The woman was due to give birth when the midwife detected anomalies while listening to the cardiotocography (CTG) monitoring, which uses ultrasound to register the baby's heart rate.
But the doctor thought the CTG was normal and wanted to wait, reports Swedish radio.
The midwife later called the doctor again when the baby's pulse dropped sharply. The doctor was then no longer able to hear a heart beat, so a caesarean section was carried out, but the baby could not be saved.
The Health and Social Care Inspectorate has now criticized the regional health board. It states that the emergency caesarean section was carried out too late and that the first CTG results were misinterpreted.
The inspectorate also writes that the birth should have been treated as a high-risk birth, because the woman had gone beyond her due date and the baby's growth curves had levelled off, and traces of meconium had been found in the amniotic fluid.
Midwives tend to be in charge of delivery care in Sweden and doctors are usually only called in if there are complications. Neonatal mortality remains among the lowest in Europe, at 1.7 deaths within the first 27 days and 3.7 stillbirths per 1000 newborns in 2015.
However, Swedish natal care has recently been in focus following reports of lack of beds at hospitals.
Last year year a baby died when a heavily pregnant woman was turned away from an overcrowded hospital in the south of the country, and another baby died after six failed attempts at vaginal birth before an emergency caesarean section was carried out.