According to the report by coroner Catherine Rudel Tessier, the baby's mother went into labour around 2:30 a.m. on June 21, 2011, while at the Lac Saint-Louis birthing centre in Pointe-Claire.
At 6:23 a.m,. the mother was told she might have to be transported to hospital if the baby's heart rate continued to decelerate, though an ambulance was not called until 9:14 a.m.
First responders from the fire department arrived within 10 minutes but were not allowed access to the mother and baby because of an agreement between the birthing centre and Urgences-santé — Montreal's emergency medical service.
Urgences-santé arrived, but the report said those responders were also denied access to the baby, and the midwives refused their suggestion to transport the girl to Lakeshore General Hospital.
At around 10 a.m., another Urgences-santé team arrived with a doctor, who was allowed access to the baby.
The doctor intubated the baby; however, the girl died a few minutes later.
The coroner's report concludes the death was caused by suffocation after a long and difficult labour.
It also states the midwives did not seem to have reacted quickly enough to signs the baby was lacking oxygen.
All the coroner's recommendations are directed at Quebec's Order of Midwives. They include better training to recognize unusually difficult labour, better CPR training, more practice intubating newborns and better monitoring of mothers' and babies' vital signs during labour.
Emmanuelle Hébert, professor of midwifery at the University of Quebec in Trois-Rivières, said that although she agrees with the coroner's report, most of the recommendations are already part of the curriculum.
"It's similar to what doctors learn about babies and health during pregnancy and birth," Hébert told Bernard St-Laurent on CBC's Radio Noon.
Quebec's Order of Midwives was unavailable for comment.