A mother giving birth screamed "get the baby out" to hospital staff but by the time an emergency caesarean section was performed the little boy was lifeless.
When Melanie Hughes woke up from surgery she was told baby Hohepa Hemara Walters-Hughes had been resuscitated but his prognosis was grim.
She and the baby's father, Martin Walters, made the heartbreaking decision to turn off life support, and the infant died in their arms coughing as he struggled for breath.
Now, a critical review of the case has raised concerns over a string of missed opportunities that led to the tragedy.
The serious adverse event review of the birth on April 5 has been kept under wraps by Waikato District Health Board but the baby's whānau released the 22-page document to the Herald.
The parents want answers over why their otherwise healthy newborn son died in what appeared to be preventable circumstances.
• Investigation launched into baby's death at Waikato Hospital
• 'Why did he die?': Doctors busy or absent when C-section needed at Waikato Hospital
• Premium - Lack of specialist after-hours cover in hospital birthing units spark safety fears for mums and babies
Hughes' uterus ruptured during the birth, expelling Hohepa and the placenta into her abdominal cavity, resulting in a lack of oxygen to the baby.
The review called it a "catastrophic unpredictable obstetric emergency, leading to immediate and severe foetal compromise".
And though it said none of the issues it identified would have "individually" prevented the rupture, they represented areas for improvement.
Mum went to doctor 16 times - but her baby still died
Hughes, 40 at the time, was scheduled to have an elective caesarean at 10am on April 5 but arrived at Waikato Hospital shortly after midnight, already in spontaneous labour.
A semi-urgent caesarean was booked but did not proceed immediately because the senior registrar was busy with other births.
The priority was then downgraded despite Hughes recording high blood pressure during a contraction.
A midwife noted that Hughes' previous delivery of twins via caesarean was only 17 months earlier, but there is no record of the information being passed on to other staff.
Short intervals between a previous birth by caesarean and another pregnancy are a known risk factor for uterine rupture.
The review found Hughes didn't have this explained to her following the birth of her twins in November 2017, and her midwife did not refer her for a consultation prior to 25 weeks' gestation as per Waikato DHB guidelines.
Hughes, whose due date was April 13, was only consulted by a senior medical officer at 37 weeks but she was not told about the short interval risks and it was not included in her "pregnancy risk factor" notes.
She had already requested an elective caesarean but no-one explained to her about the signs of labour or what action to take if she went into early labour.
Thirty minutes after arrival at the Woman's Assessment Unit Hughes was in extreme pain and wanted the baby's heart-rate monitor removed from her stomach, but the registrar was not told.
The registrar also mistakenly believed Hughes previously had one vaginal birth and one caesarean, making her think there was no suggestion Hughes could not have another vaginal birth.
Hughes' blood pressure was not checked again though she was assessed by an anaesthetist and readied for theatre.
At 1am the midwife manager rang the registrar for a second time, concerned the labour was progressing fast.
She then phoned the senior medical officer on call who had gone home earlier in the night.
The shift notes show the registrar did not think the senior doctor needed calling, but when the midwife called, the senior doctor declined to come in.
"At no time during the call did SMO1 hear that he was being requested to come in," the review stated.
Crucial minutes ticked by before Hughes complained of a sudden and abrupt change in pain from contractions to moving higher up, telling staff to "Get the baby out".
A Doppler found the baby's heart-rate had reduced to 67 beats per minute indicating he was in distress and a midwife rang the emergency bell.
The registrar told the review this was the first indication she had of complications with Hughes.
Hohepa was delivered at 1.22am, 57 minutes after his mother arrived at the hospital.
He was taken to the Neonatal Intensive Care Unit and put on a cooling mat, for babies with a brain injury, but died at 2.55am on April 7.
Hughes complained several times after his death to hospital staff, asking why she did not receive the caesarean sooner.
The review criticised communication, clinical practice and documentation during the event saying some DHB policies and processes were not followed and that communication should have been clearer to ensure the escalation of concerns was properly understood.
It recommended updating a triage tool, reviewing the DHB's elective caesarean section booklet, presenting the case to a midwifery emergency refresher day and maternity morbidity meeting, and developing a maternal early warning score tool.
• Model gives birth in the bathroom - she had no idea she was pregnant
• Oldest mum in the world gives birth to twins at 74
• Brain-dead woman gives birth to a baby girl after being on life support for three months
• Young mother-to-be Shelly Cockburn dies during birth of daughter leaving fiancé behind
Waikato DHB chief medical officer Dr Gary Hopgood said the DHB could not discuss the case publicly for privacy reasons.
"As previously advised, we have met with the family and will continue to work with them. We continue to extend our condolences to this family who lost their baby."
It's unclear whether the case has been referred to the Coroner.
Walters said the loss of Hohepa had ripped the whānau apart. He and Hughes, from Te Kūiti, had now separated.
He still felt in the dark about his son's death.
"It would be good to have better accountability."
Timeline of events that led to baby Hohepa's death
Friday, April 5, 12.25am
Melanie Hughes arrives at Waikato Hospital in labour with blood-stained waters. Triaged for medical review within 30 minutes.
Registrar misunderstands jargon and does not realise a vaginal birth may be more risky for Hughes and books a semi-urgent caesarean.
In severe pain, Hughes requests removal of baby heart-rate belt from stomach. No other continuous monitoring performed. Registrar not told.
Midwife manager calls registrar and on-call senior doctor with concerns. SMO declines to come in, later saying request was not clear.
Midwives cannot distinguish two heartbeats. SMO orders scan by phone but no-one can do it. He advises midwives to wait for busy registrar.
Hughes' blood pressure high. She experiences intense pain moving higher up.
Baby's heart rate low 67bpm. Emergency bell rang. Registrar called from other birth.
SMO called to come in, arrives at 1.25am.
Hughes rushed to delivery suite theatre. Baby heart rate dropped to 57bpm. Blood clots discovered.
1.22am [57 minutes from arrival]
Ruptured uterus discovered. Baby and placenta in abdominal cavity. Hohepa born. Hughes has lost 4 litres of blood. Almost needs hysterectomy.