An independent midwife has been censured after mistaking a woman's progress during labour, which resulted in a baby's death.
The woman arrived at hospital after going into labour with her first child, under the midwife's care.
Her labour continued for several hours in hospital but the midwife mistook the vaginal wall for the baby's head.
After pushing for nearly two hours the mistake was recongised and the woman was only 6cm dilated.
After that, the midwife did not report signs that the baby was in distress to the obstetrician.
The Health and Disability Commissioner said the midwife was unsure who was responsible for managing the woman's labour in hospital.
The baby was delivered by caesarean section, but required resuscitation. It was admitted to intensive care, but died the next day.
The Commission was critical of the midwife's lack of clarity regarding her ongoing role and the handover to secondary care.
It was also critical of the pediatric registrar who administered the wrong dose of the drug midazolam to the baby and said this was also part of the substandard care the woman received.
It recommended the DHB develop guidelines about who was responsible once a woman was admitted to hospital to give birth.
The midwife also had to undertake work to meet the requirements of the Midwifery Council competence programme.
The DHB, midwife and pediatric registrar were asked to provide apology letters to the family.