The Tragic Death of Baby R
A coroner has determined that the death of a baby following a home birth in central Victoria could have been prevented. Baby R died from perinatal hypoxia in August 2022, just six days after his mother sought emergency medical care at Bendigo Hospital.
The coroner, Dimitra Dubrow, delivered her findings today, highlighting that Baby R’s mother was not a suitable candidate for a home birth and had not received adequate information to make an informed decision. The inquest revealed that Baby R’s mother had previously experienced a traumatic delivery with her first child, which involved an emergency caesarean section due to obstructed labour.
Inadequate Care and Guidelines
Ms Dubrow stated that Baby R’s mother fell outside the recommended care for home births because of her previous caesarean section and the high-risk nature of her pregnancy. She also found that the private midwife, Elizabeth Murphy, did not adhere to Australian College of Midwifery (ACM) guidelines during the birth. The care provided by Murphy and another midwife during the labour was deemed “deficient.”
A lawyer read a statement on behalf of Baby R’s family outside the Coroners Court of Victoria. The family remains unidentified for legal reasons. The statement emphasized the emotional toll the loss has taken on the family over the past three and a half years.
The ‘What If’ Moment
During a week-long coronial hearing last year, Baby R’s mother described a pivotal moment during the home birth when she noticed meconium liquor at around 3:10 pm. Meconium liquor is waste typically passed by a baby after birth. She had been in labour since the early hours of the morning.
In her statement to the court, the mother recalled saying “oh f***” and assuming she would be heading to the hospital. However, the midwife, Marie-Louise Lapeyre, advised her to monitor the situation more closely. The mother expressed regret for not asking what “more monitoring” entailed, acknowledging that this oversight is difficult to live with.
Complications and Regrets
Baby R’s mother, who was herself a registered midwife, had worked as both a nurse and midwife before leaving healthcare during her first pregnancy. Ms Dubrow noted that the presence of meconium liquor should have prompted a discussion about transferring to the hospital and consulting with Bendigo Hospital.
“If Baby R’s birth occurred in hospital, not at home, or transfer to hospital occurred at or around 3:30pm, I consider Baby R’s death would’ve been avoided,” she said.
The court heard that there were signs of an obstructed labour, with Baby R’s mother stating she “felt stuck like last time” at 2:45 pm. At 7:43 pm, a fetal heart rate of 195 beats per minute (bpm) was recorded, and Ms Murphy advised that a transfer was necessary.
Midwives’ Regrets
Two private midwives, Marie-Louise Lapeyre and Elizabeth Murphy, admitted their care was inadequate during the home birth. They acknowledged that a transfer to the hospital should have happened sooner. Following investigations by the Australian Health Practitioner Regulation Agency and the Nursing and Midwifery Board, both midwives were prohibited from practising as private midwives, along with other conditions.
Ms Dubrow found that Ms Murphy did not follow ACM guidelines by failing to recommend a specialist obstetrician consultation at 36 weeks and providing incomplete information about the mother’s obstetric history.
Recommendations and Future Steps
Ms Dubrow recommended that the Royal Australian and New Zealand College of Obstetricians and Gynaecologists and ACM review their findings and consider streamlining guidance documents for those providing maternity care and families seeking information. She also suggested that ACM clarify its guidelines for consultation and referrals.
The coroner’s findings highlight the importance of clear communication, adherence to guidelines, and timely decisions in ensuring the safety of mothers and babies during childbirth.
