Baby A - Non-inquest findings

Contributing factors

• Failure to recognise abnormal admission CTG
• Failure to perform continuous electronic fetal monitoring despite high-risk pregnancy
• Inadequate fetal heart rate monitoring during labour, particularly in the birthing pool
• Water immersion allowed despite being contraindicated in pre-eclampsia
• Maternal pre-eclampsia (severe by admission)
• Delayed caesarean section (90 minutes from decision to delivery)
• Inadequate assessment of fetal welfare throughout labour
• Parental refusal of medical advice regarding water birth
• Inadequate documentation of risk discussions
• No continuous CTG despite clear indications (pre-eclampsia, abnormal admission CTG, meconium risk)
• Acute chorioamnionitis
• Cephalopelvic disproportion with fetal head impaction

Coroner's recommendations

1. Implemented requirement that two midwives sign and check the admission CTG
2. Admission CTG must be assessed and continued until a normal trace is identified
3. Implementation of electronic fetal monitoring for a minimum of 15 minutes at least every two hours
4. Requirement for continuous CTG monitoring in high-risk pregnancies and signed by two midwives every two hours
5. Mandatory RANZCOG training every three years for midwives after initial training
6. Updated Water Immersion during Labour for Hydrotherapy Birth Policy to clearly link antepartum and intrapartum risk factors to continuous CTG requirements
7. Enhanced antenatal education including balanced discussion of normal and abnormal labour, need for interventions, and CTG monitoring frequency
8. Birth Plan documentation process requiring signed acknowledgement of understanding when plans conflict with hospital policies or medical advice
9. Updated Education Pathway for 34 Week Interview to include specific page on risks precluding water immersion and need for CTG monitoring
10. Implementation of Cardiotocograph Request/Reporting Form with CTG envelope for storage and two-midwife signature summary
11. Updated Caesarean Section Emergency Categorisation of Urgency Policy in line with RANZCOG guidelines
12. Escalation of Management of First and Second Stage of Labour Policy ensuring timely escalation of concerns
13. Implementation of Obstetric Notification in Birth Suite Policy clarifying when obstetricians must be called
14. Monthly CTG case presentation reviews and documented educational discussions
15. Expansion of obstetric emergency courses for midwifery staff
16. Implementation of Complications of Pregnancy – Hypertension Policy with Magnesium Sulphate Infusion management in ICU
17. Monthly audits of obstetric medical records with feedback to midwifery staff
18. Staff education on importance of accurate documentation by Hospital legal counsel