Albury Wodonga Health has implemented changes following the death of a newborn girl aged just three hours old.
The newborn died from meconium aspiration at Wodonga Hospital on April 18, 2018, and the matter was investigated by the coroner amid concerns about decreased foetal movement reported before the birth.
The newborn's mother went into spontaneous labour about 7.15pm and was born at 8.45pm and seen to be pale with no tone, no heartbeat, and covered in thick and old meconium.
CPR started three minutes later with ventilation and suctioning before the baby was intubated.
She was transferred to the special care nursery at 9.24pm and checks showed her prognosis by 10pm was "very poor".
She was declared deceased at 11.44pm.
The hospital's obstetric care and labour management of her mother was examined by the coroner.
Coroner Audrey Jamieson said if knowledge of the mother's decreased foetal movement was better communicated before admission, the midwife would have been alerted to the increased risks.
"Consequently the care and management of (the mother) would have been fundamentally different," Ms Jamieson said.
"I note Albury Wodonga Health has taken restorative and preventative action in the wake of this tragedy.
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"I commend Albury Wodonga Health for implementing the improvements.
"It is to be hoped that in overcoming the deficiencies of antenatal and obstetric care and management (in) this matter will assist maternity services staff to better community and manage the perinatal risk."
The changes include CTG monitoring on all women who present in labour, the development and revision of guidelines for foetal surveillance and reduced movement, asking dedicated questions on reduce foetal movement history, and additional education training.
Staff are assessed each year on foetal surveillance, and trained on resuscitation and when to escalate care.
Ms Jamieson gave her condolences to the newborn's family.
"I acknowledge the grief and devastation that you have endured as a result of your loss," she said.
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