What I cannot understand here is that the woman was
transferred at 23.45hours for mec liquor, and "sat on" for the next 5 hours,
presumably being monitored by CTG all that time with the mec getting
thicker.
How come the midwives are copping the blame
here? The attending midwife obviously transferred appropriately, it would
appear to be hospital mis-management, either lack of monitoring, inexperience in
reading the monitor, or lack of appropriate assessment by doctor on
duty.
Either way, to allow a woman to labour with fetal
distress which must have been increasing for the babe to be so compromised is
certainly unforgiveable - but why was she left so long? That is the
question that needs to be answered. Even in hospital care the doctor was
'too busy' to assess this poor woman?
Tragic.
Sue
"The only thing necessary for the triumph of evil is for good men to do
nothing" Edmund Burke
Subject: [ozmidwifery] But there is Dr
delay to the story from NZ
Just read
the fuller details. Seems to me the midwives took her to hospital
correctly but a huge delay in being seen by the Dr! Seems to me there is
scaremongering going on. Love to know more about the Dr stats.
Barb
This article is owned by, or has been licensed to,
the New Zealand Herald. You may not reproduce, publish, electronically
archive or transmit this article in any manner without the prior written
consent of the New Zealand Herald. To make a copyright clearance
inquiry, please click here.
Alan and Heather Phillips place
flowers at the grave site of their baby daughter Tyla in Awhitu.
Picture / Kenny Rodger
Baby died after hospital errors
20.03.06 By Martin Johnston
Another baby
has died after a series of mistakes partly blamed on midwife care.
Tyla Phillips survived for only 7 hours after she was born at
Middlemore Hospital in an emergency caesarean operation last August.
A hospital specialist later told her parents, Heather and Alan
Phillips, that if the operation had been performed three hours earlier
she might have lived.
The specialist said midwives misread a
fetal heart rate monitor.
The couple now want an inquiry into
maternity and midwifery care because their case follows other newborn
deaths with similar themes.
Middlemore is saying little publicly
about Tyla's birth until the Accident Compensation Corporation has
reported its decision to the hospital and Health and Disability
Commissioner Ron Paterson has investigated.
The hospital says it
may refer the case, which had devastated the staff involved, to the
commissioner, or medical or midwifery bodies.
However, hospital
documents and a tape recording the Phillips have of one of their
meetings with senior clinicians catalogue the mistakes that led to
Tyla's death on August 18 and a follow-up internal review.
A key
failure was midwives' mis-reading of a fetal heart rate monitor,
according to the obstetric consultant on call at the time, Dr Alec
Ekeroma, on the tape.
He also indicated that the fetal
blood-acidity test which led to the caesarean decision - done after an
obstetric registrar reviewed the heart monitoring - was unnecessary in
the circumstances and wasted time.
He said the 21-minute
caesarean operation - Tyla was born at 5.53am - should have been done
"probably two or three hours earlier". If it had been, this "may have
changed the outcome".
Mrs Phillips was several days overdue when
she went to the Middlemore-allied Botany Downs Maternity Unit, which was
managing her pregnancy. The unit's midwives had her transferred to
Middlemore at 11.45pm on August 17. Her waters had broken around 9pm,
containing what her medical file says was "moderate meconium" (faeces
from the baby). Staff noticed thick meconium when she arrived at the
hospital.
The presence of meconium can indicate a distressed
baby. Because of this, the Phillips expected a caesarean on arrival at
Middlemore.
Mrs Phillips said she was not fully assessed by an
obstetric doctor until about 5am.
Her medical file states a
registrar was asked to see her after her arrival but was busy in
theatre.
At 5.32am the decision was made to deliver Tyla by
caesarean after the blood-acid test - which had consumed 20 minutes,
after one attempt at the test failed - confirmed her distress.
A
report on Tyla's post-mortem says her lungs had suffered "massive
meconium inhalation" and extensive bleeding, and she had brain damage
from oxygen deprivation.
A Middlemore document describes the
events surrounding the birth and poor follow-up with the parents as a
"multi-system failure".
A letter to ACC by clinical director of
women's health Dr Keith Allenby lists 11 recommendations being
considered to address some of the issues the case has highlighted.
These include clarifying what should be done in response to
abnormalities revealed by fetal heart rate monitoring; regular training,
for all pregnancy-care staff, in interpreting the monitoring results;
and clarifying the chain of contact "if obstetric registrar busy (as new
tier of doctors now in place)".
The Phillips have lost
confidence in New Zealand's midwife-dominated maternity system.
"If I could do it again," said 33-year-old Mrs Phillips, who had
difficulty conceiving Tyla, "I wouldn't go the midwife way. I would go
to a doctor, a specialist."
Tyla's case follows criticism of
health workers after reports on the deaths of three other babies - two
by a coroner and one by Mr Paterson, the commissioner.
Following
the criticisms arising from those cases, the College of Midwives said
New Zealand's midwives, present at virtually all births and lead
maternity carers for 78 per cent of pregnant women, provided one of the
world's safest and most effective maternity systems.
Chief
executive Karen Guilliland noted that 5 per cent of complaints to the
commissioner regarding health workers were about midwives in the last
June year and 6 per cent about
obstetrician/gynaecologists.
'She held my
finger'
During Tyla Phillips' emergency caesarean
birth, her anxious father typed on his cellphone the words "Is she going
to live" and showed the hospital anaesthetist.
When the
anaesthetist shrugged his shoulders, Alan Phillips knew his baby
daughter was in trouble.
Mr Phillips says his brown-haired girl
- his wife Heather's first child and his third - was beautiful when
born. But her appearance quickly deteriorated as she gasped at life
following a traumatic labour last August.
"I really wanted this
little girl and she really looked like her mum. She had the same
eyebrows. She was cute.
"She held my finger. That's something I
will never forget."
Seven and a half hours after her delivery,
it was decided Tyla could not survive. Her life-support systems were
removed. She died soon after.
Recalling Tyla's death, Mr
Phillips - brow furrowed, fingers tip-to-tip and quietly crying - says
he is still too upset to look at photos of her.
Mrs Phillips
looks at them often, but keeps them in a box. Tyla's cot, her pram and
the rest of her baby gear, which had been set up at the family's old
home, are now stored out of sight in the garage of their new home at
Awhitu.
But the Phillips' regularly visit her grave, in a
church-yard just 80m away.
Recent controversies involving midwife
care:
* February 2001: Saskia Marama Swagerman-Fugle of
Wellington died in hospital six days after an undiagnosed breech birth
at home.
* February 2003: Cameron Elliot of Paraparaumu died
shortly after an undiagnosed breech birth at home.
* November
2003: A baby called Charlie died aged three days after emergency
caesarean and mismanaged labour at North Shore Hospital.
*
December 2005: After an inquest into the first two cases, Wellington
coroner Garry Evans called for a review of maternity services and
greater supervision of new midwives.
