"My water broke at 32 weeks… At 34 weeks, I was finally induced as an emergency after my baby’s heart rate rose"

A mother’s experience of Oxford University Hospitals Maternity Services in 2025:

I am a 26-year-old mother and was under the care of John Radcliffe maternity services during my pregnancy and birth. I am autistic and have ADHD, which significantly affects how I process information, sensory input, and stress. These needs were documented, and I had a neurodivergence passport in place. I was also experiencing significant mental health difficulties during pregnancy. What I experienced was not a single failure, but a pattern of repeated, systemic issues that left me feeling unsafe, unheard, and traumatised at one of the most vulnerable times of my life.

Throughout my pregnancy, there was a complete lack of continuity of care. I was assigned more than four different community midwives, all of whom were described to me as “my midwife.” In reality, there was no single professional who knew my history, understood the complexity of my needs, or held overall responsibility for my care. Each change meant repeatedly explaining my medical history, my mental health difficulties, and my autism and ADHD.

Important information was lost between professionals, notes were not consistently read, and no one appeared to have a full picture of my situation. This was exhausting, destabilising, and particularly harmful given my neurodivergence and declining mental health. The absence of continuity of care directly contributed to the failures I experienced, including the missed diagnosis of severe iron deficiency, fragmented mental health support, and repeated dismissal of my concerns. Although continuity of care was implied, in practice it did not exist.

For over two months, I suffered from a missed diagnosis of severe iron deficiency despite extremely frequent contact with community midwives, the Maternity Assessment Unit (MAU), and hospital services. I was even admitted and underwent an MRI because clinicians suspected a brain tumour.

In reality, my ferritin level was 13, indicating severely depleted iron stores. This result was present in my blood tests and should have been identified far earlier, but it was repeatedly overlooked by multiple doctors and midwives. I only became aware of this when I attended Wantage Maternity Unit in a state of mental crisis, where a matron happened to be present. She sat with me, reviewed my blood results in detail, and identified the iron deficiency within minutes. She immediately started me on oral iron, but by this point the situation had already become severe. I began experiencing fainting episodes, extreme exhaustion, and was sleeping for up to 19 hours a day.

I returned to MAU, where a doctor told me that I was not iron deficient. I challenged this and asked whether he had checked my ferritin levels. He admitted that he had not. He then stated that my haemoglobin was “well above normal,” despite me having seen my own results days earlier and knowing this was incorrect. He intended to send me home. I never saw this doctor again. Within half an hour, I was admitted for an emergency iron transfusion.

It later became clear that he had been reviewing blood results from August, despite this being October. This failure was frightening and could have had extremely serious consequences. Mental health support throughout my pregnancy was profoundly inadequate. While the perinatal mental health consultant herself was compassionate and clearly trying to help, the wider system repeatedly failed to follow through. My autism and ADHD were documented, and I had a neurodivergence passport in place, yet reasonable adjustments were not made. Notes were frequently not read, departments did not communicate with each other, and there was no shared system across services. I was placed on a waiting list for mental health support in the form of CBT and told it would take six weeks.

By December, I was finally contacted, only to be told that they no longer had the capacity to provide the support I had been assessed as needing because it was too close to my due date and they wouldn’t have the time.  I had an overwhelming number of appointments across multiple services. Almost every day, every week. My partner and I spent hours repeating the same information to different professionals, reliving distressing experiences because no one had access to a unified record. This lack of coordination never improved, despite how clearly harmful it was. We both had contacted the perinatal team in writing explaining how distressing this was becoming and how it was making my mental health even worse. 

My water broke at 32 weeks. I was kept as an inpatient in false labour for eight days. During this time, my mental health deteriorated dramatically. I repeatedly begged staff to intervene and induce labour. I cried every day and explained clearly that I was not coping.  My concerns were repeatedly dismissed on the grounds that continuing the pregnancy was “best for the baby,” despite the significant toll this was taking on me and me explaining that I know it’s best for her but currently I am experiencing hours of labour pains every day with no progression. I was exhausted, in regular morphine, away from my disabled child at home and feeling the most depressed and anxious I ever have. 

At 34 weeks, I was finally induced as an emergency after my baby’s heart rate rose to 190–200 bpm and mine to 140–155 bpm. Only at this point were my concerns taken seriously. I firmly believe that if it had not been for the midwife I happened to have on MAU that day, this induction would not have happened when it did. My labour initially felt supported until a staff handover. The midwife who took over after the shift change was dismissive and did not listen to either me or my partner.

From this point onwards, I was not allowed to move freely or change positions, despite repeatedly explaining what I was feeling in my body. This was disappointing and frustrating as the previous midwives had explained and gained my consent that baby could be monitored via a direct monitor clip on her head so that I could be mobile throughout. The new midwife just repeatedly said she couldn’t monitor my baby and implied it would be dangerous if I moved. I told the midwife multiple times that I could feel my baby coming down. She dismissed this and repeatedly told me to stop pushing, stating that I was not ready. My bodily cues and lived experience (first child was a quick 3 hour labour and I was previously a band 3 maternity support worker in community) were ignored. I had also been repetitively asking for my cannula to be relocated as it was painful and causing me sensory issues. She refused to do this and kept avoiding the questions when both of us reminded her and kept asking.

When I entered the transition phase of labour, I said to my partner that it was becoming too much and that I didn’t think I could do it anymore. This is a very common and normal part of labour. Instead of offering reassurance or support, the midwife told me that she did not think I was coping and that she believed I should have an epidural. I had clearly stated at handover that I did not want an epidural. Even in that moment, I did not want one and pushed against it as much as I could. However, the midwife continued to insist, framing it as necessary because I was “not coping.” I was made to feel as though I was failing at labour.

Under this pressure, I eventually agreed. The epidural failed and only worked on one side. The anaesthetist advised that I lie on my side to improve its effectiveness. I felt relieved at this instruction and immediately followed it. Almost as soon as the anaesthetist left the room, the midwife instructed me to lie flat on my back again. I repeatedly asked to move and change positions, explaining that I could feel my baby descending and that movement felt instinctively necessary. My requests were refused. When I questioned why I had to remain on my back, the midwife stated that it was “best for her,” referring to herself, rather than for me or for my baby. My comfort, safety, and autonomy were not considered. I also explained that I had previously laboured very quickly with my first child. This information was ignored. I again told my partner that the baby was coming and that I could feel her head. The midwife dismissed me once more.

Moments later, my baby was born suddenly and without warning. She flew to the end of the bed. The midwife happened to be walking past the bottom of the bed at that moment and panicked. She did not know where the emergency call button was and asked my partner to press it, but he could not find it either. The midwife then placed my premature baby on my chest and ran out of the room screaming. The room rapidly filled with staff. My baby was not breathing and required care immediately.

While I was desperately asking doctors whether my baby was alive and what was happening, the midwife administered an injection to deliver my placenta without my consent. I had explicitly declined this intervention during staff handover. My partner was with our baby and was not present to advocate for me. After post-birth checks, I repeatedly asked to see my baby. I was left alone in the delivery room for over an hour. Eventually, a different midwife came in looking for the original midwife and asked why I was alone. I explained that I had not seen anyone for over an hour and had no idea where my midwife was. This was deeply distressing and compounded the trauma of what had already happened.

A NICU doctor later asked my partner when my waters had broken. When he explained that it was at 32 weeks, the doctor was visibly shocked and stated that what had happened should never have occurred. He said it was extremely dangerous to have planned to continue the pregnancy for so long and that the outcome could have been very different had I not pushed so hard. When I received my discharge paperwork, my labour was recorded as lasting just 11 minutes. This is completely inaccurate. My contractions began at approximately 7:30pm, and my daughter was born at 00:59am. There is effectively no accurate labour record.

Throughout my pregnancy and birth, I experienced repeated failures in care. My physical health concerns were missed, my mental health was inadequately supported, my neurodivergence was not accommodated, my autonomy and consent were violated, and I was left feeling unsafe and abandoned. I am sharing my story so that these systemic issues are properly acknowledged and addressed.

No one should leave maternity care feeling traumatised, unheard, and unsafe.