Mother Charmaine Charlton died at the Royal Gwent Hospital
A mother died shortly after her second child was born following undetected complications from an emergency Caesarean, a coroner has found.
Charmaine Charlton died at the Royal Gwent Hospital in Newport in July 2006.
John Charlton said his wife, 36, from Newport, had wanted a planned Caesarean because of a previous difficult labour.
Recording a narrative verdict, David Bowen said there was not enough emphasis on accurate record keeping. The hospital has admitted shortcomings.
Mr Bowen said there had had been discrepancies in the times of observations and confusion about the amount of blood lost and the amount given as well as a "lack of clarity" in post-operative management.
He told the court: "Charmaine Charlton died as a result of complications which had initially gone undetected following a necessary life-saving surgical procedure.
"I have noted and heard evidence from the hospital trust. As a consequence of their own investigation it has instituted an action plan to build upon lessons learned from Mrs Charlton's tragic death.
"Had they not already done so, I would have required them to do so."
The inquest at Newport Coroner's Court had heard that it became clear Mrs Charlton needed a Caesarean after being in labour all day on 4 July, 2006.
Mr Charlton said: "The baby's heart rate dropped. It was the same as before, I knew this was going to happen.
"It was pointless trying to have a normal birth."
The coroner asked Mr Charlton: "You thought a Caesarean was inevitable all along?"
He replied: "Yes, but the medical expert said it was going to be ok."
Their daughter Ava Grace was born at 1930 BST.
Mr Charlton said his wife told him she had a pain in her chest and she was later taken to a recovery room.
Shortly after, the couple were joined by Mr Charlton's sister Fiona, a midwife at the Royal Gwent Hospital, and Mrs Charlton was taken to the special care baby unit to see Ava Grace, who was in an incubator.
The visit took around 20 minutes and then they returned to a post-operative ward.
Mr Charlton said he was reassured by Dr Makiya Ashraf who told him that everything was fine.
He said she mentioned something about the uterus but said she would speak about it in the morning.
Mr Charlton said he left the hospital at 2200 BST, believing everything was normal.
He called friends and family about the birth and went to bed midnight but at 0100 BST he was woken by his mother telling him the hospital had phoned.
He said that when he arrived back at the hospital his wife was sitting up in bed but had complained about the pain in her chest.
She was taken into surgery and was expected to be out within 20 minutes.
Mr Charlton said: "The next thing I saw was people running past with different bags of liquids. It was horrific for me.
"At one stage I was on my hands and knees praying."
Mr Charlton said he was then informed his wife had died.
"You have a baby, six hours later you kiss your wife and she's dead," he told the inquest.