As Casey Nathan was being rushed to hospital, she looked at her boyfriend, Hayden Tukiri, and said: "Babe, I'm gonna die."
Not long after, the 20-year-old - who had been bleeding profusely, having endured serious complications while giving birth to her son, Kymani - died.
Nearly two days later, little Kymani also passed away.
Yesterday, an inquest into the 2012 deaths of Casey Missy Turama Nathan and Kymani Nathan began in the Coroner's Court at Hamilton.
The court heard a statement from the Nathan family spokeswoman, Jenn Hooper of Action to Improve Maternity, who was later told by coroner Garry Evans that her testimony was not considered as evidence at the inquest.
Ms Hooper said the midwife's clinical note-taking was lacking and her monitoring of Ms Nathan and her unborn son was "patently inadequate". The most comprehensive set of recordings were made by an ambulance officer as Ms Nathan was being rushed to Waikato Hospital from Huntly Birthcare on May 21.
Ms Hooper accused the midwife, whose name is suppressed, of not correctly diagnosing or documenting Ms Nathan's fundal height (size of the uterus, used to assess fetal growth), which was well above the 90th percentile.
She said Ms Nathan's abnormally prolonged labour should have raised concerns yet the midwife did not seek a further opinion.
"It is the whanau's feeling that attention was not given where it was needed and instead it was noted that [the midwife] was sending multiple texts of a personal nature, particularly about her recent holiday."
Ms Hooper said the midwife failed to insert an effective intravenous access point, nor did she arrange for someone more skilled to do so. She also did not check the unborn baby's pulse for more than an hour on one occasion and for more than 50 minutes on others.
She said Ms Nathan, who had fainted while in labour, lost three times the normal expected amount of blood before she was transferred.
Mr Tukiri had noticed "lots of blood" after she gave birth, then puddles and clots of blood around her in the ambulance.
"During the ambulance transfer, Casey rallied consciousness enough to tell Hayden, 'Babe, I'm gonna die'," said Ms Hooper.
Ms Nathan died at Waikato Hospital in May 21, 2012, six hours after giving birth to Kymani at Huntly Birthcare Centre.
Dr Aidan O'Donnell said Ms Nathan's heart stopped at 3pm. His staff began immediate CPR and then used a defibrillator, which got her heart working again.
"But after that she was worse in almost every way ... Somewhere in her chest there was blood and it began surging up her endotracheal tube. There was this tide of blood coming forward.
"Once that blood came up it was impossible to get any oxygen into her," Dr O'Donnell said.
Kymani was born with breathing difficulties and was rushed to the newborn intensive care unit at Waikato Hospital but died on May 23.
Ms Hooper said the family were concerned why the little boy was given 85 times the amount of adrenalin required for a newborn.
He also received breastmilk that would have made breathing more difficult and could have left him with fluid on the lungs.
Waikato District Health Board neonatologist Claire West said Kymani died as a result of multiple organ failure due to severe neonatal encephalopathy.
He was born in a compromised condition and was resuscitated.
Dr West raised the question of whether Kymani's death could have been avoided.
"There is a significant mortality associated with severe neonatal encephalopathy even when maximal therapy is provided," she said.
Mr Evans said the inquest would consider other issues including the management of Ms Nathan's labour and the delivery of Kymani.
It will also consider the timeliness of an ambulance being called for Ms Nathan after she gave birth, her management by staff at Waikato Hospital and the experience and actions of the midwife who oversaw the delivery of Kymani.
The inquest, which was conducted yesterday before a packed public gallery, is set to run until Monday next week; 23 witnesses are expected to be called.
•20-year-old Casey Nathan died six hours after giving birth to son Kymani. He died two days later.
•A family spokeswoman told a coroner's hearing the midwife's monitoring of mother and child was "patently inadequate".
•The week-long hearing in front of coroner Garry Evans will examine evidence on the labour, delivery and the timeliness of an ambulance being called.