Coroner investigates baby’s death after home birth gone wrong

A mother whose newborn died after a home birth went wrong was unsuitable to deliver her baby at home, a coroner has heard.

The Coroners Court of Victoria heard that the 35-year-old woman had a complicated and traumatic first birth – an emergency c-section and haemorrhaging – and had decided to have her second child at home in 2022 when the plan went awry.

The Coroners Court of Victoria will investigate the death of a baby as well as standards of home births after a woman tried to deliver her son at home.Credit: Justin McManus

The mother was taken to Bendigo Hospital for an emergency delivery before the baby – born at 39 weeks and six days gestation – died days later with a brain injury possibly caused by a lack of oxygen to the brain.

“Baby R was the second child and dearly loved by his parents and younger brother. Although his time in this world was brief, he’ll be remembered by his family members and continue to have a lasting impact on their lives,” counsel assisting the coroner Anna Martin said.

Newly appointed coroner Dimitra Dubrow was told that the parent’s first child was born at 4.8 kilograms by a complicated, emergency c-section at Bendigo in 2019 after beginning the delivery process at Castlemaine Hospital.

The mother described the first birth as traumatic and was hesitant to give birth in a hospital again.

During her second pregnancy she was under the care of private midwife Elizabeth Murphy and two local GPs who helped manage her iron deficiency and possible gestational diabetes, among other things.

The mother did not undergo a 12-week scan or 36 week appointment but did undergo other tests.

Her records show on July 26, 2022, an obstetric consultant noted she was a “high obstetric risk”.

On August 19, 2022, the mother went into labor and private midwives attended her home, from about 5.10am, where they monitored the baby’s heart rate and set up a birthing pool.

At 7.45pm, Murphy recommended an urgent transfer to hospital, before the mother made her own way to hospital at 8.25pm.

The baby was born via emergency c-section about an hour later, weighing 4.2 kilograms, and was incubated with a suspected severe hypoxic brain injury caused by reduced oxygen or blood flow.

The baby was taken to the Royal Women’s Hospital in Melbourne, where he died six days later.

Two expert reports obtained by the coroner suggested there had been a lack of documented evidence about information sharing and decision-making in the mothers case.

One said that due to the mother’s risk factors, she was unsuitable for a home birth with missed opportunities during labour to recognise new risk factors that may have changed the fatal outcome.

The coroner will investigate standards and guidelines of home births, the mother’s suitability for a home birth and the care she received at an inquest later this year.

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