Exempt from public disclosure pursuant to offline a. § 13 cf. PAA. § 13 first paragraph. 1
The public demands for transparency in individual cases are handled through that anyone can request access to individual documents, based on publicly available mailing lists.
Norwegian Board of Health has decided to issue a warning pursuant to the Health § 56 first paragraph. We have determined that you have violated the acceptability requirements of the same Act § 4 in connection with a home birth the XXXXXX .
You can appeal the decision within three – 3 – weeks of receiving this letter.
Procedural process
Norwegian Board of Health received the letter from the County XXXXXX XXXXXX in submitted a supervision about your business as a midwife. Audit case concerns your midwife and XXXXXXs health care to XXXXXX (hereinafter the patient) when she gave birth at home the XXXXXX.
We oriented you by letter XXXXXX that we would consider giving you a warning. You stated you to this by letter dated XXXXXX.
Norwegian Board of Health has the resolution of currently imposed midwife XXXXXX a warning pursuant to the Health § 56 first paragraph of violating acceptability requirements of the same Act § 4.
We apologize for the long processing time.
the subject matter
You are a graduate of XXXXXX and became certified nurse the XXXXXX and midwife the XXXXXX, HPR no. XXXXXX. At the time of the incident had you pattern agreement with HELF0 as privately practicing midwife registered sole proprietorships. You worked with a midwife XXXXXX.
Norwegian Board has considered the matter on the basis of the documents you’ve got submitted earlier in the proceedings. Below is a discussion of the factors that has been important for our assessment.
The patient, who was born XXXXXX, was a healthy first-time mothers with no special complications in pregnancy with forward XXXXXX. She was pregnant after IVF with a pregravid BMI of 28 and large symphysis-fundusmål during pregnancy. The patient had contacted you because she wanted a planned home birth, and you had agreed assistance during childbirth at home.
The XXXXXX kl. 18.05 she gave birth to a girl in her own home with midwifery from you and midwife XXXXXX. You were primary midwife during the actual birth.
Placenta came not spontaneously after delivery of the child. The patient sat in fødekar during and after birth, and stated in your note from birth that there was a small amount of blood equivalent to 100 ml of water at. 18.55. It is further stated that the patient ca. kl. 19.00 was asked to try to push out the placenta, without result. It was then inserted acupuncture needles, and the child was put to the breast to promote the disposal of the placenta.
Tl. 19.20 fainted patient in approximately one minute and she was then given a sugary drink. It appears that the patient was given 5 IU syntocinon i.m., and it was made controlled strokes in the umbilical cord. New dose syntocinon 5 IU was given at. 20.10.
Tl. 20.15 decided you to transfer the patient to the hospital. You made at least six attempts to call inpatient phone pregnant before you contacted AMK center at. 20.25, when the patient had abdominal pain and started bleeding. After this put you into same line and began i.v. liquid supply. In conversation with AMK was bleeding described alternately as “part” and “a little bit” . It was agreed hastetur with AMK (yellow response), and that you yourself should inform Kvinneklinikken on XXXXXX about admission.
The ambulance arrived at. 20.40, and the bleeding was when increasing and projected to 1200 to 1400 ml according ambulance journal. The patient was then circulatory influenced by pulse 140, respiration 18 to 26, BT 130/105 and pale / dank. The patient was in the upstairs and she syncopated when she was put up in a stretcher chair. The ambulance drove from home at. 21.06 and arrived at the hospital about kl. 21.15. The patient was on arrival at feed presjokkert without detectable blood pressure. It was immediately started væskeresucitering and made manual extraction of the placenta under anesthesia.
Statement dated XXXXXX to the County of XXXXXX
In the joint letter from you and midwife XXXXXX to County of XXXXXX states among other things that you just before kl. 19.00 as signs that the placenta could be loose. It appears that the umbilical cord slipped further forward after acupuncture and urination, and noon. 19.45 came membranes appear in the vaginal opening. Active printing, gently support the fundus and pull the umbilical cord was attempted unsuccessfully. It also appears that the fundus of the uterus all the way was monitored manually, that bleeding was observed continuously and that it was normal and sparse until. 20.20.
It further appears that you have undergone their own judgments and actions during the birth and that you criticize yourself for not having followed the recommendations in the guidelines for home birth Chapter 5.3. You said that the ambulance doctor in the car should have been called 60 minutes after the baby was born, although everything looked normal out at that time.
Statement from the patient and the baby’s father received XXXXXX
in a letter to the County Governor in XXXXXX, the patient and the child’s father stated that they had a nice birth, but it took too long before you went to XXXXXX hospital.
Your statement dated XXXXXX to the State Board of Health
you state that you chose to call Kvinneklinikken because it was scanty bleeding. You looked for a peaceful transfer, and you wanted to save time by taking a single call instead of two. According to you were you disagree on whether the placenta was loose but not passed cervix, or if it stuck to the uterine wall remains. You write that the decision to stay home over this time and try all possible measures, was theirs and not the woman. Same line was added at approx. 20:30. You see in retrospect that you should ask your colleague to add same line while you contacted the Women’s Clinic. You also commented that the amount of bleeding was estimated at 1000-1200 ml, not 1200-1400 ml. You tell that syntocinon should have been set at an earlier date.
Statement by midwife XXXXXX dated XXXXXX to the State Board of Health
at home birth parts you on tasks by defining one as primary midwife and the other as secondary midwife. Primary Midwife leader birth and journal responsibility. Secondary Midwives provide practical help.
XXXXXX is of the opinion that an ambulance should have been called one hour after birth.
She writes that same line should have been at. 19:00 and that AMK should be summoned at once. Same line should have been at the latest. 19.20, when the patient fainted in connection with lavatory. XXXXXX acknowledges that managing syntocinon as prophylaxis of bleeding before the placenta is delivered can cause uterine and cervixkramper obstructing placenta inside.
XXXXXX says that you have clear procedures in that it is AMK 113 which should always be present complications, and she was therefore surprised when she became aware that you had called inpatient phone Kvinneklinikken.
Legal basis for the assessment
the information in supervision by the case to consider whether you have acted contrary with the requirement for proper business in the Health § 4 subsections.
Below we list the relevant provision.
the Health § 4 subsections:
Health personnel shall conduct their work in accordance with the requirements to professional responsibility and diligent care that can be expected based on their qualifications, the nature of work and the situation in general.
Health personnel shall act after their professional qualifications, and shall obtain assistance or refer patients further where necessary and possible. If the patient needs dictate, the profession shall be by collaboration and cooperation with other qualified personnel. Health professionals have an obligation to participate in developing individual plans, when a patient or user is entitled to such a plan for patient and user Rights Act § 2-5.
The provision requires professional responsibility and caring help and to health professionals’ professional practice.
When assessing the contents of the acceptability requirements will Norwegian Board have regard to relevant administrative statements. Reference is made to the CMO Guideline for home birth (IS-2012).
What is prudent is decided after an assessment of each case, and how health workers ideally should have acted.
Norwegian Board of Health review
Norwegian Board has considered whether your health care to the patient after the child was
born (after byrds time) was medically justifiable. We are initially to remark that it was you who was the primary midwife during the actual birth.
In a home birth is not access to advanced monitoring or quick means of a doctor if the need arises. The decision on when a physician should be involved done by a midwife at the background of what is proper health care in the situation that exists. Soundness evaluation will be related to midwifery consensus, knowledge about the normal birth and general guidelines for selection by and under home birth.
The uterus is very blodrik in pregnancy, and the rejection of the placenta will guys who have supplied the placenta with blood described above. The closing of these guys are totally dependent on the uterine muscles to contract and squeeze the vessels so the bleeding stops. This usually happens naturally without complications during the first few minutes after child birth. At & lt; 5% last phase longer than 30 minutes and can take up to one hour.
There are various risk factors for unsatisfactory contraction. The placenta (in whole or in part) is still in the uterus is one of them. In case of disposal of the placenta after birth, it will be especially high risk of bleeding if parts of the placenta detaches without the whole placenta is loose and let them squeeze out. Initially can also bleeding lie behind the placenta or membranes and did not appear, when there is an partial solution. During the first 30 minutes, bleeding quantity may be insignificant, but from 30-60 minutes often increases the amount and suddenly sharply increasing bleeding by sessile placenta is a well known problem. Risk of damage to health and death is great by severe bleeding at birth. After Byrds Bleeding is a serious and potentially fatal condition, and 30% of maternal deaths worldwide are caused by this.
Good practice at extended under byrds phase is to observe the patient clinically, accompanied by bleeding amount, inform the patient about the situation the risks that exist and refer the patient to hospital for 60 minutes, or earlier if there is bleeding. Physiological measures to encourage after-mills by adding your child to your chest or give other breast stimulation can contribute to the placenta detaches. Midwives can provide an easy and controlled kite in the umbilical cord to see if the placenta is free, though unacknowledged, and possibly let the umbilical cord is drained of blood. Powerful features in the umbilical cord, massaging and manipulation of the uterus before the placenta is loose must be avoided as it can cause partial solution and thereby increased bleeding.
Norwegian hospitals it is customary to give mandatory oxytocin to enhance drug right after baby is born to reduce bleeding amount and to prevent pathological bleeding. This reduces the risk of a byrds bleeding and shortens etterbyrdfasen. In the national professional guidelines for home birth (IS-2012) recommended that “ woman gets information about uterine agent and that she can choose whether she wants what routine or refrain . “
If the placenta has not arrived within 60 minutes, it is likely that the woman needs further active assistance for it to loosen and bleeding risk is then great. In guideline IS-2012 stated the following: “It is recommended that the woman transferred to hospital after 60 minutes If the placenta does not come by itself. Transfer shall take place even if after byrds bleeding is normal. “
The baby was born at. 18.05 and one hour later the placenta still not arrived. You gave the patient acupuncture and child were added to the chest to stimulate contractions. Kl. 19.10 was patient followed to the toilet to urinate further morkakeløsnende measures. After the State Board of Health assessment, this measure should have been done earlier to support the physiological processes.
Good practice after an hour would have been to inform the patient about the situation, call the AMK and book transport on red response. Although it was not proven heavy bleeding at this time, the risk of sudden onset of bleeding with possible health large in the existing situation. Meanwhile, would you like risk prevention measures have prepared their departure and paved the way for the patient to be able to reside in the floor that end residence is located in while she waited for transport. In addition, should you have filed venous access.
Ca. kl. 19.30 fainted patient. It was then passed about 1.5 hours after birth without placenta resolution. Although there were only observed normal and sparse bleeding at this time, should you / your midwife have thought that the cause of fainting could result bleeding. Instead of giving the patient sweet drinks should you at the latest at this time called AMK and ordered transport on red response for transfer to the hospital and given patient venous access and hung up intravenous bag.
Ca. kl. 20.00 you had still not contacted AMK and commandeered transport. However, it was made controlled kite in umbilical cord and drug riestimulering. Drug riestimulering should not be used as steps to get the placenta away by prolonged etterbyrdstid. According to guidelines, the composition can be routinely as part of active approach to delivery of the placenta. The preparation is then right after the baby is born, such a practice by many hospital births. This will then usually shorten after third stage of labor and the amount of bleeding.
When the placenta is still not born after 60 minutes, there is a great likelihood that it sits so firmly that it must be scraped out. Syntocinon is perilous as measures in such a situation, as it can stimulate contraction which cause partial solution without placenta detaches completely and acknowledged, which can lead to severe bleeding. It should not be measures to get loosened one undescended placenta that is beyond 60 minutes at home birth. In such situations, patients should be sent to hospital. For patients in hospitals is this different, since any bleeding in a similar situation there can be handled quickly and efficiently.
We have noted the information that you and your colleague disagreed on whether the placenta was loose, but not passed cervix, or if it stuck to the uterine wall
still. In our opinion, it had no effect on the placenta was loose or not whether you should have made a transfer. The national guidelines suggest a transfer if the placenta is not reached after 60 minutes. We have also noted that in your back meling dated XXXXXX shows lack of understanding of how serious and potentially dangerous condition is when the placenta still unacknowledged one hour after birth.
First kl. 20.15 was transferred to hospital decided. In a situation that prevailed there was urgent need for ambulances and AMK should have been contacted directly and commandeered transport with “red response”.
Norwegian Board of Health finds an overall assessment that your health care to the patient after the baby was born (after byrds time) was professionally irresponsible.
Assessment of whether you should be given a warning
Norwegian Board of Health finds that you have violated Health Personnel § 4.
violations of Health Personnel provisions we can give warning pursuant to the Health § 56 which reads:
the board can issue a warning to healthcare professionals who willfully or negligently violates obligations under this Act or regulations issued pursuant to it, if the breach of duty is liable to endanger the safety of health and care services, to affix the patients and users with a substantial load or to substantially undermine confidence in healthcare or health – and care service.
The board can give a warning to health care professionals who have demonstrated a behavior that is likely to significantly impair confidence in the profession.
Warning are individual decisions under the Public Administration.
To give warning is firstly a condition that you have acted negligently. In this assessment, the Norwegian Board of Health to decide whether you can be blamed. In the assessment, we could focus on whether you had alternatives of action in the current situation. You could summoned paramedics and prepared the patient for transfer to hospital earlier. Norwegian Board of Health finds on this basis that you acted negligently.
The second condition that must be met is that the act is likely to endanger the safety of health care services, apply patients or users a significant load or to substantially undermine confidence in healthcare or health and care services. It does not matter whether the action in the present case actually received such consequences.
In our assessment, the action likely to cause patients considerable load.
The main conditions to give you a warning pursuant to the Health § 56 first paragraph are fulfilled. The Board shall make a judgment on whether you should be given a warning. Such assessments are based on the purpose of giving warning that is responding to serious violations of the Health. The reaction will help to promote quality in health, patient safety and help prevent future breach of duty.
In our assessment, infringement of the Health so serious that it is necessary to respond with warning. We show that you have failed in a central area for a midwife who provides health care at home births, where there were clear guidelines and where the consequences of mistakes can be fatal.
Resolution
State Health provides pursuant to the Health § 56 first paragraph a warning for violation of the Act, § 4.
We will send information about the decision to Supervisory för care och care (IVO) in Sweden and National Board of Health in Denmark, see attached copy.
you have the right to appeal this decision to the State board for Health Personnel, ref. the Health § 68. the deadline for appeals is three – 3 – weeks of receiving this letter. Read the attached information sheet with further information about the rules for appeal.
This should be sent to the Norwegian Board of Health. You must complain before eventually traveling litigation concerning the validity of the decision,. Administration § 27 b and the Health § 71.
Sincerely,
XXXXXX
XXXXXX
XXXXXX XXXXXX
The letter is approved electronically and sent therefore without signature
Attachments :
notification of the right to appeal administrative decisions
A copy of the message to the Supervisory för care och care (IVO) and National Board of Health
Cc:
County of XXXXXX
XXXXXX
Legal officer: XXXXXX
Health Academic coordinator: XXXXXX
Other letter on the matter
the decision on warning.
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