Finding into death of Baby R

Contributing factors

• Planned homebirth unsuitable for high-risk pregnancy (previous caesarean section, fetal macrosomia, postpartum hemorrhage)
• Failure to arrange required obstetric consultation at 36 weeks
• Inadequate discussion of risks and applicable guidelines with mother
• Inadequate assessment of labour progress (only two vaginal examinations over 14 hours)
• Failure to appropriately respond to meconium liquor at 3:10pm
• Inadequate fetal heart rate monitoring (not continuous, inconsistent frequency)
• Delayed transfer to hospital (8:05pm rather than approximately 3:30pm)
• Lack of documented collaborative care plan between private midwives and hospital
• Communication failure: Shared Care Form sent to referring GP instead of midwife

Coroner's recommendations

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Safer Care Victoria and Australian College of Midwives should review guidance documents relating to maternity care with a view to streamlining them, making them more consistent and cross-referenced to provide clear guidance to all practitioners providing maternity care, women and their families
2. The Australian College of Midwives should review the National Midwifery Guidelines for Consultation and Referral to provide clarity regarding the reference to 'relevant medical practitioner or other health care provider' for Level B indications for consultation and/or provide training in understanding and application of this aspect of the Guidelines