Doctors report trauma from fatal free birth
Doctors who desperately tried to save the life of a wellness influencer who bled to death after a free birth were left with ongoing trauma and were considering leaving the profession, a court heard.
On the third day of the forensic inquest into the death of Stacey Warnecke, who died hours after giving birth at home last year, Nisha Khot, Frankston Hospital’s director of obstetrics and gynecology, said the tragedy had led some doctors to question their profession.
“Each doctor described flashbacks, insomnia, anxiety, depression, guilt and a general feeling of hopelessness in the days and weeks following this tragedy,” Khot told Victoria Coroner’s Court on Wednesday.
“[They] They found themselves questioning the value of their education and the purpose of their chosen profession.”
Khot said this despair stems from the fact that postpartum hemorrhage, which was the cause of the 30-year-old’s death, is a common and treatable condition when treated quickly in a hospital.
The nutritionist arrived at the hospital by ambulance following an unassisted home birth on Sept. 29, attended only by Warnecke’s husband, Nathan, and doula Emily Lal.
The court heard medical staff at Frankston Hospital depleted a significant blood sample, performed a hysterectomy and drained fluid that had accumulated around her heart in an attempt to save the new mother’s life.
Khot, who has been tasked with supporting Warnecke’s family and leading a review of the health service’s handling of the tragedy, was presented with a copy of the young woman’s birth plan on Wednesday.
The plan, shown on the screen in the Coroner’s Court, instructed her husband, Nathan, to use his fist to push on the pubic bone as a way of dislodging the baby if it became stuck during labour.
If the baby’s body did not follow the head and turned whitish gray, the birth plan also internally instructed Nathan to “grab the armpit” and “try to turn the baby.”
There were also instructions on how to respond in the event of a miscarriage, shoulder impingement, or the umbilical cord becoming wrapped around the baby’s neck.
Khot said he was “very concerned” about an untrained person following orders outlined in a birth plan.
“These maneuvers can easily cause serious injuries to babies,” he said.
Warnecke’s husband did not need to perform any of the maneuvers outlined in his wife’s birth plan, as the couple’s baby boy, Axel, was born without complications.
The court also heard that on the afternoon of Warnecke’s death, Bayside Health Peninsula director Shyaman Menon reported doula Emily Lal to a local police station in Frankston.
Menon said this followed a meeting earlier in the day in which a senior hospital administrator raised concerns about the language Lal was using at the hospital, even though he described himself as Warnecke’s friend.
“The language used was more than a general member could understand,” he told the court, referring to the medical terminology used by Lal.
“This created concern about whether there was someone with the knowledge element providing this care.”
Menon said staff were concerned Lal could pose a public health risk.
Associate Professor Alexis Shub, chair of Pediatric Infant Perinatal Emergency Relief (PIPER), said clinicians were increasingly treating women coming to hospital with serious complications associated with free birth.
“Free birth was actually unknown until about five years ago,” Shub told the court.
“Damage rates are increasing”
Data from PIPER, a statewide service that provides rapid expert advice to healthcare providers in obstetric emergencies, shows seven serious adverse events linked to unpaid births and home births occurred in 2023. By 2025, this number has increased to 20.
More than 11 of these events were recorded in the first five months of this year alone and include serious postpartum hemorrhage, death and permanent disability.
Shub called for the coroner’s powers to be expanded to allow them to investigate full-term babies who die in the process of being born. The coroner can currently only investigate the deaths of babies who die after birth.
“Whether they die just before birth or right after birth is not a meaningful distinction,” he said.
“It’s really important to recognize that these babies are people and they’re important. I think if we had a coronial role in investigating some of these deaths before a baby is born, it could contribute a lot to our ability to prevent some of these deaths.”
Earlier in the week, the inquest heard that in the months before Axel was born, Warnecke had a deep fear of birth trauma and was determined she wanted to have her baby on her own terms, without medical intervention.
She had expressed growing concern about the increase in the number of caesarean sections, induced births and excessive medical interventions.
The inquest heard the woman twice refused an ambulance after she crossed the placenta and began bleeding, but agreed when asked a third time.
The trial continues.
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