A midwife failed to care for a woman in the last hours of her pregnancy, nearly resulting in the newborn baby dying, according to a report released by the Health & Disability Commissioner.
A woman, Mrs A, pregnant with her second baby, enlisted the services of a midwife, Ms C, in 2016.
They agreed the birth would take place at a small, local hospital, about two-and-and-half hours from the main centre hospital, but commissioner Anthony Hill says there was no written care/birth plan recorded and pain relief was not discussed.
At 38 weeks, Mrs A went into labour and met Ms C at the local hospital, but was sent home after contractions became less frequent.
Nearly three hours later Mrs A returned to the hospital and Ms C declared herself "quite happy with progress at that stage".
There was no heart rate of the baby recorded in the 30 minutes before the baby was born and following delivery of the baby's head, one of its shoulders got stuck, delaying delivery by another five minutes.
The baby was born at 4.87kg, "in very poor condition" and needed to be resuscitated, according to Mr Hill's findings.
The baby was transferred to the main centre hospital by helicopter for further treatment, while Mrs A suffered heavy bleeding afterwards.
Mr Hill said the decision not to consult a specialist during the first hospital visit - when contractions stopped and she went home - was a failing within the midwifery guidelines; Ms C failed to recognise the labour was not progressing normally; Mrs A was sent home without support and there was a lack of information given about the possibility of transferring to another hospital.
"These failings are very poor midwifery care," Mr Hill said.
Ms C was suspended and Mr Hill said a review should be undertaken should she apply to return to practice.