Charlotte Harding would be 4 now if she had lived, but a series of errors by medical professionals before and during her birth resulted in her death at just 10 hours old.
Baby Charlotte's parents, Stacey Barrell and Kris Harding, wanted a caesarean section because of Barrell's history of foetal growth restrictions and meconium-stained liquor during previous pregnancies and delivery.
But an emergency caesarean on August 11, 2015, at Palmerston North Hospital was put off in favour of induction and trial of a natural birth by a senior obstetrician who misread a heart trace report before going home.
However, a Coroner, whose decision into the case was released yesterday, has not made recommendations for change following the doomed delivery because MidCentral District Health Board has already addressed concerns.
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Barrell was 39 weeks and five days pregnant when she alerted her midwife to concerns the baby's movements had slowed significantly.
In her two previous pregnancies, Barrell's babies were growth restricted and one child was born with a brain injury because of meconium - baby faeces - she breathed in, in the womb.
That baby was treated in a neonatal intensive care unit for 10 days and has no ongoing negative effects.
But because of that experience, Barrell was anxious about Charlotte's birth and was taking medication for her anxiety, and she and Harding asked their midwife about an elective c-section four weeks before the birth.
Coroner Morag McDowell said the midwife reassured the couple they could try for vaginal delivery but the couple made her aware their preference was for a caesarean should anything go wrong.
McDowell said, given Barrell's risk factors, the midwife should have made a referral for a specialist obstetric consultation prior to the birth.
It was accepted that something caused the baby to be deprived of oxygen up to three days before her birth, which compromised her.
Abnormalities were later found with the placenta, as well as a knot in the umbilical cord, but the Coroner said she still could have been born alive if different choices were made on the night Barrell went to hospital.
Barrell arrived at the hospital at 9.20pm and consulted by a junior obstetrician at 11pm after abnormalities were recorded in the cardiotocography [CTG], which measures the baby's heart rate.
That doctor concluded the baby was not doing well and rang the senior consultant obstetrician, who was at home asleep and said he would come in.
En route, the junior doctor noted further deterioration of the baby's heart rate and ordered an emergency caesarean, calling in a second surgical team from home because the first team were already in theatre.
When the senior doctor arrived he cancelled the emergency c-section because he did not think the situation was so serious and considered it reasonable to trial labour, which the Coroner said was not unreasonable.
The doctors broke Barrell's waters at 11.58pm, when thin meconium stains were noticed, and left Barrell while they attended other births.
At 2.10am the senior doctor viewed the CTG and ordered syntocinon to induce labour but stated that if the heart trace became abnormal a c-section should be done, before going home.
What he did not notice on the trace and was not alerted to were two marked decelerations already in the baby's heart rate and a raised heart rate just before he and the junior doctor had left to attend another birth.
The Coroner said syntocinon should not have been commenced and there was clear evidence at the time to show this was the case.
The drug probably caused contractions which likely compressed the umbilical cord, restricting oxygen further to an already compromised baby.
To make matters worse a hospital midwife increased the infusion only 15 minutes after starting at 3am, instead of 40 minutes after as per hospital policy.
That midwife also did not alert the junior doctor to more complicated and closely spaced decelerations following the increase and when the doctor discovered it herself at 4.14am she doubted her instincts because of the earlier cancelled emergency caesarean.
She decided to check the baby through a foetal scalp clip, a mistake the Coroner said cost precious time.
Charlotte's heart rate plummeted and an emergency c-section was finally performed at 4.45am.
Charlotte was born lifeless and had to be resuscitated. Her parents made the heartbreaking decision to withdraw her life support later that day and Charlotte died at just 10 hours old.
Unlike her siblings she had not been growth restricted.
McDowell ruled Charlotte died of acute antepartum asphyxia. She had also developed pneumonia after breathing in the meconium.
"... Charlotte was compromised prior to her delivery. I accept the expert evidence that the induction of labour and syntocinon infusion caused additional stress to Charlotte which she was struggling to recover from.
"If a caesarean section was ordered at or before 1.20am I am satisfied that Charlotte would more likely than not have been born alive, but it is impossible to say what neurological impacts she would have suffered."