" I apparently lost 1.25L of blood. I was not offered any blood products to aid my recovery"

A mother's experience of Oxford University Hospitals Maternity Services in 2022:

I have a complaint/concerns about the community midwifery team in Wantage and about the staff on the maternity unit at the John Radcliffe in Oxford. I was pregnant with my son, now 3 years old, in summer of 2022.

I was scheduled in for induction at the JR on the 4th July but was admitted before this date at my own insistence after becoming concerned about the level of pain, spacing of contractions, lack of progress, lack of medical support that was experiencing were all causing concern and distress, which was reiterated by my partners mum (retired midwife of 20+ years), and also the attitude of some members of staff, particularly the midwife that I saw when I was experiencing my contractions at home, a nurse/midwife I spoke to when I went to the JR and the midwife I saw in the community after coming home.

Timeline of events:

·      20th June - expected due date based on scans

·      24th June - went to see the community midwife at Newbury Street Practice. I was offered and accepted a cervical sweep, which was uncomfortable - when the midwife was performing the sweep my body was being moved around as she tried to reach the area. Afterwards I experienced pain and bleeding. She said the bleeding was a good sign as I would likely go into labour soon after. I had seen this midwife before and she was very cavalier and cocky, a previous time she had been training a student midwife and was boasting about how she predicted the results of the baby’s heart rate without having to calculate it.

·      Between the 24th and 29th I experienced contractions that became increasingly frequent and severe to the point that they were making me gasp for breath. During this period, I barely slept due to the pain I was experiencing.

·      On the 29th (maybe also on the 28th, I can’t remember at this point and don’t have call logs beyond 2023) I called the JR and raised my concerns and reported that I was having contractions every 4 minutes to which I was told that as a first time mum they wouldn’t admit me until I was having contractions every 3 minutes. I had originally wanted a home birth so the labour was less stressful. But my due date had passed and at this time the midwives I had been seeing were unavailable.

·   29th June - I called the community midwife as was sent the midwife on call. I explained how far apart my contractions were and how much agonising pain I was in but she seemed disinterested and unconcerned. I asked her if she could examine me to see how dilated I was but she said she wouldn’t do that at this stage. She listened to the baby’s heart and took my blood pressure and left.

We had been updating my partners mum (retired midwife) and at this point she emphasised that she was concerned for me, the baby and didn’t like the lack of care and attention I was receiving. At this point my partners parent drove to us from Brighton and took us to the John Radcliffe. We have no family in the area and my partner doesn’t drive so didn’t have any other way of getting there.

When I got the JR after I was seen by a nurse/midwife and explained my concerns and symptoms she did a cervical examination. And then afterwards she said ‘what would you like me to tell you?’ Which felt like she was being dismissive and playing some kind of game with me. I am still furious and aghast at her lack of care and professionalism. She told me that I was one centimetre dilated and I should return home and take paracetamol. I couldn’t believe that’s all the progress I had made after all that time spent in such severe pain and having contractions as close together as I had been having, I was exhausted from a lack of sleep, the pain, and I couldn’t understand how much longer I could/was expected to go before I made any significant progress.

When the nurse left the room, my partner's mum returned and was disgusted and encourage me to insist I was admitted stating that they owe you a duty of care and she was concerned for how long I had been in labour for and not making any progress. I took her advice and was admitted in the early hours of the 30th June.

·      30th June - while I was at the JR I was put in a private room to the side (I can’t remember where) for about 18 hours. During that time I was seen my a medic (I don’t remember her position, she had pink scrubs on) she examined me a couple of times. I was told that there was a pocket of amniotic fluid trapped in front of my son which was preventing him from moving down the birth canal. I was given two doses of oramorph which did nothing for the pain I was experiencing (I’d love to know what paracetamol was supposed to do), I did manage to get some sleep. Towards the end of the day on the 30th I was moved to the maternity unit to be induced.

·      30thJune/1st July: I was given entonox which helped. The first midwife I had was lovely, she got me a sandwich and drink because I wouldn’t be able to eat after the epidural was administered. I was given an epidural (the anaesthetist didn’t seem very serious, my partner described him as being very showy and a bit like Dr Nick from the Simpsons, which doesn’t matter except later once I was in theatre we heard the theatre staff remark that the epidural had been placed very high up, I don’t know whether that was recorded in my notes or not).

I had my waters broken and was given oxytocin to induce labour.

A second midwife came to relieve the first one briefly who was called to a different patient. And she took the entonox away which was still helping despite having the epidural and she told me ‘you don’t need that now you’ve had the epidural’.

The first midwife returned and handed me over to a third midwife at the end of her shift. An obstetrician evaluated my progress, asking me to do something pushing, she returned and checked that I was pushing correctly and examined his position, said that she suspect he wasn’t in the best position, did an ultrasound to confirm her suspicions and he was front-to-back, she was concerned about this and the process on his health and mine and recommended I have a forceps delivery and an episiotomy.

I went to theatre. I was given anaesthesia via the epidural. Sometime after I noticed my face started to tingle off and on at random places. Initially I thought nothing of it, it felt like a tickle from a bit of dust, but then did mention it and had a foam wedge placed underneath me as I think the anaesthetic was progressing too far up my body, but I don’t know.

After my son was born my placenta torn part of my womb and I started to bleed. I apparently lost 1.25L of blood. I was not offered any blood products to aid my recovery as this was ‘borderline’. The medical staff massaged my lower abdomen to try and get the bleeding to stop, which it eventually did.

I was then transferred to a stretcher at which point I heard some of the staff attending say that the epidural was placed very high up. I don’t know if this was the reason that I felt the tickling sensations earlier.

My experiences post theatre were unremarkable. I would have like some kind of help considering my blood loss. Maybe not a blood product but I don’t know whether I could have had an iron infusion, or something similar to help with my recovery.

A few days after when I was visited at home by the midwife I raised the positioning of my epidural to her and she told me it’s just higher up because I’m tall. Which I believe is nonsense as it’s should be in proportion. I don’t know whether that was recorded. I’ve never seen any of my notes so I don’t know what the staff reported about any of my symptoms or complaints.

As I arrived in theatre under the lights I remember thinking ‘what’s going to happen if I die?’ And then mentally told myself that I couldn’t think about that now.

Recently, in the last year or so I was sent for an ultrasound after experiencing painful periods (I have always had painful periods, my concerns had been dismissed by GPs, I believe I have always been menhoraghic), this pain was different following labour and I have been diagnosed as having adenomyosis, which now finally explains my years of heavy, painful periods. I have also seen published account of a patient who had adenomyosis and suffered heavy bleeding after a tear in her womb which resulted in her eventually having a full hysterectomy to stop the bleeding.

With hindsight I shudder at how badly my experience could have gone as my circumstances/diagnoses were the same. The lack of care and acknowledgment of my concerns couple with this have put me off trying to have a second child, which I do want, for fear of being ignored and overlooked by the medical staff I will be under. I even considered that if I were to get pregnant that I would go and stay with my family back in Chesterfield until I went into labour so that I would receive a better standard of care.

At present I have undergone a similar problem as I now enter perimenopause, my concerns that I am experiencing this have been written off and ignored my the GPs at my practice since before I got pregnant, which is why I decided to try to have a baby.

I consider myself lucky. And I consider myself very lucky that my experiences didn’t turn out as badly as some of the other reports that I’ve heard about as part of this group complaint.

I feel immensely sad for those who had more traumatic experiences and worse outcomes than mine. Whilst my experiences have put me off having another child, their experiences ended in loss of life which is unacceptable and should be held to account.