CHANGES to midwifery procedures have been implemented following the death of a newborn baby.
The inquest into the death of Rafe Angelo continued today at Portsmouth Coroner’s Court.
As previously reported, the newborn died shortly after his birth on September 2014 following complications during labour.
Kelly Angelo, from Gosport, was due to give birth at Blakes Birthing Centre in Gosport but was transferred by ambulance to Queen Alexandra Hospital after third grade meconium – the baby’s first faeces – started leaking.
The court heard from Julie Woodman, a former supervisor of midwives, who carried out an investigation following Rafe’s death.
She told the court how a number of changes have been made into the policy and procedure of community midwives.
An updated procedure for calling for an ambulance is now in place at Blakes to clarify the correct terms to use. Rafe’s case got an ‘emergency response’ instead of the appropriate ‘time-critical’ response, as the caller did not know the difference between the two.
Ms Woodman said: ‘Since then, we have done quite a lot of training with community midwives to ensure they use the correct terminology.’
Mothers who take antidepressants during pregnancy, like Ms Angelo, can still deliver at a birthing centre but must go to hospital for a period of observation over 72 hours.
Also revisions to midwives’ notes will be made, as it was unclear when Ms Angelo made the decision to go to Blakes and the record of this.
‘We have learned a lot around the conversation we have with women and how we document things,’ said Ms Woodman.
Pathologist Dr Peter Gonda, who carried out a post-mortem examination on Rafe, told the inquest the medical cause of death was ‘difficult to ascertain.’
He added: ‘However it is likely to be caused by sudden oxygen starvation caused by umbilical cord compression which happened during delivery.
‘But it’s impossible to say at what stage.’
The lack of timings has raised questions about whether or not Rafe was stillborn.
Assistant coroner Karen Harrold, who is leading the inquest, said: ‘It’s a significant matter that we need to address.’