A midwife failed to pick up warning signs during a labour where the baby later died, an inquiry has found.
The unnamed self-employed midwife breached of the Code of Health and Disability Services Consumers' Rights by failing to monitor the baby's heart rate in the second stage of labour, Health and Disability Commissioner Anthony Hill says.
"[She] failed to provide services to the woman with reasonable care and skill".
The 20-year-old woman was pregnant with her first child when a 39-week ultrasound revealed "a significant deficiency in liquor surrounding the baby", and an induction was booked.
The midwife carried out cardiotocography (CTG) monitoring of the baby's heart rate during the labour and recorded it as "reassuring".
Mr Hill was critical that the midwife interpreted the CTG as being reassuring when it was not and didn't communicate effectively with a hospital midwife about a concern regarding the woman using the birthing pool during labour.
She also didn't monitor the baby's heart rate closely enough in the second stage of labour.
Despite transfer to intensive care, the baby died soon after birth.
The midwife said she was aware there was a reduction in the liquor, but not that it was serious.
However, she admitted she didn't check the baby's heart rate frequently enough during the second stage of labour.
Mr Hill recommended the midwife undertake further training on foetal monitoring and has referred her to the director of proceedings for possible disciplinary action.