Mum’s births highlight value of monitoring
Denise Simpson-Vogan credits electronic monitoring with saving her firstborn’s life. She blames the absence of continuous monitoring for her second baby’s death.
Monitoring was started by Rotorua Hospital staff when she arrived in labour with her second baby, Axton, on February 21, 2009. This was in line with the earlier advice of an obstetrician, based in part on her previous caesarean delivery and the risk of the uterine scar rupturing.
But when Ms Simpson-Vogan’s independent midwife, Priscilla Punita, arrived, she disconnected the CTG (cardio-tocograph) machine. She recorded in the notes that the fetal heart monitoring trace was “good”, although a subsequent review concluded it was “suspicious”.
This disagreement over the monitoring reflects a 2011 audit for a mortality review committee which found that abnormalities recorded on a CTG may often go unrecognised.
Mrs Punita’s actions have been faulted by the Health and Disability Commissioner, whose independent prosecutor has now elected to take disciplinary proceedings against her.
Ms Simpson-Vogan, struggling to speak through tears, said she did not notice the machine was disconnected from her.
“I had been throwing up, I was in pain. I kick myself to this day about it because I know how important it is. It’s the only reason my oldest daughter is here — because of CTG monitoring.”
She has two daughters, Shana, 9, and Souleen, 4. Shana was born by emergency caesarean after CTG monitoring during labour detected she was in distress. She has no health problems.
With Souleen, Ms Simpson-Vogan, now aged 30 and living in Hamilton, chose to have an elective caesarean three weeks before the full term of the pregnancy. “I was terrified. I didn’t want to go through another labour.”
Commissioner Anthony Hill found there were a number of failings in Mrs Punita’s care, some of which were “severe departures from the accepted standard”. He cited medical evidence from Axton’s inquest that continuous CTG during labour could have prevented his death, although the problem — severe lack of oxygen — may have begun even before labour started. Mrs Punita has retired from midwifery and does not have a current practising certificate, although she is still registered. She declined to comment to the
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Axton was delivered with a ventouse suction cup. Pale and floppy, he survived for just 26 hours. Ms Simpson-Vogan is glad the case is going to the Health Practitioners Disciplinary Tribunal.
“I just want to see midwives knowing they can’t get away with it, having that in the back of their heads. I feel that they get away with a lot.
“It’s not fair, the way the system is. It really does feel this whole five years I have had to fight; it’s not only for justice for my son, it’s more for other babies, to stop babies dying.”
She urged parents to be alert to what was happening in the delivery room.
“If you feel something is not right, speak up; don’t be afraid.” Fifty-six per cent of the 125 near-term stillbirths and neonatal deaths — excluding those with congenital abnormalities — in 2009-2012 were considered “potentially avoidable”. Staff factors were identified as possibly contributory in 45 per cent of cases, organisation factors in 30 per cent