Another baby has died after a series of mistakes partly blamed on midwife care.
Tyla Phillips survived for only 7 hours after she was born at Middlemore Hospital in an emergency caesarean operation last August.
A hospital specialist later told her parents, Heather and Alan Phillips, that if the operation had been performed three hours earlier she might have lived.
The specialist said midwives misread a fetal heart rate monitor.
The couple now want an inquiry into maternity and midwifery care because their case follows other newborn deaths with similar themes.
Middlemore is saying little publicly about Tyla's birth until the Accident Compensation Corporation has reported its decision to the hospital and Health and Disability Commissioner Ron Paterson has investigated.
The hospital says it may refer the case, which had devastated the staff involved, to the commissioner, or medical or midwifery bodies.
However, hospital documents and a tape recording the Phillips have of one of their meetings with senior clinicians catalogue the mistakes that led to Tyla's death on August 18 and a follow-up internal review.
A key failure was midwives' mis-reading of a fetal heart rate monitor, according to the obstetric consultant on call at the time, Dr Alec Ekeroma, on the tape.
He also indicated that the fetal blood-acidity test which led to the caesarean decision - done after an obstetric registrar reviewed the heart monitoring - was unnecessary in the circumstances and wasted time.
He said the 21-minute caesarean operation - Tyla was born at 5.53am - should have been done "probably two or three hours earlier". If it had been, this "may have changed the outcome".
Mrs Phillips was several days overdue when she went to the Middlemore-allied Botany Downs Maternity Unit, which was managing her pregnancy. The unit's midwives had her transferred to Middlemore at 11.45pm on August 17. Her waters had broken around 9pm, containing what her medical file says was "moderate meconium" (faeces from the baby). Staff noticed thick meconium when she arrived at the hospital.
The presence of meconium can indicate a distressed baby. Because of this, the Phillips expected a caesarean on arrival at Middlemore.
Mrs Phillips said she was not fully assessed by an obstetric doctor until about 5am.
Her medical file states a registrar was asked to see her after her arrival but was busy in theatre.
At 5.32am the decision was made to deliver Tyla by caesarean after the blood-acid test - which had consumed 20 minutes, after one attempt at the test failed - confirmed her distress.
A report on Tyla's post-mortem says her lungs had suffered "massive meconium inhalation" and extensive bleeding, and she had brain damage from oxygen deprivation.
A Middlemore document describes the events surrounding the birth and poor follow-up with the parents as a "multi-system failure".
A letter to ACC by clinical director of women's health Dr Keith Allenby lists 11 recommendations being considered to address some of the issues the case has highlighted.
These include clarifying what should be done in response to abnormalities revealed by fetal heart rate monitoring; regular training, for all pregnancy-care staff, in interpreting the monitoring results; and clarifying the chain of contact "if obstetric registrar busy (as new tier of doctors now in place)".
The Phillips have lost confidence in New Zealand's midwife-dominated maternity system.
"If I could do it again," said 33-year-old Mrs Phillips, who had difficulty conceiving Tyla, "I wouldn't go the midwife way. I would go to a doctor, a specialist."
Tyla's case follows criticism of health workers after reports on the deaths of three other babies - two by a coroner and one by Mr Paterson, the commissioner.
Following the criticisms arising from those cases, the College of Midwives said New Zealand's midwives, present at virtually all births and lead maternity carers for 78 per cent of pregnant women, provided one of the world's safest and most effective maternity systems.
Chief executive Karen Guilliland noted that 5 per cent of complaints to the commissioner regarding health workers were about midwives in the last June year and 6 per cent about obstetrician/gynaecologists.
'She held my finger'
During Tyla Phillips' emergency caesarean birth, her anxious father typed on his cellphone the words "Is she going to live" and showed the hospital anaesthetist.
When the anaesthetist shrugged his shoulders, Alan Phillips knew his baby daughter was in trouble.
Mr Phillips says his brown-haired girl - his wife Heather's first child and his third - was beautiful when born. But her appearance quickly deteriorated as she gasped at life following a traumatic labour last August.
"I really wanted this little girl and she really looked like her mum. She had the same eyebrows. She was cute.
"She held my finger. That's something I will never forget."
Seven and a half hours after her delivery, it was decided Tyla could not survive. Her life-support systems were removed. She died soon after.
Recalling Tyla's death, Mr Phillips - brow furrowed, fingers tip-to-tip and quietly crying - says he is still too upset to look at photos of her.
Mrs Phillips looks at them often, but keeps them in a box. Tyla's cot, her pram and the rest of her baby gear, which had been set up at the family's old home, are now stored out of sight in the garage of their new home at Awhitu.
But the Phillips' regularly visit her grave, in a church-yard just 80m away.
Recent controversies involving midwife care:
* February 2001: Saskia Marama Swagerman-Fugle of Wellington died in hospital six days after an undiagnosed breech birth at home.
* February 2003: Cameron Elliot of Paraparaumu died shortly after an undiagnosed breech birth at home.
* November 2003: A baby called Charlie died aged three days after emergency caesarean and mismanaged labour at North Shore Hospital.
* December 2005: After an inquest into the first two cases, Wellington coroner Garry Evans called for a review of maternity services and greater supervision of new midwives.