"When looking at my medical notes months later, they’d put me on a sepsis pathway and had never told me"

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

I had my 1st baby in early 2023 and I didn't know what to expect, but I did not prepare for what had happened. I had my usual 40week (I was 40+5) midwife appointment and my blood pressure was taken. It was a little high, but I thought it was nerves due to having a sweep during the appointment. The reading didn't go down, but no protein was in my urine but advised to go to the maternity assessment unit at the JR.

We had waited a few hours before being seen, and baby and I was put on a monitor and blood pressure being taken, as well as my urine and bloods. A doctor had come in and said that if my blood looked ok then I would be sent home. We didn't hear anything until a few hours went by and my husband had to check and they said I could be discharged, so we left.

I started contracting that night, but didn't go into hospital until 2 days later when my contractions where closer together. When I phoned, as I wanted to go to the Spires, they told me I couldn't as I had preeclampsia. This was the first time anyone had told us this. When I, months later, requested my medical notes I had seen that protein was found in my urine during my visit to MAU and my bloods were off - but no one had told me this and I was sent home not knowing that I should have been kept in.

When we did arrive at the hospital at 8am, we had to wait a little bit to be seen to ensure I was in labour. We were put into a side room and checked, and it was confirmed I was 4cm and now needed to wait for a space in the Delivery Suite. We were left alone in the side room for 4 hours, with no pain relief or help.

At 4pm we finally got down to the delivery suite, and then at 5pm my waters were broken as I had only progressed 1cm. There was meconium in the waters, so they wanted to progress my delivery quickly. I was asking for pain relief, and the midwife just pointed at the gas and air and did not tell me how to use it. I used it incorrectly and felt incredibly nauseous so stopped after a few breaths.

At this point, my contractions were thick and fast and I could barely breath through them, but the midwife was struggling to find a heartbeat as she did not believe me when I said I think I am getting close to 10cm and that she should try lower. She would flip me and force me to move during contractions to find a heartbeat. She eventually said, not asked, that we need "the clip".

I could barely talk at this point from the pain and my husband asked about alternative pain relief. The midwife said she was going to get a doctor to fit the clip and could see about alternative pain relief then, as she said that she doesn't believe I had progressed at all. The doctor came in, and surprise, I was 9cm. They fitted the clip, and there was no issues with the heartbeat after that. Because I had progressed to 9cm, I couldn't have any other pain relief. Luckily at this point we changed midwives and I have someone else who helped deliver the baby.

After delivery, I had asked for some support in getting colostrum from my breasts. I had explicitly told them I was not directly breastfeeding, but I was going to express milk. Someone had come in and was aggressively squeezing my breasts to get milk out, and it was incredibly painful what she was doing and I asked to stop, she did not. I asked for someone else, and they put my breast into my baby’s mouth, even though I said I did not want this. We moved onto the ward and me and my baby were getting regularly monitored - but I wasn't told why.

In the afternoon, I asked for the breastfeeding specialist to come as I was still struggling to express. This was ignored and instead the ward staff had come in, and were physically shoving my breast into my baby’s mouth which was hurting me, going against my wishes, and making my baby hysterical. I asked them to stop, they didn't. When the breastfeeding specialist was in my bay, I managed to get a hold of her to stop by and help me express - which she did. She was never told about the earlier request.

My baby was cleared for discharge, but they wanted to keep me in but did not tell me why. I pressed on this, and they only said it was because my heart rate was a bit high. I explained it has been high all of my 3rd trimester, and if this is the only reason - I want to be discharged. I had to self discharge.

When looking at my medical notes months later, they’d put me on a sepsis pathway and had never told me. Luckily both me and my now toddler are fine, but the misinformation and the lack of communication is astonishing. To only find out why certain things had transpired after, and to only find out about diagnoses because I requested my notes is disgusting.