Health and Disability Commissioner Ron Paterson has recommended three midwives apologise for a botched delivery in which a baby girl sustained brain damage and the mother lost up to two litres of blood.
The commissioner's decision released today related to an incident in a rural area during September 2005 and the names of those involved were withheld.
During labour a midwife, referred as Ms B, noticed the baby's heart rate was dropping - generally caused by pressure on the baby's head - and called for assistance
She was joined by two other midwives, Ms C and Ms D. They decided to call an ambulance in case they needed to rush the woman and her child from the maternity unit to hospital.
Ms B's records showed when the baby was born she was dark grey, floppy and gasping for air.
Ms B and Ms C began working on the baby, performing chest compressions and giving her oxygen via a mask and bag. Some colour returned to the child but her heart rate continued to fluctuate.
Twenty three minutes after the birth Ms C said she attempted to intubate but failed.
Her second attempt eight minutes later was deemed a success and the baby's heart rate stabilised.
A neonatal team from hospital was called and they arrived shortly after to transfer the baby to the intensive care unit.
However, the team noticed the baby was still struggling to get air into her lungs and there were sounds coming from her abdomen, indicating the tube had been placed in the oesophagus and not the trachea.
The baby spent two weeks in intensive care before being transferred to another area of the hospital.
She was found to have sustained a major brain injury and at five months had limited control of her limbs, suffered spasms, showed limited social awareness and was thought to be nearly blind.
While her baby was being treated the mother was also experiencing difficulties. She was unable to deliver the placenta and was losing blood.
The woman complained later that Ms D had been charged with looking after her but had not followed protocol in monitoring her condition and had left her unattended despite her condition.
"I delivered the placenta by myself - no medical staff were near me. I had to shout to announce the placenta was out."
She said her concerns that she felt a "gushing" of blood after the delivery were ignored.
The woman was taken to hospital where it was estimated she had lost 1.8 to 2 litres of blood. She was treated for tearing and had clots removed from her uterus and remained at the hospital for more than three weeks.
The commissioner found the care given to mother and child had been "deficient in several respects".
Ms B had been in charge of the procedure and had failed in both her assessment of the woman and resuscitation of the baby. Ms C failed to resuscitate the baby "with reasonable care and skill" and Ms D had not been sufficiently vigilant in her care of the woman.
Mr Paterson recommended all three apologise and Ms B review some of her practices and the manner in which she documented the birth.
Mr Paterson intended to discuss with the New Zealand College of Midwives whether those practising in a rural setting would benefit from additional resuscitation training.
In a meeting held at the hospital shortly after the birth the mother mentioned she would have been unlikely to complain if Ms B had "put her hand up in the beginning and taken responsibility".