"I was taken back up to the delivery suite to try for a "natural birth”… I still really struggle to understand why this risk was taken"

A mother's experience of Oxford University Hospitals Maternity Services in 2018:

This was a complaint email I had drafted but had never sent as I had exceeded the 3 years but it details my experience:

I would like to raise a complaint about the care I receive in October 2018.

Unfortunately, I suffered with post-natal Anxiety and PTSD for which I underwent counselling. I then fell pregnant with my second son and did not want to re-live the trauma whilst pregnant and suffer any further pre/post-natal mental health problems. I now feel in a much stronger place mentally to raise and discuss the care I received so I am hoping that it will still be possible for me to raise a formal complaint as it will hopefully mean the care is reviewed and this can only benefit other mothers, babies and staff.

At the very beginning, I had a particularly bad experience with MAU. I lost my mucus plug early on the 4th October, I started contracting and was passing blood and large clots. We called MAU who advised us to go in. I waited for 4 hours to be seen, the Doctor had to remove a very large blood clot just to see my cervix, but I was told the blood was due to my cervix being vascular and no further tests were done, I was told to come back when I was having contractions 3 times in 10 minutes. I did not feel happy with this, but I was told I would be putting my baby at risk of infection/illness by staying on the pre-natal ward so the best place for me was at home as nothing was untoward. I believe we should have been given further information around signs of complications e.g. water leaking, infections to look out for - we weren't and that I should have been tested to see if my waters were leaking. I also should have been monitored more closely for this point.

After 2 days of ongoing bleeding and my contractions stepping up a gear at 11pm on the 5th October (but still not 3 in 10 minutes so MAU did not want to see me), I visited Wallingford Maternity Centre on the 6th October. They had a look at the blood I was passing and called ahead to the JR to advise we would be coming in and needed to be seen urgently as I was passing fresh blood, clear fluids and large clots and that an Amnisure test needed to be completed – but it seems my symptoms did not warrant the £18 test.

On this second visit to MAU, no one came to see us in the room for 4 hours except to set up and remove the CTG monitoring. I still had not seen a doctor and an Amnisure test still hadn't been completed. Upon finally seeing a doctor, an Amnisure test was completed which I believe confirmed my waters had been leaking. However, the MAU team used a time of 11pm on the 5th October as to when my waters had started leaking, although I was clear to them that this was when my contractions stepped up a gear and I had no idea when my waters started leaking, it could have been when I lost my plug which was on the 4th AM. If they had tested for this on our first visit as this would have slimmed down the timeframe and I could have been monitored appropriately, should they have been leaking.

A canula was put in my arm and we weren't told why we were going to the prenatal ward, we were completely ignored by the 3 people on the desk when we arrived on the ward. No midwife/nurse came to see us/ talk us through why we were there etc – when one did come to see us, she just commented on me being tearful and that she would be back soon (we didn't see her again). My back waters then broke, we had to get to reception to try and find someone to help as my waters were full of meconium.

I had an awful labour which stalled at about 4cm, which was terrifying as I knew my baby was in foetal distress and his heart rate kept dropping, he was back-to-back, his head was stuck, I was losing a lot of blood and it then became apparent I had the on-set of maternal sepsis. I felt like we were continually advised not to have the epidural and it took so unbelievably long to get one. I understand why they are not ideal in a normal birth, but this was not a normal birth. When I finally had the epidural, I went from 4cm to 8cm very quickly but my baby was in distress and his heart rate was dropping too much and too regularly.

All of a sudden, the room filled with people (doctors etc) and I was told the baby was struggling and there was not enough time to give me the local anaesthetic so I needed a general and I was rushed down to theatre. When we arrived, my baby's heart rate had recovered slightly, so I was then taken back up to the delivery suite - despite begging for them to just do the operation so my baby would be safe. But I was taken back up to the delivery suite to try for a "natural birth". We then spent some more time in the delivery suite before being taken down a second time for the c-section.

I still really struggle to understand why this risk was taken, it was quite obvious we were both unwell and the birth needed to happen as quickly as possible.

After being stitched up in theatre, I was then taken to the observation ward, into a room on my own and then my baby had to be taken to SCBU by my husband, they were gone for nearly 2 hours - this time is so critical for mother and baby, why wasn't I allowed to go with him? I lay in bed absolutely terrified that he wouldn't come back. It definitely did not help with the relaxing and endorphins to help the foundations of positive mental health and post-natal period and breastfeeding. We had no help with establishing breastfeeding and we were just left alone in the room, my son had low blood sugar levels and I was really struggling to get him to latch but there was no support. We did not stay on the ward very long as I was hurried along to have a shower so they could discharge me, I was very unwell and I could barely stand.

I also believe I should have been offered a blood transfusion or at the very least an iron transfusion. Also, the blood loss recorded did not take into account the blood I had been losing prior to the delivery - which was a lot and I was already anaemic. I was not offered either, even though one doctor had told me this would be discussed once I was moved.

Post-natally, the general care was, at times, awful, I had just had major surgery, I had an infection and the onset of sepsis, no sleep for over 80 hours, quite an amount of blood loss - when I was already Anaemic plus a newborn baby. I did not feel safe and I did not feel my baby was safe. I was unable to get to my baby easily, it took me around 5 minutes each time - getting out of bed was excruciating enough without the fact that each time I shuffled on the bed, I pulled at the catheter. 

Many times I just sat on the edge of the bed, in agony, falling asleep over the cot as it was too painful to get back into bed again and knowing I would just need to go through the pain to get out again. There was no help/advice as to the best way to get in and out of bed or to pick my baby up and when I should call for help. I was told twice when asking for help to get to the baby that the needs of the baby were more important than my own and I just needed to "get on with it". 

Bells regularly took in excess of 5 minutes to be answered, nurses would then come and say they’ll be back – not to be seen again. We were left waiting 20 hours for results from by son's blood tests/potentially missed critical antibiotics or left with a cannula in hand for 20 hours when not needed. Having had a traumatic birth/c-section, barely able to stand up, needing to carry a catheter around with me, I was left to set an alarm for 4am to push a heavy and cumbersome cot, which was carrying my day old son, down to SCBU for his antibiotics, I was offered no help and one nurse just stood and watched me struggling to get the cot through the door. When another patient finally offered me help and to walk me to SCBU the nurse said “she does not work here” – no she didn’t, she was just being kind and offering me assistance as she could see me struggling!

My c-section wound was not checked at all, it was only when I asked if my dressing should be changed before we went home, that a nurse looked at it, only then did they realise it had opened up and was bleeding. At one point my catheter leaked all over the floor because it had not been changed. Bedpans of bloody urine were left in the toilet for hours on end – I am not sure if mine were ever even checked as I don't know how anyone would know it was mine!

The support for feeding was so very, very poor in the postnatal ward, I strongly feel my sons' weight loss as a newborn, issues with weight gain and his ongoing issues with feeding are down to the issues which stemmed from the abysmal care on this ward in my baby’s first hours/days. Considering my baby was being treated from suspected Sepsis – I don’t think any risks should have been taken with regards to him receiving inadequate feeds, especially when his blood sugar was low and he was needing to have gels to help bring his sugar levels up. No allowances were made for the fact I had a lot of blood loss, I was anaemic, had an infection/was on antibiotics and had a c-section which would affect my supply and that my baby also had issues latching. 

Each nurse told us something different to the last and there was no consistency in the information provided, sometimes no information was provided – my boob grabbed, shaped and shoved in my wailing baby’s mouth. We were left for hours waiting for someone to help me feed the baby as I could not express the little colostrum I could produce. I was not made aware that donor milk or a pump was available until the point I was 2 days in and in tears through worry about the amount of milk my baby was getting because every time he went for a blood sugar analysis I was told I needed to feed him more and I wasn't doing enough. Formula was never put forward as an option - I didn't even know it was available. I was left waiting hours for donor milk and then I was then shouted by nurses for not feeding the baby every 3 hours, despite ringing for help an hour leading up to the next feed.

On the 3rd day SCBU said my son’s blood sugar levels were stabilising, but then there were no follow ups on this. The ward was busy, so it was decided I would move to oral antibiotics and we would go home earlier than expected but on getting home my son was so sleepy and hard to feed due to supply and latching, but breast feeding was still pushed on me, despite his weight loss and despite me asking continuously for a referral to the infant feeding team. I was only offered domperidone to try and increase my milk production?!

We did attend Birth Afterthoughts. This was sold to us as a counselling service, but it seemed to be a defend and deflect session. I do not feel this helped us deal with/process our experience, in fact we left feeling more negatively.

When we arrived, we were informed that this was not an opportunity to discuss the experience or to provide feedback for improvements – this was for the medical facts and timelines. We were encouraged to deal with the experience by being more politically active and by writing to our MP about staffing levels. There was no explanation for the very poor experience in MAU and the Post Natal ward outside of staffing levels.

The whole experience left my mental health in a very poor state, both myself and my son could have quite easily had very different outcomes, whilst I am so extremely thankful this was not the case, it took many months for me to work through this and the aftereffects of the experience, with professional help. It took a big toll on my husband too who was involved I the whole thing from start to finish and who has supported me and our son.

For a while, we did not think we could go through the experience again, but we managed to work through it and fell pregnant again, I was extremely apprehensive throughout my pregnancy and unfortunately, when I had my second son (planned c-section), the experience on the post-natal word was very similar. But this time, I was not poorly, my son was well and we did not have a traumatic birth, plus I knew more from my first experience so I was in a much better place to deal with the negative experiences, which is why I thought it would still be a good idea to put this complaint in as I also hope this information can in some way go towards making improvements - which can only help mothers and babies not have this very special, important and very vulnerable time tarnished due to feeling neglected by the people that should be caring for them and all alone in a life changing journey.