A baby's life could have been saved if midwives had investigated the "very unusual" presentation of a first-time mother a week before the birth.
Tracy Humphrey, a professor of midwifery, told a fatal accident inquiry that it would have been "reasonable" to send Rozelle Bosch for an ultrasound following a 37-week antenatal appointment which identified that her daughter's head was not "engaged" - or fixed - in the pelvis ready for delivery.
Mirabelle Bosch was 12 hours old when she died at Wishaw General hospital on July 2 2021 after life support was withdrawn.
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The inquiry has heard that she was an undiagnosed breech baby whose head became trapped throughout labour, resulting in oxygen deprivation and severe brain damage.
Mrs Bosch, who emigrated to Scotland from South Africa in 2015, had attended a routine antenatal check-up at full-term - 37 weeks - where the midwife carried out an abdominal examination and concluded that the head was not engaged.
Prof Humphrey, a former consultant midwife in NHS Grampian who now teaches in Australia, said it was "very unusual" for the baby's head not to be engaged at 37 weeks in a first-time pregnancy.
She said this should have signalled potential problems to the midwife, including the possibility that the head was too large for the birth canal or that the baby was in the breech position - pointing bottom or feet-first, instead of head-first.
Prof Humphrey said: "That would be alerting me to be curious and I would take action to try to find an explanation.
"Only if I had reassured myself that there was not a concerning reason for this would I be satisfied for that person just to progress to spontaneous vaginal delivery."
She added: "All midwives should know this is uncommon and take some kind of action in relation to investigating."
Prof Humphrey said it would have been "reasonable" at that point to refer Mrs Bosch for a precautionary ultrasound given that another scan, at 31 weeks, suggested the baby was in the breech position.
Subsequent abdominal examinations by midwives at 34 and 37 weeks had concluded that the baby had moved back into the cephalic - head-first - position, but Prof Humphrey said it is very likely they were mistaken given that Mirabelle was ultimately delivered breech at 38 weeks.
She said: "I really don't think the baby moved from being a breech position. If she had turned the likelihood is she would have engaged in the pelvis...my opinion is that the baby stayed in breech position."
Had this been detected, Mirabelle could have been manually repositioned or Mrs Bosch booked for an elective caesarean.
On June 30 2021 - at 38 weeks - Mrs Bosch attended maternity triage at Wishaw General after her waters broke but contractions had not yet started.
She was seen by midwife, Michelle Tannahill, who has told the inquiry that there were "no red flags".
Following an abdominal examination, Ms Tannahill concluded that the baby was engaged and in the cephalic position, and discharged Mrs Bosch home with an appointment to return for an induction at 9am on July 2 - or earlier if she went into active labour.
Prof Tannahill told the inquiry that - based on the case notes - she did not agree with Ms Tannahill's assessment that the baby's head was engaged.
Asked whether it was possible that Mirabelle genuinely had been in a cephalic position but moved in the 24 hours prior to delivery, Prof Humphrey said: "In theory, yes...but have I ever seen that happen? No. It is very unlikely."
Mrs Bosch developed complications when she went into labour at her home in Shotts on July 1 2021.
Paramedics attended but were unable to fully deliver Mirabelle, and Mrs Bosch was eventually transferred by ambulance to hospital.
Prof Humphrey said that an estimated 2-3% of babies are breech at term and it has been "normal practice" for the past 20 years to deliver them by elective caesarean due to international evidence that this is safer.
In her own career she said she had been involved in just 20-30 vaginal breech births which were either planned or unplanned out of thousands of deliveries.
She added: "I suspect that nowadays some midwives might go their whole career and not attend a vaginal breech birth at term, even unplanned."
The inquiry, at Glasgow Sheriff Court, will also examine the deaths of two other newborns in Lanarkshire in 2019 - Ellie McCormick and Leo Lamont - whose deaths the Crown Office said gave rise to "serious public concern".
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