The woman kept labouring with little progress when the duty midwife was called for a second option.
The duty midwife said she spoke with the woman about transferring to hospital to have a an obstetric appointment, but the conversation was not documented.
But neither the woman nor her partner could recall at any point being told by either midwife about their concerns about the labour not progressing.
The woman's partner said they were under the impression that there was no need to go to the hospital.
When the woman had been in labour for well over 12 hours and had still made little progress, she was eventually transferred to hospital and seen by the obstetric team.
Her baby was delivered via C-section and when she suffered a post-partum haemorrhage and did not stop bleeding, a "life-saving hysterectomy" was performed.
In her findings, Wall criticised the midwife for not recommending an obstetric consultation to the woman due to her slow progress in labour.
Wall found the midwife in breach of the guidelines and said the woman would not have been able to make an informed decision without being presented with all the information.
Wall also criticised the midwife for not recommending the woman see an obstetrician when her blood pressure was found to be high during pregnancy.
The midwife was ordered to apologise to the woman and was recommended to undertake a Special Midwifery Standards Review, and undergo training on the referral guidelines and documentation. Wall also recommended the Midwifery Council review the midwife's competency.