the Incident occurred when the health service decided to initiate the birth of a pregnant woman who had gone over the time. According to the criticism from the Ivo has the midwives at the event, misinterpreted the fosterljudsövervakningen and failed to tillkala doctor when they should have done it. The documentation of the event was also flawed.
Ivo mean that midwives in a better way would have ensured that the monitoring of the fetus is working as it should, because the unit is not turned on some fosterljud at all. Instead, it was first at an ultrasound that one could conclude that the fetus had died.