An independent midwife faces possible disciplinary action over a birth in which a woman was left screaming in pain during labour.
The case is detailed in findings released by Health and Disability Commissioner Anthony Hill on Tuesday.
The case involves the role of two unnamed midwives in the care they gave to a mother in 2010 who had suffered a tear during birth and was worried it would happen again.
Despite this, the woman's lead midwife failed to get a copy of the previous labour and birth notes and to consider referral to an obstetrician.
A back-up midwife managed the birth which was painful and ended in another major tear, but no harm to the baby.
That midwife suffers from sinus tachycardia which makes her heart beat rapidly and irregularly and leaves her feeling light-headed.
The stress of the event caused her to have an irregular heartbeat. She then left mother and baby alone with family members while she recovered.
Mr Hill says both midwives breached the patient rights code and the back-up midwife also faces possible action.