Matthew and Madeline McConnell are sharing their harrowing story in the hope it leads to change, sparing others what they are going through.

Late on Good Friday Mrs McConnell, a midwife, went to Warrnambool Base Hospital in Victoria's south west, because she knew something was wrong and ended up needing an emergency C-section. But unlike city hospitals, anaesthetists were not on site 24 hours a day. That meant there was a 20-minute wait and during that time baby Wren lost critical blood supply.

"No-one should go through this grief," Ms McConnell said.

"She was a healthy baby. We should have a healthy, nearly month-old baby at home and we don't want anyone else to go through that.

"If that means pushing for services to change in regional Victoria, then hopefully we can get something out of it, so it doesn't happen to anyone else."

They are calling for 24-hour theatre capability, and an on-site 24-hour anaesthetist presence at the hospital.

Mrs McConnell said she had a smooth pregnancy but was in some pain and had reduced movement when she went to hospital. After being induced she suffered a cord prolapse, which is an obstetric emergency.

"Once the cord goes down, you lose blood supply from the placenta to the baby," Mrs McConnell said.

"She sustained quite significant brain damage from the lack of blood flow."

They were taken to Melbourne and after many tests they got the news it was "catastrophic." The following Saturday Wren took her final breaths.

"It was a pretty horrendous ordeal, especially being a midwife I've seen cord prolapses but this is the worst outcome I've ever seen," Mrs McConnell said.

"But if you don't have the services, you can't get the baby out."

Mr McConnell said they wanted to share their story not to scare people but make others aware.

"If we don't speak, then other people might find themselves in the same position. It might be midnight on a Good Friday, and there might be no theatre and no anaesthetist and you've got to wait when you can't afford to wait.

"We don't think it's the hospital's fault, because you've got to have funding to provide those services. They did everything they could for Wren. That time that we had to wait is the time that our little girl needed. It's hard for us to know that there's a 'what if'."

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They thanked the hospital staff who fought tirelessly to save Wren - many of whom were their friends and colleagues.

"The hospital services such a large region and to have an anaesthetist present, it could save a lot of people's lives," Mrs McConnell said.

"Healthcare's not nine to five, and birth especially is not nine to five. Especially now Portland's shut, Terang is shut, Camperdown only does low risk births, and a lot of Hamilton people come to us as well. Warrnambool is the hub."

They are now left wondering if their daughter was born in Melbourne, would she still be alive today?

"She didn't get to have the life that she deserved," Mrs McConnell said.

"She should be a well child and to have her life taken just because we don't have the services... it's pretty hard.

"When you move to regional Victoria you know you don't have access to some things but you just don't, even as a midwife, I would never have expected this to be our story."

It's even harder to explain to their two-year-old daughter Edie, who was excited to be a big sister.

"She misses her baby sister, she doesn't fully understand and doesn't quite understand why we're sad all the time," Mrs McConnell said.

"She says goodnight to the stars each night. She knows her baby sister is a star and she's in heaven."

Friends, family and loved ones across the community have painted their nails pink in honour of Wren.

The incident is being investigated, South West Healthcare chief executive Craig Fraser said.

"This has been a terrible and traumatic event for all involved and South West Healthcare expresses its sincere condolences to the McConnells on the loss of their beautiful baby girl, Wren," Mr Fraser said.

"South West Healthcare has declared this a sentinel event to Safer Care Victoria who we will work with to investigate her case, including the appointment of an independent clinician."

He said the family met with the executive medical team at the hospital.

"A full review will take place."

Liberal member for South West Coast Roma Britnell urged the state government to fast-track the Warrnambool hospital's redevelopment.

"This is one of the most heartbreaking stories I've heard," Ms Britnell said. "It shows a glaring gap remains between the level of healthcare available in rural and regional Victoria compared to Melbourne."

Ms Britnell said while there had never been 24-hour theatres at the hospital, the McConnells' tragedy showed the need to expedite upgrades.

"The redevelopment at South West Healthcare needs to be prioritised to ensure this type of tragedy never happens again," she said.

Ms Britnell said there was confusion about when the hospital redevelopment was scheduled to be finished, with government officials seemingly at odds with South West Healthcare's assertion in its annual report that it would be delayed by a year.

"The government is saying the redevelopment will be completed on time in 2026, however the annual report says it won't be delivered until 2027 because of delays caused by COVID - so we really need some clarity and certainty around that," she said.

The state government was contacted by The Standard for comment.