Handover of care of a pregnant woman with previous high-risk pregnancies

Executive summary

A woman in her twenties had a history of two high-risk pregnancies that had required an emergency Caesarean section, and was pregnant with her third child.

The woman saw her lead maternity carer, a registered midwife, for an antenatal appointment, and was suffering from worsening hand and facial oedema, and protein in her urine. The midwife ordered blood tests to rule out the onset of pre-eclampsia.

The midwife went on leave the next day, and did not provide a verbal or written handover to her back-up midwife. As a result, both her back-up midwife and her employer were not aware that the woman had undergone a blood test to check for pre-eclampsia, and that the results were pending.

Five days later, the midwife’s employer came across the blood test results and noted that they were abnormal. The woman was contacted and advised to present to hospital as soon as possible.

The woman presented to hospital and, given the impression of possible fulminating HELLP syndrome, the decision was made for her to undergo an emergency Caesarean section. The baby was delivered approximately seven weeks early, and was transferred to a Neonatal Intensive Care Unit (NICU) for further care.

This case highlights the importance of good peer support and back-up arrangements, particularly in rural settings where midwifery providers are otherwise working in isolation.

Findings

Despite the deteriorating clinical picture and previous medical history, the midwife omitted to follow up (or arrange for another midwife to follow up) the PET blood test results. The Deputy Commissioner found the midwife in breach of Right 4(1) of the Code, and also made adverse comment about her communication.

The Deputy Commissioner found the birthing unit in breach of Right 4(1) of the Code for failing to have in place a formal handover procedure to ensure that the blood test results were followed up in a timely manner.

Recommendations

The Deputy Commissioner recommended that the midwife provide a written apology. No other recommendations were made regarding the midwife, as she is no longer practising midwifery.

The Deputy Commissioner recommended that the birthing unit develop and implement a formal procedure regarding what to do when a midwife goes on leave, including the handover process.

The Deputy Commissioner recommended that should the midwife return to practice, the Midwifery Council of New Zealand consider whether a review of her competence is warranted. The Deputy Commissioner also recommended that the Midwifery Council of New Zealand consider reminding midwives that when they employ people, they become an employing authority, and may be vicariously liable for the acts or omissions of an individual provider where that individual provider is an employee, agent, or member of that employing authority.