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"Stressful birth experience at Box Hill Hospital"

About: Box Hill Hospital / Maternity Service

(as the patient),

In 2014, I gave birth to my one and only little baby. The pregnancy had been a dream and we were looking forward to a water birth. Unfortunately, our little baby took their time and so at almost 42 weeks we were induced. That was when everything went wrong.

We called before we came down for a 2pm induction and were told to head straight in. We arrived at 1: 45 and waited in the waiting room for over an hour. Once called up we lugged all our bags into a delivery suite where we were monitored for about 20 minutes. Having small contractions, the midwife advised us that they were very busy and we would be moved to a ward to be induced later.

We were moved to a ward and did not hear from anyone until around 7pm. We asked when my dinner would be served only to be told that I hadn't technically been admitted so I would need to make other arrangements. I hadn't eaten much since 2pm so my quick thinking partner ran to get dumplings which I scoffed down.

We were again moved to a delivery suite where we were told a doctor would come and speak to us soon; no doctor arrived until 2am. We had hardly slept believing the induction could be started at any moment. When the doctor arrived she explained that she would administer half the induction gel internally so I could sleep and rest and then return to give the second dose at around 9am. We agreed that I needed to sleep and proceeded with the gel. We were told that I would need to wear a monitoring devise for about 1 hour and then it could be taken off (a major part of our birth plan was being able to move unrestricted and we explained this to the staff).

Within 10 minutes, strong contractions began and within 30 minutes I was told I was in full labour. Exhausted, but excited, we were transferred to yet another delivery suit. My partner organised a fitness ball, as per our birth plan and asked about our water birth/access to shower and when the monitoring strap would be taken off. We were quickly told that the monitoring strap would stay on for the entirety of the labour and that we would have little access to water because of the induction. We were really disappointed but stuck to our plan as much as we could. Like any parents-to-be, we wanted to ensure that the staff had whatever means they required to make sure our baby was safe throughout the labour.

The labour seemed intense, but being a first time mother, I thought I just didn't know what to expect. After just 30 minutes from the start of the induction, the contractions were 1 minute apart and very strong. After 8 hours I started to reach my breaking point. I had wanted a drug-free birth and lasted as long as I could. We had been assigned 4 midwives up to this point and had remained positive in the face of the aggressive labour. We called in the midwife as I began to cry. I told medical staff that I could not manage the pain anymore and that the contractions being 1 minute apart left me with no chance to recover. They called in more midwives to look at my chart who all assured me how well I was doing and that the labour was going well. The funny thing about labour was that it actually heightened my senses so I quite clearly heard the midwives whispering "she's clearly hyper sensitive to the induction that's why the contractions have been so close together". At no point did any member of staff tell me this had occurred. I asked them if there was anything they could do to slow down the contractions and they gave me medication which worked for about 30 minutes until the unbearable close contractions started again. I was fast moving towards 2nd stage labour and I was physically and mentally spent.

Desperate, I called the midwives back in. They explained that an epidural might be the only option. I can't tell you how much I tried to hold on without such intervention. I asked for some time to think about it. My partner counselled me as I sobbed and barely made it through each contraction; he assured me that we had gone as far as we could. I reluctantly agreed that I had tried as hard as I could. We called the midwife back in and advised that we had no other option but to proceed with the epidural. The pain was too great and my body was too exhausted. Our baby was doing well and all signs were that they had coped well with the accelerated labour.

A midwife advised us that the anaesthetist was held up in ED. It would be 20 minutes. I had waited until breaking point, 20 minutes seemed unimaginable. I focused on my partner and on the clock. I made it 30 seconds, then to a minute, to 5 minutes, then 10 until it had been 20 minutes. Another 20 minutes, we were told. I burst into tears - I can't do that again. Well, there is no anaesthetist available, we're calling the on call anaesthetist in and she's not here yet, she's driving in they told us.

After another excruciating 20 minutes we were told another 20 minutes. All manner of senior midwives rushed in, as well as the doctor to "manage us". It's amazing the levels of pain the body can take, you'll be fine. Box Hill Hospital had induced our birth, but did not have the staff to properly manage it.

Things got worse, 2nd stage labour was in full swing, when the anaesthetist finally arrived, 2.5 hours after we agreed to have the epidural, 2.5 hours of nightmare pain. The epidural took 20 minutes. Other than signing the paperwork the anaesthetist did not acknowledge me, but had time for plenty of social chatter with the midwife whilst I was painfully perched at the end of the trolley. The bearing down of 2nd stage labour whilst I was crunched onto my stomach for 20 minutes felt like I was in a torture chamber. I almost passed out. I only made it through by holding onto my partner. Then, we heard the anaesthetist say, oh no, it fell out. So after more chatter and personal stories and another 20 minutes later, the pain was finally relieved. I felt like Dorothy, I had tapped my toes three times, and I had escaped the nightmare.

Being fully dilated I asked when we could deliver. We were told to rest for 40 minutes and then we would deliver. After a quick visit from my parents we enquired about the doctor again. We were informed that no doctors were available, so, with yet another midwife (number 5) we were told that while we waited for a doctor to deliver our baby we would try and push naturally. After another 2 hours we were exhausted, the pushing was not productive and a paediatric team were called to the ward. Without any notice or information, 4 lifesaving machines were wheeled into the ward. We asked what they for. It's just a precaution. Why, we pressed. Well, your baby is showing signs of struggling and their vital signs are slowing. Where is the doctor? Why aren't we delivering? The doctor is held up, but she's coming soon. We became very worried.

Once Doctor Amy arrived, she was superb. She was the only person who kept us informed. Although the forceps delivery and episiotomy were incredibly painful (and have left me with terrible nerve pain even a year after) the skill of Amy was undeniable. My baby was delivered, a healthy beautiful baby, but something was wrong. As I held my baby against my chest I started to heave, I quickly passed our baby to my partner and told the nurse I was going to throw up. Sorry, that's because of the medication I just gave you - I forgot to tell you that would happen. It took a long time to sew up the episiotomy cut, and although very uncomfortable, I was happy to concentrate on my baby. But I found it difficult; I didn't feel like I was in my body. I felt like I was blacking out. I told the midwife this who said that it was completely normal.

During our first breastfeeding session, my parents were shown into the room without our knowledge or permission and, after resting, I walked back to ward.

My partner stayed for as long as he could and then was told he had to leave. I fell asleep but awoke, freezing with just one sheet. I had terrible shakes with a hot and cold fever all throughout the night. Midwives were stretched and as they ran in and out to quickly check on my baby and the breast feeding and then dashed on again. I later found out that 26 babies were born that day.

Over the next 4 days midwives continued to be understaffed and nurse replacements gave inconsistent advice. Unable to conduct timely rounds, I was expected to remember 5 hours of breast feeding times - they were rude when I gave estimations. I was awoken at 6am for a blood test to test for iron. I wasn't told why and I was too sick to enquire. I noticed a yellow tinge on my baby's skin and asked about Jaundice. No they’re fine they all look like that.

On night 2, a new mother occupied the bed opposite me. Her baby screamed all through the night. Her baby screamed for the next 3 nights. I had no sleep. No staff assisted. The ward door were left open all night and nurses cackled loudly waking me up. The special care nursery babies nursed outside our door. It was so noisy. I was so impossibly tired. I was desperate to go home.

The final tests showed that our baby did indeed have jaundice and needed to be in a 24-hour sunbed, the sunbed took 5 hours to arrive and the nursing bank nurse didn't know how to operate it or put the sunglasses on my baby. She left it up to my partner and I to work out.

There were two exceptional midwives who took time to listen and care. The paediatric team who visited us in the ward treated my baby gently and attentively. We were so grateful to leave and be home where my partner looked after me and we had the peace and quiet we needed to get to know our baby.

It wasn't until my GP 6-week visit that I was told about the severe haemorrhaging post-birth. It explained a lot and made me angry at how much information had been kept from us. Looking back, I know my experience was not normal and can only blame severe shortages in funding paired with high birth rates that day for my traumatic experience. It took me 4 months to get over the panic of flashbacks throughout the night. I am very apprehensive about having another child. I just feel so lucky to have my baby, happy and healthy.

I hate to think of how the delays in our labour put both myself and my baby at unnecessary risk and have completely lost faith in our public health care system. Women and their babies deserve a higher level of care, both physically and emotionally.

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Response from Alan Lilly, Chief Executive, Eastern Health 8 years ago
Alan Lilly
Chief Executive,
Eastern Health
Submitted on 12/06/2015 at 12:56 PM
Published on Care Opinion at 12:58 PM

picture of Alan Lilly

Dear POJUN03

I am so sorry to read and learn about your experience at Box Hill Hospital which has left you lacking confidence in our health service and our health system more generally. I am personally disappointed that we appear to have fallen short on a number of fronts and I am also keen to ensure that we can address and alleviate your concerns for potential future interactions. It’s very clear to me that there are issues and practices which we need to review as our first priority. I will be asking our most senior obstetric doctors and midwives to review the issues which you have raised and seek their feedback and comments on your experience in Box Hill Hospital.

I also think it would be a really good to have the opportunity to meet with you to be able to respond to the matters you have raised, to be able to discuss them fully with you and to help restore your confidence in our service. Your clearly documented comments tell me that we have much to learn from this most unfortunate situation and just as we accept feedback when things go well, we also need to always focus on making sure that we improve wherever and whenever we can.

POJUN03, I am truly sorry that your experience was not as you and your partner had been so excited for and I am keen to focus on ensuring that this never happens again. If you would be comfortable to do so, I would encourage you to contact me at and provide me with some more personal details so that we could contact you and arrange to meet with you if you would like to do so. I appreciate that you have taken the time to provide this feedback and I want you to know that we take this very seriously too.

I do hope to hear further from you and will fully respect your wishes in this regard.

Kind regards, Alan Lilly

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