"a plastic cap at the end of the syringe was squirted into the mouth of [son’s name]. He swallowed the cap"

A mother's and father's experience of Oxford University Hospitals Maternity Services in 2023:

Unfortunately, we struggled to conceive a baby naturally and between 2019 and 2021, I was an outpatient of the Women’s Centre, despite ongoing treatment and assessment at the centre, we were not able to conceive and were eventually referred for IVF treatment at TFP Oxford – as an NHS-funded couple by the Trust – in early-2022. I am pleased to say this referral eventually led to us falling pregnant in September last year, to which we will always be extremely grateful to all involved, including the Trust.  

As the pregnancy advanced, we used the services of the Maternity Assessment Unit (MAU) at the Women’s Centre regularly. This was often due to non-movements and – at this point – we are keen to reiterate that the service and compassion we received on each occasion was second-to-none. We constantly and consistently felt reassured by the MAU staff during a number of stressful moments.  

This was the same excellent care and service we received when we first arrived at MAU after my waters broke at 4am on 21 May. Upon arrival, it was clearly explained to us that we could either head home and wait for labour to naturally begin, or head to Level 6 of the centre to be induced and hopefully speed-up the labour process.  

Unfortunately, following our decision to move forward with an induction, our birth experience was a difficult one to comprehend with little of our proposed birth plan followed.  

On several occasions, we are saddened to say that a number of extremely stressful situations were created for us as a couple, and for my mother too, who accompanied us for the entire birth.  

The induction received during the late-morning of 21 May was not successful in hastening labour and it took a further ‘stretch and sweep’ procedure (also on Level 6) at around 4pm on the same day, before the remaining waters broke and initial labour pains began. Following this, I have summarised our continued experience;  

Level 6 (21 May, 4pm to midnight):  

• Following the induction, we remained on Level 6 for several hours and as labour moved from its early stages and progressed to higher levels of dilation, there appeared to be little urgency in providing adequate pain relief, despite being in clear, significant pain.

• Quite often during this period, assessments of my levels of pain needed to be prompted by Husband and Mum, including having to regularly visit the department’s reception, versus staff being able to find the time to check the latest status unprompted. Paracetamol was the only pain relief provided, despite it clearly not being enough, backed by a tens machine we had brought from home.

• In addition – we do not believe my cervix was checked following the initial ‘stretch and sweep’. We feel this situation could have been managed much more effectively and perhaps, if it was checked, this could have led to the later difficulties encountered (listed below) not occurring.

The Spires (22 May, midnight to 4am):  

 • We were transferred from Level 6 to The Spires shortly before midnight, at which point labour pains were extremely intense.

• Though much care and compassion was given by The Spires team upon our admittance to our private room, it was clear that because the pain relief was not fully-addressed on Level 6, the option of gas and air and entering a birth pool did little to support pain management.

• This situation eventually led to a diamorphine injection being administered, which provided some respite to the situation, though at this point, there was little – if any – advancement in the birth itself.   Delivery Suite, room two (4am to 5pm):  

• Given the severe labour pain endured – as well as the need for a quicker delivery, due to the risk of infection (this was now 24 hours after my waters broke) – an epidural was administered.

• Thereafter, the labour pains eased and labour itself started to move at a steadier rate and by late-morning, I was in a position to ‘push’.

• As we got closer to delivery, it was advised that a forceps delivery would be required (due to the position of baby), as well as an associated episiotomy.

• Following this decision our son, [son’s name] was delivered successfully via forceps (around 2.14pm) – sadly, what followed were a number of difficulties that caused distress to us all.   

➢ I lost three litres of blood from the episiotomy wound (it would appear that a blood vessel was cut in the process), leading to two blood transfusions on the delivery table.

➢ Following his birth, the top of [son’s name]’s penis was clamped during the process of securing his umbilical cord. This left him with visible cuts and swollenness around the top of his penis, which was present for around two to three weeks, before appearing to heal.

➢ When being administered with pre-collected colostrum via a syringe that we had brought from home, a plastic cap at the end of the syringe was squirted into the mouth of [son’s name]. He swallowed the cap and despite being advised by hospital staff that it was extremely unlikely that he had indeed swallowed it, this was confirmed when he passed the cap – in its entirety – two days’ later.

➢ It should also be noted that the colostrum, which we had frozen at home and brought in, was originally lost – but later found – in the hospital following our transfer to The Spires.  

After we spent the evening of 22 May on the observational unit within the Delivery Suite, I was admitted to Level 5 of the centre on 23 May where I stayed for the following two nights, before being discharged on 25 May. During this time, my iron levels and recovery from the episiotomy surgery were monitored, as well as [son’s name] vital signs.  

I needed the loo three days following the birth and I did not want to leave [son’s name] so I bought him in his cot into the loo with me, as you well know that loo trip is not a pleasant experience as it is, [son’s name] was very upset at the time and I tried to console him by holding him whilst I was on the loo. I rang the emergency bell three times and no one came to see if I was ok. I eventually managed to struggle around to the nurses station when I explained what had happened for them to reply ‘well it’s not rang out here we would have heard it’ with no energy and strength left I just returned to my bed.  

Sadly – following our initial discharge from the Trust on 25 May, I was readmitted to Level 6 on 28 May. This was due to an infection within the episiotomy wound developing.  

Our experiences on this occasion included:

• Upon arrival on Level 6 (at around 5.30pm) we were frustrated by the general tone and attitude of staff fronting the department’s reception desk, given that I was clearly visibly traumatised and anxious by the latest situation. Staff were giggling amongst themselves upon our arrival, which did not appear to be professional nor empathetic given ours – and indeed – many other people’s delicate situation on the ward.

• We subsequently waited in our allocated wardroom on Level 6 for close to an hour and a half before being seen to by staff, after we initially handed-in our discharge notes to the reception team.

• The first midwife to enter our room did not correctly identify me. For several moments, she referred to an incorrect patient’s notes and described treatment for a completely different patient – no checks were conducted as to my identity upon entering the room. This caused further stress and anxiety.

• A second member of the ward team then entered our room and was unaware as to the medication that needed to be administered, advancing to a point where the incorrect medication was going to administered, before being challenged by us. Again, this added to our anxiety.

• Following this – when we raised our concerns with the senior nurse on shift that afternoon – there appeared to be more concern as to the feelings of the staff team (not that we dismiss this as not being important), as opposed to addressing the nervousness and anxiety that we felt.

• On our second stay in hospital I needed the loo again, as I went to the loo there was a lot of blood which was on the floor and over the loo seat - I went back to my room where my Mother was with Isaac, sobbing as I was really scared at the amount of blood there was following the blood loss earlier in the week. My Mum rang the bell which did not work, so went to the nurses station where they were laughing and messing around. My Mum explained what had happened and they said to her that it’s completely normal. My Mum insisted that they come and check me over. When the midwife came into the room, she was extremely curt and asked me to lay back on the bed, I went to get on the bed and lay down and she told me not too and just to sit against and lay back - this was not very comfortable at all. The midwife examined my tummy and said it’s normal. There was no empathy at all and it felt as though I was an inconvenience.  

Thankfully, the nightshift team operating on Level 6 that evening showed great compassion, as did the team who performed a re-suturing of the episiotomy the following day on 26 May.  

Those working within the observational unit in the Delivery Suite that afternoon were also particularly compassionate and knowledgeable to our situation and made our time on ward – prior to a discharge on 27 May – a much more settled time.  

We are also pleased to say that our subsequent appointments with consultants from the Women’s Centre – particularly those overseeing post-episiotomy care – has also been of a high standard, to which we are incredibly grateful.  

We are though disappointed that, given our series of traumatic events (which was regularly acknowledged by many of the Trust’s staff), that no real additional counselling has been offered to us by Trust. We feel as though this would have benefited us all. Indeed, there has been a lack of outreach from the hospital to check upon our mental health status – away from our follow up appointments – which we feel was merited given our difficult situation.  

We had been referred to Birth Reflections, but a major backlog of appointments meant we were unlikely to access this service until the autumn – around four to five months after [son’s name]’s birth.  

Upon reflection, we also feel as though we really had to push hard to receive reassurances on whether or not the swallowed cap might have caused damage to Isaac. Though he received an MRI scan immediately following the incident, as well as being contacted directly by a senior consultant from the high dependency unit, we do feel as though a more detailed examination of [son’s name] for reassurance – given that we are new parents in particular – could have been forthcoming.

I have not felt as though I have PTSD and therefore have not been to the Doctor for this, thankfully not had any serious side effects following the awful experience. However I think about our experience daily and I can’t help feel envious of other families who have had straight forward births.

I have had a number of visits to the hospital since and on every visit, I have been extremely anxious and upset. Particularly when I had to go back the second time to get resutured. I had no faith in the hospital or staff whatsoever and I was petrified of losing so much blood again. I had two more infections following this which were extremely debilitating as they caused considerable pain, which meant I struggled to look after Isaac – this left me feeling very helpless and emotional.   

I have not felt myself since giving birth - whether this is normal 9 months on I am unsure - I find myself thinking about the blood loss/transfusion. I have many questions and wonder if this is why I do not feel ‘normal’ or is it all psychological and perhaps there is a little bit of PTSD now starting to show as we are out of the newborn bubble!   

I absolutely understand that from a physical point of view, the surgery and trauma caused during the birth would ultimately mean that my recovery period was always going to be a long and extended one – however, our overall experience has meant that the initial stages of parenting with our first child was an extremely difficult one and not what we had anticipated.