Midwives at a Pointe-Claire birthing centre reacted too slowly when a baby was in distress during a delivery two years ago, a Quebec coroner’s report revealed Tuesday.

The newborn died at the Lac St. Louis birthing centre in June 2011, leading coroner Catherine Rudel-Tessier to recommend the Order of Midwives review its practices and training protocols.

In her reports, Rudel-Tessier lists the extensive errors, miscommunications, and lack of training that led to the death.

The report recommends that all midwives get better training in recording the stages of birth and recognizing birthing difficulties, knowing when to go to a hospital, and in using emergency resuscitation equipment.

At the time, staff at the birthing centre told CTV Montreal that they called 9-1-1 when the woman began experiencing major complications during labour, initially with the plan of rushing the woman to the Lakeshore General Hospital just two minutes away.

When paramedics and firefighters arrived ten minutes later, a secretary refused to let them into the building, saying the woman had already delivered and no longer needed to be taken to hospital since staff was resuscitating the infant.

About 35 minutes after the first 9-1-1 call was placed, a doctor from Urgences Santé arrived and took over attempts to reanimate the infant, without success.

The coroner's report outlines a much more serious chain of events, showing that the baby was in distress for several hours before being born, and had actually crowned more than two hours before birthing centre staff called 9-1-1.

The report shows the child's heart rate began dropping three hours before birth, and that midwives lost track of the baby's heartbeat after the infant was in the birth canal for more than an hour. It was only half an hour afterward when midwives called 9-1-1.

“Right away having a prolonged pushing and abnormal fetal heart should have triggered the intention of getting the patient some help and the baby some help, and considering transferring the patient into another centre,” said Dr. Isabelle Girard, president of the Quebec Association of Obstetricians and Gynecologists.

Rudel-Tessier's report shows that there were many medical problems that the midwives should have reacted to long before they called 9-1-1, including the drop in fetal heart rate, not keeping adequate track of contractions, and not acting urgently after the baby was in the birth canal for more than 15 minutes.

The coroner also said paramedics should not have been turned away from the birthing centre.

“Even at a hospital, sometimes as doctors we do not necessarily have access to a C-section or an anesthetist, so we always have to take that into consideration what is the time of reaction if I should get into an emergency,” said Girard.

Midwives already regularly review their training and practices as the coroner now recommends, said Marie-Eve St-Laurent, president of the Quebec Order of Midwives.

St-Laurent said midwives get retrained for emergency scenarios every three years, and CPR every two years.

The emergency that led to the baby's death that day seems to Dr. Girard to be a result not of lack of training, which Girard agrees is excellent, but rather a lack of experience with emergencies.

“It probably comes from the fact that they're doing deliveries at a very low risk and they do not do a lot of deliveries per year so their chance of seeing something abnormal once they graduate is very low and you can lose your training because of that,” said Girard.

Dr. Girard said what’s most unfortunate is that the midwife responsible for the delivery was never questioned by the Order of Midwives. She left the practice right after the incident, so the issue may never fully be resolved.

Her assistant has since had more training.

The report also outlines a series of errors with the 9-1-1 dispatch system, with the dispatcher not treating the case as being of the topmost priority, and a second call not going to the correct person.

The 9-1-1 operator has since received extra training and the computerized system has been altered.


 

Coroner's report: death of infant