When baby Saskia's traumatic home birth started, the midwives knew they were facing an emergency when they saw a foot rather than her head.
"It was immediately apparent to the midwives they were dealing with an undiagnosed footling birth," says Wellington coroner Garry Evans.
This was at 10.06pm on February
6, 2001. Birth was complete at 10.12. Calling an ambulance was delayed for a further three minutes.
"It should not on the evidence have been so delayed," Mr Evans said in his written decision on the death of Saskia Marama Swagerman-Fugle, of Newtown.
She died seven days later in Wellington Hospital after brain damage related to oxygen deprivation during birth.
Mr Evans also reported on a second newborn death following delivery at home. Cameron Elliot died at Peka Peka Beach on the Kapiti Coast in April 2003.
The two deaths are linked by Mr Evans' criticisms of the lead care midwives' failures to conduct vaginal examinations, which he said would have diagnosed the breech presentations in both cases.
He has also inflamed a decade-old dispute between midwives and general practitioners by saying that midwives are not adequately prepared in some cases to look after high-risk patients.
His recommendations include:
* An independent review of maternity services.
* An audit of baby death rates relating to public and independent-midwife services.
* The re-integration of GPs into state-financed maternity care.
* Internship and supervised practice for new-graduate midwives.
GP groups welcomed Mr Evans' findings, but the College of Midwives considered them ill-informed.
Its chief executive, Karen Guilliland, said there was no evidence to support his concerns about midwife education or the maternity system.
Internship and supervised practice were already covered by the clinical experience students received during the last year of the three-year midwifery degree training. And the infant death rate was declining.
Midwifery Council chairwoman Dr Sally Pairman said that before the coroner's findings were released, the council had decided to require midwives to undertake updated training on neonatal resuscitation and management of undiagnosed breech birth.
