 6 August 2005; and/or
  • added the addtional note ("H.V") on four occasions, including the appointments dated 13 July 2005, (13/7) 22 July 2005 (22//7) 29 uly 2005 (29/7) and 6 August 2005 (6/8); and/or
  • recorded an appointment on 7 August 2005 and/or blood pressure and/or notes on the position and descent of her client's baby and/or notes recording that her client had commenced labour and had some contractions.
• 4.3 On the page entitled "Notes" the midwife added a note indicating discussions on 22 July 2005 about a birth plan and the baby's movements;
  4.4  On the page entitled "Careplan" the midwife added notes about purported discussions concerning pain relief including pethidine, epidural, panadol and warm showers.

Finding

The hearing proceeded on the basis of an agreed summary of facts and the midwife accepted that the circumstances amounted to professional misconduct.  The Tribunal found the midwife guilty of professional misconduct.

Background

The patient was referred to the midwife, who saw her from 10 March 2005, when she was about 17 weeks’ pregnant.  An ultrasound scan on 5 April 2005 indicated a normal and healthy baby boy, and the expected delivery date was 18 August 2005.

On 6 August 2005 the patient’s blood pressure was elevated (140/90).  This was the first time during the pregnancy that her blood pressure had been elevated.  Further assessments were undertaken at Middlemore Hospital where the patient found wearing the CTG belt very painful and she experienced a constant pain across the lower abdomen while the CTG belt was on.

There was some discussion about reduced fetal movement.  The midwife explained that fetal movement decreased because the baby was getting bigger and there was less room for it to move.  The patient was discharged home the same evening, once her blood pressure had stabilised.

The patient did not feel any fetal movement throughout the following day (Sunday 7 August 2005).  She was not concerned about the lack of fetal movement because the midwife had assessed her the day before and had assured her that everything was fine, and that this was not unusual.

At about 11.00pm on Sunday 7 August 2005, the patient began to feel constant lower abdominal pain. The pain gradually became worse and by 2.00am on 8 August, the patient was experiencing significant constant lower abdominal pain.  The midwife was contacted, and soon thereafter saw the patient at the midwife’s home, which was nearby.

At that assessment the midwife undertook an internal examination and commented that the patient had not really commenced dilating and was only in early labour.  The midwife also checked the baby’s heart rate with her sonic aid but did not take the mother’s pulse.

The patient told the midwife that she was experiencing constant pain.  The midwife told the patient to go home, and to take panadol and have hot showers for pain relief.  This assessment was not documented in any way.   The patient returned home, took two panadol but had very little sleep.  The pain remained constant.  At about 6.00am, the patient experienced a large gush of dark red blackish/maroon clotted blood.

At about 10.00am the midwife came to the patient’s home and undertook another internal examination.  No pulse or blood pressure was taken, nor did she listen to the fetal heart rate.  The patient told the midwife that she was in constant and piercing pain across her lower abdomen.  She was about 2cm dilated.  The midwife was concerned about the amount of pain, and suggested that they go to hospital.  No record was made of this assessment and examination.

At 12.00 midday, the patient was given pethidine.  The midwife did not take the maternal pulse prior to or after the administration of pethidine; and did not take the patient’s blood pressure after the administration of the pethidine.

The patient slept for about 30 minutes following the administration of pethidine, and when she woke up was told she could go home.  As she got up to leave, her membranes ruptured.  No other assessments were undertaken following the rupture of the membranes.  Nor was there any monitoring of the patient’s blood pressure or pulse prior to the discharge and after the rupture of the membranes; nor did the midwife listen to the fetal heart rate.  The midwife subsequently recorded “membranes ruptured at 12:30hrs, clear liquor”; but the patient recalls that the liquor was blood mixed with water.

The patient returned home soon after 12.30pm, but the pain continued and she returned to hospital at 3.00pm.  At that time, the midwife undertook another internal examination and recorded that the patient was 5cm dilated, but did not take the maternal heart rate or blood pressure. She recorded the fetal heart rate at 3.00pm (130-140 BPM); at 4.30pm (120-130 BPM); and at 5.00pm (120-130 BPM).

Throughout the afternoon the midwife did not take the patient’s pulse rate and she did not undertake continuous CTG monitoring.  At 5.00pm, the midwife told the patient to start pushing.  The patient said she did not feel the urge to push because the pain she was experiencing was across her lower abdomen and was constant. She could not feel any specific contraction pain.

At about 6.00pm the baby crowned; a consultant arrived soon thereafter and noticed, when assisting the delivery of the baby’s shoulders which had become stuck, that the baby’s skull was soft and his skin was peeling.  The baby was born flat at 6.15pm with an APGAR score of 0.  Resuscitation commenced but was unsuccessful.  The placenta was then delivered.  It had a large retroplacental clot (500 ml of clotted blood).

The pathologist stated that the infant had died in-utero after a massive retroplacental hemorrhage that essentially lead to placental separation, and a rapid loss of oxygen to the fetus, some 18 to 24 hours prior to birth.

The agreed summary of facts went on to detail retrospective changes made to the documentation.  These are fully described in particulars 2 and 4, and it was common ground that the midwife had made these retrospective alterations.

Reason for Findings

Particular 1

There was no doubt that the midwife did not record the patient’s blood pressure at any point during the labour. 

The midwife admitted not taking the maternal pulse throughout the entire labour (that is from about 2.00am to 6.15pm on 8 August).  If she had taken the maternal pulse during the patient’s labour, its elevated rate would have alerted her to possible complications, and to the fact that the fetal heart rate she thought she heard was indeed the maternal pulse.  To have a fetal heart rate and a maternal heart rate recording the same rate would be very unusual and a cause for concern.

This particular also referred to a failure to adequately assess or monitor the nature of the patient’s pain.  The patient experienced severe constant lower abdominal pain.  The midwife admitted being informed by her client that the pain was constant and severe.

An expert gave evidence that constant lower abdominal pain is atypical of labour.  Contraction pain is intermittent, whereas pain from a hemorrhage is ongoing.  The Tribunal was satisfied the nature of the pain should have alerted the midwife to the fact that something was not right and to the possibility of an antepartum hemorrhage.  Standard midwifery practice would have been to undertake further assessments to ascertain the nature and cause of the pain.  This did not happen, and this subparticular was established.

The majority of the Tribunal concluded that the established facts of particular 1 did amount to  negligence, and of a sufficiently serious nature as to warrant discipline. This particular, considered separately, constituted professional misconduct.

Particular 2

The midwife recorded the fetal heart rate on three occasions during the labour.  She admitted that she did not take a maternal pulse during the labour.

The partogram, which she completed at some point during 8 and 15 August 2005, recorded the fetal heart rate at being consistently 150 BPM, and the mother’s pulse at being consistently 70 BPM, with one acceleration to 80 BPM.  The midwife made a retrospective recording of assessments that were made in an inaccurate way; but more significantly, there was also a fabrication of events (the recording and fabrication of the mother’s pulse that did not happen).

The Tribunal accepted that such retrospective recording amounted to a severe departure from accepted midwifery standards.  This particular, considered separately, amounted to professional misconduct.

Particular 3

The midwife admitted that there was no taking of the maternal pulse or blood pressure prior to or after the administration of pethidine; and no monitoring of the mother’s blood pressure or pulse prior to discharge, after the rupture of the membranes.  Nor did the midwife listen to the fetal heart rate.

An expert stated that the failure to take thorough assessments before and after intravenous pethidine, and again not to do so after the rupture of membranes, was concerning and contrary to accepted standards.  The Tribunal accepted the evidence of the expert.  It concluded that the facts of particular 3 amounted to a serious departure from acceptable standards and considered separately amounted to professional misconduct.

Particular 4

The various alterations and additions described in Particular 4 of the charge were admitted.  The changes made involved fabrications and as such were dishonest.  The Tribunal concluded that there was a serious departure from acceptable standards and this particular amounted to professional misconduct.

Cumulative Finding

The Tribunal was satisfied that the charge, considered cumulatively, amounted to a very serious departure from the acceptable standards amounting to negligence, malpractice and to the bringing of discredit to the midwifery profession.

The Tribunal considered that a disciplinary sanction was required, having regard to these departures, for the purposes of protecting the public, for the purposes of maintaining professional standards, and for the purposes of punishing the practitioner.

Penalty

The Tribunal ordered that the midwife be:

• censured; and
• practise under the following conditions:
  • Within eighteen months from the date when she resumes practice as a midwife undergo training as directed by the Midwifery Council and meet the assessment standards as required by the Midwifery Council with regards to:
    • The assessement and monitioring of the woman and baby in labour with particular regard to fetal heart monitoring and maternal assessments;
    • The use of CTG monitoring;
    • Appropriate note taking and documentation requirements;
    • Midwifery ethics and responsibilities
    • Limit her caseload to fifty births for the first twelve months of the eighteen month period, and thereafter according to a limit to be set by the Midwifery Council for the balance of the eighteen month period.  There was also to be a formalised arrangement for backup and cover as required, which is satisfactory to the Midwifery Council.  This condition wss framed in this way to enable regular time off, annual leave, and to enable the midwife to undertake appropriate ongoing professional development and education.
    • An eighteen month period of supervision was imposed.
• Fined $5,000.00
• Pay total costs of $15,000.00

 The Tribunal directed that the details of the decision be published in the newsletter of the Midwifery Council, on the website of the Midwifery Council, in the Midwifery News published by the New Zealand College of Midwives, and on the Tribunal’s website.