‘Mum held newborn baby for few seconds before he died’ – inquest

AMOTHER got to hold her new baby for only seconds after he was born “lifeless, unresponsive and needing resuscitation,” an inquest has heard.

Coby Conway had been placed in his mother’s arms just long enough for his dad Luke to cut the umbilical cord, before being rushed off into the next room at Ystrad Fawr Birth Centre in Ystrad Mynach for emergency care.

The newborn would die just hours later.

His mother Charlene Conway, of Mill View, Caerphilly, had initially been referred to the Royal Gwent Hospital in Newport earlier that same month where both her blood and urine were tested and found to be normal.

In addition, aside from her showing some signs of edema – which occurs when tiny blood vessels in the body, or capillaries, leak fluid - the baby’s heart rate also appeared healthy.

As a result, along with the fact all her previous scans had seemed fine, Mrs Conway was not admitted to hospital at that time.

Indeed, the Royal Gwent had been where she and her husband had requested Coby be born, but due to the worsening of the Covid pandemic and the fact her two previous pregnancies had been ‘uneventful’, the location was changed to Ystrad Fawr Birth Centre.

And it was to the community hospital’s birthing centre she went at just after midnight on May 14, 2020, having begun her contractions.

However, following an assessment and being found to have raised blood pressure, Mrs Conway was sent home - only to return again “in some discomfort” at 2.10am.

Now in the first stage of labour, she was told by the midwife Rhuanedd Woods that the baby’s heart rate was “a little on the low side,” but a CTG scan shortly afterwards at 2.20am assessed it to be a “more reassuring” 140-150 beats per minute (bpm).

But, despite the recommendation that checks take place every 15 minutes at this stage of the birth process, the next documented foetal heart reading wasn’t until half an hour later when the results again proved “reassuring.”

In pain, Mrs Conway was then placed in the birthing pool at 3.30am, where she was joined at 4.10am by second midwife Claire Preece.

At that stage the baby’s heart rate appeared to drop to 107bpm, but, given the added difficulty of taking foetal heat readings in a birthing pool, it’s thought this could have been the maternal pulse which was being detected.

At 4.20am the baby’s heart reading was confirmed as 131 and, 10 minutes later, he was born – only to be rushed into the next room and because he didn’t appear to be breathing.

“Sometimes a baby can come out shocked and stunned, especially if the labour is quick, as this one was,” said Ms Woods.

She added that it was during attempts to resuscitate Coby that he brought up a mixture of mucus-like fluid and meconium – the medical term for a baby’s faecal discharge – the inhalation of which can sometimes occur during birth.

Paramedics and emergency doctors were called and continued to administer care as Coby was taken to University Hospital of Wales in Cardiff where, despite the best efforts of the clinical team he died at 6.05am from damage caused by a lack of oxygen to the brain.

“Baby Coby was born lifeless, unresponsive and needing resuscitation,” said Senior Coroner for Gwent Caroline Saunders, recording a narrative verdict at Newport Coroners’ Court.

She added that the exact reason why could not be determined, even despite regular monitoring.

“Numerous checks were made, although there were times when they were not documented or taken exactly to schedule.”

“And whilst I do not consider this altered events, the failure to do so can later prove distressing for families in trying to establish the facts about what has happened.”