AHPRA, the Medical Board and 'Standards' Part 2

So a few weeks ago we covered AHPRA, the NMBA and their 'standards of care/ in the case of baby Hugo, whose primary midwife missed 6 hours of fetal compromise on a trace, didn’t pass this information off to an obstetrician, resulting in Jenna Mcgregor being augmented with syntocinon, which killed her baby within an hour. 

Another high profile case we have been assisting with was that of Neethu Thomas in WA in 2023. The news came out in 2024. News story can be found here: Traumatic birth at King Edward Memorial Hospital shines spotlight on maternity care in WA - ABC News

 The media didn’t really capture an ounce of what actually happened at her birth, but the family have let us convey what went on as per medical notes.

We have shared this so that consumers can see these medical boards and regulators want patients to accept serious sub-standard care that kills or nearly kills women and babies and try to pass off these outcomes 'risks' and 'random adverse events.'

There is a huge element of medical racism in Neethu’s case, but I will cover the main alleged medical negligence in her care (there were so many other issues with her treatment, but too complicated for one blog).

Neethu presented to the hospital in early labour and reported the release of a mucous discharge mixed with blood—commonly known as a “bloody show,” which is a normal physiological sign of cervical change during labour.

However, the attending midwife for some reason misinterpreted this as excessive bleeding and proceeded to perform a speculum examination and also sought the opinion of an OB.

Despite the fact that no frank bleeding was visualised and no clinical signs of antepartum haemorrhage (APH) were confirmed, Neethu was admitted on that basis—without being informed that this was the reason for her admission.

This decision was not supported by ongoing assessment or appropriate monitoring of blood loss, as would be required under WA health and RANZCOG guidelines for suspected APH or intrapartum haemorrhage.

According to clinical standards, a bloody show is distinctly different from APH, which is characterised by fresh or profuse bleeding from the genital tract, typically without associated mucous and often requiring continuous maternal and fetal monitoring, escalation, and clear documentation.

In this case, no such monitoring or reassessment occurred after the initial decision to admit, and the failure to distinguish between a benign symptom and a pathological condition represented a significant lapse in clinical judgment.

This was around early morning before 7 am.

After 10:00 a.m., she received an epidural, in line with her birth plan for a pain-free labour. At that time, she was contracting at a regular rate of 2 to 3 contractions in 10 minutes—well within the range of spontaneous labour progression.

Despite this, the attending doctor (we never found out who) instructed the midwife to commence augmentation with syntocinon. This decision was made in the absence of any medical indication against all state health and obstetric guidelines.

It is somewhat common knowledge augmenting a labour should have a medical reason.

Those of us who understand the medical system know, they augmented Neethu's labour in order to ‘speed ’ things up for operational convenience. Not that it gave them any convenience, which we will see shortly.

Neethu was in gaps of untreated or poorly managed hyperstimulation throughout the day (5 contractions in ten minutes).

After 5 pm, she received a 40 minute break from syntocinon, unknown to her or why this was occurring.

A doctor came in and injected something into her leg and told her and partner it was a drug to help the baby’s heartbeat. (There is no such drug, but we figured it was probably terbutaline, but it wasn't documented).

The midwife told her to push at 10cm dilated and didn’t do the usual protocol of waiting an hour for passive descent. The baby was also OP (face up).  Obstructed labour occurred (naturally). 

The doctors were called in for some concerns on her CTG trace. A senior and junior register, arrived, both of whom spent twenty minutes in there, doing an ultrasound and not talking to their patient. They decided on an instrumental delivery. The senior consultant came in five minutes before this occurred.

At this point there are several people in the room. Three doctors, two midwives (two pediatricians on the side).

Not a single one of them sought consent from the patient or explained the process or what was going on. A ‘verbal’ consent was documented for a vacuum delivery. According to Netthu, they simply told her briefly they were going to utilise the vacuum.

The junior register performed an episiotomy without consent. Neethu’s husband explained what they were doing.

Vacuum was placed and 4 pulls occurred, against RANZCOG guidelines. It is disputed in the notes.

They switched to the forceps, did not obtain consent or explain things. The junior register allegedly extended the episiotomy (it is disputed). 

The forceps were inserted so roughly that it was documented that Neethu’s perineum came apart before the first pull of the forceps. 

The RANZCOG guidelines state: "Trauma to the vaginal or perineal tissues may occur from incorrect placement or insertion of the forceps blades. Care should be taken to insert the blades gently and correctly to minimise trauma."

— RANZCOG C-Obs 16, Instrumental Vaginal Birth, Revised 2022

The UK RCOG guidelines state:  Perineal trauma may occur due to incorrect blade application or inadequate attention to insertion technique, even in the absence of traction."

— RCOG Green-top Guideline No. 26 (Operative Vaginal Delivery)  

Baby came out. The doctor then pulled on Neethu’s umbilical cord and the placenta was delivered less than two minutes after birth. ‘Careful cord traction’ was documented.

Now management of third stage requires informed consent, the administration of syntometrine. It takes two to three minutes just for the drug to take effect on average.

As per the Western Australian Health guidelines and RANZCOG guidelines, several clinical checks must occur before cord traction is commenced. The most important being that it is confirmed the placenta has separated from the uterus.

This is requires a lot of things such as checking the abdomen, among other signs.

Source: Queensland Health – Third Stage of Labour (2022)

Further, the WHO clearly advises:

“Cord traction should only be applied after uterine contraction and clear signs of placental separation. Premature cord traction significantly increases the risk of haemorrhage.”

Source: WHO Recommendations for the Prevention and Treatment of Postpartum Haemorrhage (2012)

Given that Neethu was now at a high risk of haemmorage (syntocinon, hyperstimulation, episiotomy, instrumental delivery-all documented risks in guidelines of PPH), her third stage management required careful oversight.

So there is no way with the timing in the notes,  the doctor has met the required checks in the clinical guideline let alone consent as per the Australian Healthcare Charter or even met basic standards of care.

Neethu had a catastrophic PPH immediately. She was taken to theatre, her uterus removed, in a coma for 6 days and hospitalised for 22. Now permanently injured and maimed.

These doctors and midwives butchered this woman.

They treated this woman as a literal sub-human body to do things too, not even worthy of speaking to like a human being.

 It was also the first time, when a consumer was seeking our services, we had to report 5 clinicians to AHPRA in one go. Usually in multi-failure cases, you can usually pin down one person who was negligent and who would serve the basis for a report.

In this case they all were.

Why are we sharing this? Because no action has been taken nor a sufficient explanation as to how this meets standards of care.

We are increasingly seeing medical boards and health authorities excuse care that is dangerous. negligent and is killing people and expecting patients to accept this. It is also a problem because these health professional are then affirmed in their 'care' and so go on doing what they are doing.

It is not case of yanking their license, but having provisions in place to make sure they are adhering to their guidelines.

It brings up the case of the Bega Butcher, Graeme Reeves to mind. According to the Sydney Morning Herald, he was previously investigated after 7 women allegedly died under his care and saw basically saw 750 times the national average rate of expected maternal mortality in Australia. They didn't yank his license for a long time.

At the end of the day, we should refuse to accept a system in which medical boards routinely excuse negligent or harmful care as “appropriate” or “within standard practice,” when the outcomes involve the maiming or death of women and babies that could have been prevented.

Of course, we anticipated that regulators might justify what happened to Neethu. That’s why, months ago, we developed Neethu’s 5 Signs for Safe Placental Delivery and Hugo’s 7 Rights of Safe Induction of Labour...now freely available on our website.

These tools are designed for use by doulas, childbirth educators, and informed parents alike.

We strongly encourage all birth workers and support people to share these resources with their clients. When health regulators normalise dangerous deviations from care standards, those patterns inevitably trickle down into everyday clinical practice and it’s women and babies who suffer the consequences.

Now more than ever, it is important to be a self-aware patient or birth support person, able to ask questions, spot red flags, and speak up when care veers from established medical guidelines.

Empowerment is not a luxury; it is a form of protection in a system that too often fails to be accountable.