Coroners report finds fault in Middlemore’s post natal care

DOCTORS AND midwives are being urged to strictly adhere to policies for post-natal care in hospitals following the unforeseen death of a newborn baby at Auckland’s Middlemore Hospital three years ago.

Tiah Tinousi Neemia was only three hours old when she died in her mother’s arms from complications relating to ‘skin-to-skin time’.

It appears difficulties arose when the attending midwife left the room for a short period after the baby’s mother had finished breastfeeding.

When the midwife returned to carry out a clinical examination on the baby, she noted that Tiah’s ‘hands dropped’ and that she speared ‘flat” and was starting to turn blue. She called for emergency help but Tiah could not be revived.

Tiah’s death has led to new guidelines for post-natal care in hospitals to ensure there is proper supervision of breastfeeding, skin-to-skin time and safe infant sleeping practices for all newborns.

These measures were highlighted in a Coroner’s report released this month into Tiah’s death, which included comments from paediatrician Heidi Baker about the importance of supervised post-natal care in hospitals.

She said it was critical that measures were in place to prepare parents to support and understand their newborns.

She stressed the importance of hospitals following the protocols set down by the New Zealand College of Midwives and the Royal Australian and New Zealand College of Obstetricians and Gynecologists.

The “Observation of Mother and Baby” guidelines state that all mothers and their babies should receive active and ongoing assessment in the immediate postnatal period, regardless of the context around their birth – and during this time, the mother and baby should not be left alone, even for a short time.   

The guidelines also state there should be ongoing assessment of the newborn for a minimum of one hour and that monitoring of the baby’s wellbeing should include ongoing assessment of the baby’s colour, tone and respiration at all times, with particular care during periods of skin-to-skin contact.

Dr Baker said it was crucial that policies, training and procedures were developed to support adherence to the protocols.

In the Coroners Report into Tiah’s death, the director of midwifery at Counties Manukau District Health Board Thelma Thompson confirmed that education sessions had been carried out for all health professionals involved in maternity care.

Meanwhile, there have been renewed calls for parents to heed safe sleeping practices in the wake of the death of a five-month-old infant boy from cot death.

Although the incidence of Sudden Unexpected Death in Infancy has declined significantly since public prevention campaigns began in the early 1990s, New Zealand still has one of the highest rates of SUDI in the developed world.

Māori infants form the overwhelming majority of SUDI deaths, with a mortality rate five times that of European infants.

The increased incidence of SUDI among Māori in particular is thought to be due to greater levels of high-risk behaviour, such as maternal smoking, and poorer knowledge about SUDI risk factors.

In her findings released this month into the death of Tairawhiti Popata-Anderson, Coroner Morag McDowell said the five-month-old died in an unsafe sleeping environment – bed-sharing with an adult and two other children. The mother had been seen regularly by a Plunket nurse and health worker and had received advice about safe sleeping practices on at least five occasions.

The advice was that the baby should sleep in his own cot, face up, face clear and smoke-free. On at last one visit, the risks of bed-sharing were also raised.

McDowell said considerable effort had been made over the years to ensure that health professionals promoted a consistent message that every sleep for a baby should be “a safe sleep”.

“That is, for every sleep, babies up to one year of age should be put to sleep on their backs in their own sleeping space with their face clear,” McDowell said.


cookStephen Cook is a multi award winning journalist and former news editor and assistant editor of the Herald on Sunday.

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