Alba May Pemberton · Prevention of Future Deaths report

On the 12th March 2018 I opened an inquest touching the death of Alba May Pemberton , 2 days old. The inquest concluded on the 12th June 2018. The conclusion of the inquest was “Consequences of complications during the second stage in childbirth.”, the medical case of death was 1a Hypoxia, 1(b) Ischaemic Encephalopathy.

On the Tenth of August 2016 Alba was born having suffered a period of hypoxia during the active stage of the second stage of the delivery. It is likely that by 21.45 hrs on the Ninth of August the active second stage had begun and that auscultation of the heart should have taken place every 5 minutes, this level of monitoring did not start until 23.12. This period had a bearing on Alba's death in that there is a possibility that 5 minute monitoring would have lead to the discovery of hypoxia at an earlier stage. If a CTG equipment had been used the trace is likely to have been abnormal for a considerable period and earlier delivery is likely to have resulted in Alba surviving. Alba was born seriously unwell as a consequence of the hypoxia and had only two days of life

The presence of meconium should be classified as meconium, and not graded, and once present should result in the use of CCG equipment.

That every patient at a birthing centre should be the subject of obstetric review

That obstetricians should be more involved in the management of low risk cases

There should be MDT meetings with the obstetric staff and midwifery staff and obstetric staff encouraged to work closely together in the management of low risk cases.