Coronial inquest begins into care given by midwife after 30-hour-old baby died

Coroner Bruce Hesketh at the first day of an inquest into the death of baby Zoey Field. Photo / Jeremy Wilkinson

“The desire to breathe is greater than the desire to feed.”

Those are words that have haunted Mark and Amy Field for eight years now after their daughter Zoey June Field passed away at just 30 hours old.

They say their fears about whether their daughter would be able to breathe while breastfeeding were met by the midwife’s reassurance that yes, she would take a breath if she needed it.

Zoey was born without any initial complication at Palmerston North Hospital on March 18, 2015, and was left with her parents to settle in after the midwife says she talked to them about breastfeeding techniques.

However, when the midwife returned to check in on the family 90 minutes later, Zoey was limp and not responding to light or pain. She was whisked away to intensive care at Wellington Hospital but passed away the next day.

The pathologist’s report identified hypoxia as a result of lack of oxygen as the primary cause of death - meaning the newborn was essentially suffocated.

The events leading up to Zoey’s death and why she wasn’t able to breathe were today under scrutiny at a coronial inquest in Palmerston North.

The primary issue for the coroner is to determine whether the Field’s lead midwife, whose name is suppressed by the court, gave adequate advice about how to breastfeed Zoey and to make sure she was breathing.

She told the court this morning that she instructed the couple how to hold her, how to get her to latch and then how to press a finger on the breast under the baby’s nose so she would have space to breathe whilst feeding.

After doing this the midwife then left the new parents alone to rest and enjoy some family time alone. She says they were instructed to use the call bell should any issues arise.

However, when the midwife came into the room 90 minutes later she noticed Zoey wasn’t breathing and had a mottled colour to her skin.

She immediately called the emergency bell and she and other staff attempted to resuscitate the baby.

After Zoey died the matter was referred to the coroner who requested several expert opinions including that of a pathologist, and two midwifery experts.

The mother’s lead midwife disagreed with the findings of those experts and obtained a second opinion from another independent expert.

Because of the differing opinions, the coroner ruled that an inquest take place.

Amy and Mark Field

In the aftermath of their baby’s death, Mark and Amy Field described the following days as being extremely traumatic.

They had to leave the hospital and stay in a motel nearby, but then had to come back and identify their dead child through a screen so that a post-mortem could be conducted.

After this, they told the court they waited three hours for police to turn up at their motel to interview them.

Today they appeared by video link at the inquest and answered questions from Coroner Bruce Hesketh and the midwife’s lawyer Andrea Lane about how much education they’d had about breastfeeding prior to the birth.

“The antenatal classes were a waste of time quite frankly,” Mark told the inquest this morning. “I didn’t get a lot out of them.”

He said he didn’t recall the midwife giving him or his wife instructions on how best to safely breastfeed following the birth.

“I’m quite confident I would remember that discussion given what’s happened,” he said.

Under cross-examination, he was asked whether he was sure that the midwife had reassured the couple with the phrase “the desire to breathe is greater than the desire to feed”, in response to their concerns about feeding and sleeping for a newborn.

“They’re words that have lived in our heads for a long time now.”

Amy Field said she was surprised at how close her baby needed to be while feeding.

“I remember asking if she would be able to breathe,” she said.

Under further questioning from Coroner Hesketh, their own lawyer and the midwife’s, they said they were mostly left alone for around an hour and a half before the midwife came back in and noticed Zoey wasn’t breathing.

A coronial inquest eight years in the making started in Palmerston North today. Photo / Jeremy Wilkinson

Lead maternity carer

The midwife, who was granted name suppression late last week, told the court she didn’t remember telling the couple that the baby would take a breath if it needed to while feeding.

“It’s not a comment I would usually make,” she said.

She was adamant that she had instructed the couple on safe ways to breastfeed immediately after birth and during a birth plan. Her usual practice would be to make sure the nose was clear.

She also said the couple would have been given a pamphlet about safe sleeping for babies, which is for them to be on their back with their face clear.

“It’s very clear in my head, I can still see that day in my head,” she said.

“I can see the events in my mind…I cannot get rid of it.”

The midwife told the court about the moment she re-entered the room after giving the couple some space.

“She [Zoey] was lying across Amy’s body flat on her back with her arms hanging down with no blankets on, just lying there.

“As soon as I walked in the room it didn’t look right…It sticks in my mind, it’s an unusual place to see a baby.”

Under questioning, the midwife said that certain aspects of her practice had changed in the years since Zoey’s death.

“I am much more acutely aware of what occurred so I minimise the amount of time I’m out of the room,” she said.

“Now I remain around…pottering around, usually now for the whole breastfeeding.”

The midwife disagreed with the expert opinion of Dr Susan Crabtree that unobserved skin-to-skin contact was not appropriate, safe nor in the recommended practice for newborns and inexperienced mothers.

She said she’d observed Mark as awake, alert and capable of supervising his wife and child while she was out of the room.

After Zoey’s death, three experts concluded that she was growth restricted and was at a higher risk of post-birth complications because of this.

The midwife said that by her tests and calculations there was no indication that Zoey was growth-restricted, disagreeing with the opinions of those experts.

“This was the first breastfeed…don’t you have obligation to be there and to assess?” Coroner Hesketh asked her under cross-examination.

“Isn’t that what the spirit of what these guidelines are about.”

“In hindsight…absolutely,” the midwife replied.

Coroner Hesketh didn’t mince his words this afternoon when he questioned the midwife.

He said that the guidelines for best practice clearly stated that unsupervised skin-to-skin contact was clear and that she should have stayed in the room for longer.

“I mean you gave them five minutes of your time to go over the breastfeeding procedure and then you left,” he said.

“Do you really consider that that was appropriate?”

Coroner Hesketh said the guidelines reiterated an overarching theme: vigilance.

“This is to maximise the safety of mother and baby in the first hours following birth.

“Is this not part of your training?”

The inquest continues into its second day where two midwifery experts are expected to testify before the court.