A midwife was not trained to free the baby’s head during a caesarean when she was asked to carry out the manoeuvre, an inquest has heard.
Nixon Tonkin died shortly after being delivered at Royal Brisbane and Women’s Hospital in June 2014 at 38 weeks’ gestation.
A coronial inquest into his death heard on Monday that a midwife was asked to help during surgery when Nixon got stuck in the birthing canal.
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The midwife, who cannot be named for legal reasons, told the Coroners Court in Brisbane she had not received any training on how to free the baby’s head when it becomes lodged in the birth canal.
She said she approached it as she would a vaginal examination by splaying her index and middle fingers to try and break the suction but did not recall pushing on the skull.
“It’s such a small space, there wasn’t really anywhere to go,” the midwife said.
She said she removed her fingers once she felt the doctor’s hands from the other side.
Nixon never breathed on his own despite resuscitation efforts.
An autopsy revealed he had skull fractures, most likely caused when the midwife's fingers had pushed against his head.
The court previously heard the not uncommon manoeuvre didn't usually cause such catastrophic injuries but cases had been reported.
First-time mother Simone Tonkin had earlier inquired about an elective caesarean because Nixon was a large baby, but this was not decided by her treating doctors for an unknown reason.
A separate midwife who also treated Mrs Tonkin told the court she dismissed her request for a caesarean while she was being induced.
"Women say a lot of things when they're distressed with pain," said the second midwife, who also cannot be named.
"She mentioned she wanted a caesarean when she was in pain.
"She said a few times like 'I'm over it'."
The second midwife said she did not tell anyone else at the hospital about Mrs Tonkin's request but would have if she had "demanded" it.
"It didn't seem like an issue when she wasn't in pain," she said.
"In retrospect I might have gotten a doctor."
Nixon's family are seeking to raise awareness about Ryan's Rule, which allows relatives to request a second opinion if they are not satisfied with a hospital's care or response.
"We hope that the inquest will reveal what could have been done to help prevent Nixon's death and make recommendations to prevent future tragedies of this sort," they said in a statement.
Director of obstetrics and gynaecology Karin Lust said the hospital had made changes to improve practices over the past three years and would adopt any necessary recommendations made by the coroner.
The inquest continues.