A stillborn baby could have been delivered 90 minutes faster than he was if doctors were informed of the extent of his distress, an inquest heard.
Baby Arthur Reina Chagas was unresponsive when he was born at 8.59pm on March 28, 2018.
Parents Cintia Reina and Alan Chagas, from Brazil originally but living in Phibsboro, Dublin 7, said they were devastated to lose their "perfect and beautiful" baby boy.
News of their pregnancy was the ‘best news of their lives,’ Mrs Reina told an inquest at Dublin Coroner’s Court.
On the day of the birth, Mrs Reina was feeling pains and went to the Rotunda Hospital at 5.30pm. She said her baby had been moving as normal that morning. However, at the hospital, she told staff her baby was moving less.
The baby’s heart rate raised concerns and a midwife said she informed the registrar on-call at 6pm.
The woman was reviewed by an Obstetric Registrar at 7pm and was deemed not to be in established labour. Dr Davor Zibar said it takes time to open retrospective CTG’s on the computer system and he did not do this.
He said if he had all the information at 7pm he would have called for an emergency Caesarean section then and baby Arthur could have been delivered by 7.30pm.
The court heard that the two obstetric registrars on duty were busy with an instrumental delivery during this time.
Two separate midwives said they did not inform the consultant on-call. Both said they were waiting for doctors present on the ward to become available to assess Mrs Reina.
The baby’s heart rate had dropped to a dangerous level by 8.43pm and Dr Zibar entered Mrs Reina’s delivery room one minute later.
An emergency Caesarean section was performed and baby Arthur was born unresponsive at 8.59pm.
A midwife told the baby’s father the infant had died.
“He was in shock and could not think properly,” Mrs Reina said. “I asked why they didn’t take the baby out earlier and got no answer.”
The parents were able to hold their baby and take pictures with him after the birth.
Mrs Reina said:
“He was perfect and beautiful.”
An autopsy found baby Arthur died due to an acute hypoxic event that occurred between four and six hours prior to delivery. The cause of this event is not known.
Coroner Dr Myra Cullinane said she may need to look at systems in place at the hospital that might prevent similar future tragedies.
The coroner adjourned the inquest to October 1 to hear from two further witnesses.