"Negative labour experience."

About: Box Hill Hospital

(as the patient),

I would like to make a formal complaint in regards to my labour at Box Hill Hospital. I would not like another mother to go through the same experience. I understand the month in which I had my baby is a busy month for the hospital (as I was told several times). However this does not mean my baby or I should be put at risk and not receive the proper care we deserve from the health system. If this particular month is a known busy month then practices and procedures should be put in place to cater to this known event. It is not good enough to stall expectant mothers from being admitted because there are no beds available. If this is the case, the hospital should have procedures in place to ease the stress placed on its employees, which is then transferred to patients seeking services from the hospital.

I had a fairly straightforward pregnancy and very few issues with Box Hill Hospital (long wait for some results of ultrasound) but towards the end of my pregnancy I felt there was a breakdown of communication. At my last antenatal appointment at 40 weeks the midwife was concerned as I had high blood pressure and I had phoned the day before as I was having some leaking, since I had an additional medical concern, I was feeling anxious. She took me through to the birthing suite for some tests. Another midwife did a short monitor on the baby, gave me very little information and sent me home.

The next few days I started to feel the onset of labour. I did not sleep for more than ten minutes at a time over more than 3 days until my baby was born, as I was in agonising pain. As a first time mum I was unsure of what I was feeling, the extent of the pain of labour and had to rely on the experts for guidance and advice. I was given several fact sheets from Box Hill Hospital about when to contact them. On the list is - severe or persistent pain. After approximately 22 hours of irregular contractions and severe back pain I phoned the hospital to be met with a midwife who seemed less than concerned and told me they had no beds, might send me to Angliss and would call me back. After about an hour I felt she reluctantly called me back and told me to come in for an assessment. They monitored the baby and I was still having irregular contractions and back pain. She felt it was unnecessary to do an internal and in my opinion made me feel like I was a nuisance and taking up space when I was not a valid patient. I feel that she didn’t believe my pain was severe as she gave me one Endone, told me I would sleep through the night and sent me home. Looking back on this event now I find it very patronizing. The pain subsided for about an hour and then it was back to being unbearable. After a few more hours pacing around the house I noticed I had started bleeding. First it was pink then darker and seemed more like a period. The information sheet also states to contact the hospital if there is - any bleeding from the vagina. I called the hospital back to make sure this was ok and the midwife seemed less than impressed I was calling back. She said - that’s ok, we might see you in the morning. After not sleeping for around 40 hours, and the pain becoming increasingly worse I called the hospital again in search of pain relief. She asked how I slept, and I informed her I didn’t due to the pain. Her only advice was to go to a pharmacy and get some Panadeine Forte, and if I need later to come into the hospital and maybe get a script. She didn’t however mention I needed the script for the Panadeine Forte. Finding a pharmacy open at 6am on Sunday proved to be challenging and I was very limited in my movements due to the pain, so to hear I was unable to buy Panadeine Forte added to my anxiety levels. I had to settle for Panadol Extra. I lasted 8 more hours in intense pain with the only comfortable position on the toilet, where I would rock back and forth or kneeling in the shower. I phoned the hospital again, as I believed my waters had broken. I tried to call back twice after this conversation as there was now a greenish secretion, but there was no answer. After my next dose of Panadol and no improvement my mental state had very seriously declined. I called the hospital again to inform them I was extremely uncomfortable at home, and I believe reluctantly they told me I could come in. A sense of relief washed over me as I was finally heading to the hospital and there might be some end to this overwhelming pain. As I arrived the same midwife was there with, in my view, her unwelcoming attitude and I was sent to a visitor waiting room. For one hour I paced around the waiting room and one hour feels like forever when you are in intense pain. Visitors to the hospital could see how much pain I was in, they then avoided this particular waiting room as they didn’t want to disturb me. On reflection I do not think a visitor waiting room is an appropriate location to have a mother in extreme pain. It appeared the midwife however could not see this, was unaware or did not care. Finally I was assigned a midwife and was allowed into a birthing suite. I did not hesitate when offered sterile water injections which lead to much needed relief and even had a secondary dose after one hour. The next few hours proved challenging for me, both physically and mentally because I had not technically been admitted and was waiting on the Registrar. The midwife informed me they were considering sending me home. The level of stress at this point was immense as the pain was unbearable and the thought of going home was unthinkable. I was under extreme duress. After a few hours and no show from the registrar I informed the midwife I could not sit down as there was too much pressure. The midwife did an internal and felt my baby’s nose. Two doctors came to assess me and it was found the baby was transverse and face presentation. I was fully dilated and there was no possibility that the baby was coming out naturally by itself. The decision was made to either try and turn the baby or an emergency caesarean.

I am very relieved the outcome was not tragic. An emergency c section was performed as the baby’s head was stuck and had to be manipulated and pushed/pulled back up. The baby was swollen, bruised and spent time in the special care nursery with oxygen as the baby had ingested meconium. I believe this could have been avoided with earlier monitoring. This could have been achieved if beds were available and staff able to accept patients.

After all of this I didn’t think it could get any worse, however I didn’t get to see or touch my baby for the next 15 hours. This was devastating as I only saw a photo of my baby's bruised and swollen face and I was intending on breast feeding. I asked the midwives several times if I could go and visit my baby in the special care nursery, but apparently they were all too busy to assist me to see my baby for the first time. My baby was born at 11pm and at 2pm the next day I was able to see them. This caused me further distress and anxiety after such a horrible and traumatic birth experience.

I hope the hospital can improve the quality of their service, their understanding of patient’s needs and overall performance, this can only be achieved if beds and staff are available. I hope no other woman has to go through a similar situation.

The clinical notes do not reflect the true events as I made 9 calls to the hospital as evidenced in my phone call log. In my opinion the labour times are all fanciful as I had irregular contractions and severe back pain for a longer period than reported in the notes. I tried to follow all advice as per the hospital’s information sheets but in this instance this did not help me. On reflection I believe the only mistake I made was staying calm even when in extreme pain, as this invalidated my need to be on the priority list for admission. I was informed that all beds were full. They had admitted two mothers for induction and therefore I had to wait.

I do however wish to thank the emergency theatre staff for their efficiency and skill. I shudder to think of the outcome that could have transpired. I would also like to acknowledge that there were some kind and supportive staff members but my overall experience was not one that I would ever wish to re live. Box Hill Hospital has many good reports but unfortunately I cannot concur. My outcome may have been better and without an emergency c-section had there been earlier intervention, assessment and monitoring. This could only be achieved with adequate staffing levels, with staff who are well trained, equipped, and resourced.

Responses

Response from David Plunkett, Chief Executive, Eastern Health 2 years ago
David Plunkett
Chief Executive,
Eastern Health
Submitted on 28/09/2017 at 10:19
Published on Care Opinion at 10:20


picture of David Plunkett

Dear My birth experience,

I was very concerned to read your story on Patient Opinion and would like to apologise that your birthing experience was so distressing and traumatic for you.

Whilst this is indeed a busy time for the service, this should not have compromised your care or your experience.

I understand that you have logged a formal complaint with our Centre for Patient Experience and I am aware that an investigation into your care has commenced.

We will be in contact with you directly shortly to discuss your concerns and the outcome of our investigations.

Once again, I am sorry that your experience fell well short of expectations and I trust that you are settling into life as a new mum with your baby and managing to get some much needed rest!

Kind Regards,

David

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Response from David Plunkett, Chief Executive, Eastern Health 2 years ago
David Plunkett
Chief Executive,
Eastern Health
Submitted on 11/10/2017 at 07:03
Published on Care Opinion at 10:08


picture of David Plunkett

Dear My birth experience,

Further to my previous response to you, I am aware that you have since discussed your concerns with our Director of Obstetrics and a review has commenced.

Post this review, we will again be in contact with you to discuss what has been identified for improvement so that others do not have a similar experience.

Thank you again for taking the time to not only report your concerns but also for assisting us to identify improvements in the care and service we provide all our patients and their families.

Kind regards

David

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