Inquest into the death of Baby R (Link to Coroners Court Victoria).
Baby R was born at Bendigo Health on 19 August 2022 at 39 weeks and 6 days gestation by emergency caesarean section after his mother was transferred from home where she had been in labour as part of a planned homebirth with two privately practising midwives in attendance. Baby R was born in poor condition requiring transfer to the Royal Women’s Hospital and died six days later. The cause of death was perinatal hypoxia.
An inquest was held to examine the management, care and communication provided to Baby R’s mother during her pregnancy and labour, the relevant procedures, standards and guidelines relating to homebirth and the suitability of Baby R’s mother’s pregnancy for homebirth.
The coroner made a number of findings, not all of which are mentioned here. She formed the view that the pregnancy was not suitable for homebirth ([296]). The coroner accepted that the death of baby R would have been prevented, had transfer to a hospital occurred earlier in the labour.
The coroner made two recommendations under s 72(2):
Recommendation 1
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, Safer Care Victoria and Australian College of Midwives review this finding with a view to consider how guidance documents relating to maternity care can be streamlined, be more consistent and cross referenced to assist in providing clear guidance to all practitioners providing maternity care, women and their families and the public.
Recommendation 2
The Australian College of Midwives review this finding and the National Midwifery Guidelines for Consultation and Referral and consider any revisions to provide clarity to the reference to “relevant medical practitioner or other health care provider” for the purposes of a Level B indication for consultation and/or training in the understanding and application of this aspect of the Guidelines.
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