There were no complications with the birth and the little boy was considered healthy, with an Apgar score of 10, the maximum.<\/p>\n
After he was born, the baby was placed on his mother\u2019s chest for skin-to-skin contact and breastfeeding.<\/p>\n
The mother had suffered a second-degree perineal tear during labour, which required suturing.<\/p>\n
The midwife left the room to collect equipment, then returned and checked on the baby before she began suturing, starting when the baby was about 50 minutes old. <\/p>\n
The mother was given nitrous oxide gas for pain relief.<\/p>\n
From her position at the end of the bed, the midwife was unable to see the baby\u2019s face while she was suturing. <\/p>\n
Deputy Health and Disability Commissioner Rose Wall. Photo \/ Lance Lawson<\/p>\n
She later recalled checking with the mother twice during the procedure, which lasted about 20 minutes, asking if he was warm enough and what he was doing.<\/p>\n
The mother replied that the baby was warm, and that he was sleeping. <\/p>\n
Action to Improve Maternity Health (AIM), an organisation that seeks to improve the maternity system, acted for the baby\u2019s wh\u0101nau before the HDC,<\/a> and said the mother\u2019s sight of the baby was obstructed by the mask she was wearing to receive the gas.<\/p>\n AIM also said that it was \u201cinappropriate\u201d for the midwife to rely on the mother\u2019s opinion as she might have been affected by the nitrous oxide.<\/p>\n The baby\u2019s father had also left the room, to make a phone call. <\/p>\n When the suturing was finished, the midwife went out of the room again to turn on a shower for the mother.<\/p>\n She returned and at about 12.30am, about an hour and a quarter after the birth, she lifted the baby to complete a full postnatal check. <\/p>\n The midwife realised that the baby was unresponsive and had stopped breathing. Efforts to resuscitate him were unsuccessful.<\/p>\n A coroner later found that the probable cause of death was accidental asphyxiation.<\/p>\n Guidelines require an hour of assessment<\/p>\n