An inquest into the tragic death of Baby R who died in August 2022 is still ongoing. This study is helping to illuminate the nuances at work in maternal health care decision-making. Baby R had the most tragic outcome of perinatal hypoxia following emergency caesarean section at Bendigo Health. She was the sixth child of a mother who had earlier worked as a registered midwife. The inquest aims to explore the circumstances leading up to Baby R’s birth and the decisions made regarding her mother’s care.
For Baby R’s mother, her first pregnancy, which resulted in giving birth to Baby R, proved much more difficult. She had a traumatic birth experience and almost died from postpartum hemorrhage. In her second pregnancy, she’d stepped away from the health care field. Yet, she was set on the idea of a home birth, despite her complex history. Initially, both parents were under the impression that they would not be eligible for a home birth. This worry was born out of the emergency caesarean their first-born needed whilst giving birth.
Medical Consultations and Birth Plans
In 2022, Zimney partnered with Dr. Veronica Moule to provide a 12-week prenatal consultation with Baby R’s mother. What she didn’t know is the postpartum hemorrhage that happened in the first delivery. This data might have been used to shape her judgment in the determination of the mother’s fitness for a home birth. Dr. Moule stated that had she been informed about this complication, she may have advised against a vaginal home birth.
Following the second consultation, four separate doctors referred Baby R’s mother to private midwives for care. They encouraged her to try this alternative for her next birth. The midwives involved, Marie-Louise Lapeyre and Elizabeth Murphy, expressed concerns regarding potential civil liability should complications arise during the home birth.
“It’s hard not to reflect deep sadness. But in terms of the guidelines … she met the criteria [for a home birth] under the guidelines.” – Dr. Veronica Moule
Monitoring and Communication Gaps
Midwife Mary Louise kept a watchful eye on Baby R’s mother as she went through labor at home. She promised her that they would be watchful through all of it. Baby R’s mother later reflected on this assurance, expressing regret for not clarifying what “more monitoring” entailed.
“I wish I asked what ‘more monitoring’ looked like to discern if we were on the same page. I didn’t do this, and this is hard to live with.” – Baby R’s mother
The inquest has, quite rightly, raised questions about Baby R’s mother. Was she truly able to make an informed decision if she couldn’t speak to an obstetrician prior to the birth? Dr. Moule recognized the challenge of making these decisions without all the relevant data.
“Possibly not,” – Dr. Veronica Moule remarked regarding the importance of thorough consultations.
Ongoing Inquest and Implications for Maternal Care
As the inquest moves forward, it works to peel back the layers of decision-making and communication that led to this preventable tragedy. By the time Baby R’s mother came to us, she was understandably upset about her experience. She calls it “a box-ticking exercise,” stressing the absence of individual care during her high-risk pregnancy.
This case brings to the forefront significant issues involving maternal health care. Most importantly, it underscores the importance of clear communication between healthcare providers and patients. This example illustrates the ways that past medical history can heavily influence future care choices, particularly when seeking out alternative options such as home births.
