K.M.'s Story - Royal Victoria Hospital, Barrie

Spring 2017 - When I was 30 weeks pregnant I remember telling my midwife that I was itchy head to toe. My midwife brushed me off. At about 32 weeks pregnant I broke out in a hives-like rash on my hands and arms. I was still itchy, but now it was more intense and waking me up at night. I called my midwifery office - without seeing me or offering to book an appointment I was just instructed to use a benadryl cream or to see a doctor at a walk-in clinic.

I went to my local emergency room (OSMH) and was treated poorly by the doctor on shift. He ignored that I was pregnant and told me I was covered in bug bites. He spoke to me like I was dirty and gave me a script for a steroid cream claiming it would solve my problems.

I decided I wanted a second opinion so I drove to Barrie and was seen at a walk-in clinic by a doctor who openly admitted that she didn't know much about pregnancies, but she ordered blood work for all pregnancy rashes she found on Google. She promised to call me with my results. 

Two days later I received a phone call. She advised that I be seen immediately as my results showed elevated liver levels. She gave me all the results over the phone. I contacted my midwife who agreed to meet me at RVH.

She ordered more blood work and did a NST. Blood work again showed elevated liver levels. She consulted with the Ob/Gyn on ward. He suggested an ultrasound to ensure my gallbladder was okay. Ultrasound was clear. No signs of anything. He decided that I needed to return that next morning for more blood work to check my bile acid levels as he felt I may have had cholestatis of pregnancy. Due to this complication, my care was transferred from midwives to this doctor whom I'd only just met.

My midwife assured me that I could still labour in water and that they had special belts/belly bands that I could wear and it would let me walk through my labour and move around so that I wouldn't have to labour solely on my back.

He started me on a medication for cholestatis because the results take two weeks to come back. I met him once in office and he forced a Group B Strep test on me. I had to administer my own test in the bathroom of his waiting room. He ignored my concerns and questions, and brushed me after only seeing me for two minutes. I was booked for an ultrasound to check baby's growth and for another NST.

I ended up being booked for a NST every 2-3 days for 2 weeks. Each time, I asked if my results were in. I was not seen by my new doctor at all. His student would see me. The nurses would promise that the doctor would come by to explain everything to me. When I finally met my doctor again he told me I needed an early induction for baby's safety. Looking back, he never once answered my question on whether or not I truly had cholestatis.

My induction was booked at 38 weeks 5 days. I went in for my NST every other day, but didn't see my doctor at all until May 7th - the day I was being induced. I needed to be there for 8:30 am. I was hooked up for an NST. The nurse was rude, impersonal and was annoyed that I asked questions about what to expect that day. She handed me pamphlets and told me to read them. As she brought me to my room an hour later, she asked me who was being paid for my delivery. She handed me a gown and instructed me to pee and change as the doctor would be in to gel me. I did as I was told.

She asked about allergies and as I started listing my many allergies, she belittled me and told me to only tell her "the ones that mattered" she became irritated when she learned of my sensitivity to latex. My doctor entered the room. He gloved up and instructed me to lay back, knees spread. Before I was able to completely lay down he had tried to check my cervix. I gasped in shock, he hurt me when he entered my vagina. I was not expecting the pain, I was not expecting him to check before I was ready. That's when the nurse chimed in and asked the doctor if his gloves were latex free. They were not. The doctor changed his gloves and then scolded me and told me I needed to drop my knees further down to "open up" and make it easier for him. He tried again. I was 0 cms. He inserted the gel. I cried from pain and embarrassment the entire check. He then left the room.

The nurse set the NST and told me she would check on me. When she came back into the room she gave me a dirty look and told me that if a cervix check hurt me that much that I should just take an epidural and be done with the pain. I kindly told her I didn't want one. She went on for 30 minutes about my "low pain tolerance". I was crying from not only pain, but fear, embarrassment and anxiety.

When the hour was up I was instructed to walk. I was to wait 4 hours in hospital before the doctor would check me again. I was in pain from cramping, not too much pain it was tolerable. It reminded me of period cramping. When the pain peaked I would pause my steps and hold my belly. The nurse made comment again about how I should "take the epidural".

There was another woman on the floor labouring with no pain meds. My room was beside hers. The nurse would enter my room and tell me that I was going to sound like her and make a scene on ward and cause problems if I didn't receive the epidural. When the doctor returned for the second cervix check I was still at 0 cms. He gelled me again. And I walked. It was another 5 hours before I saw him again. The 5 hours was spent cramping with a nurse who belittled my medication-free choices and made me feel like I was weak for feeling pain at all.

My doctor came back at 5:30 pm. He was going to check my cervix again. I requested a new nurse and thankfully he complied. During this cervix check I was in so much pain I remember hitting my head on the wall. 4 people had to hold me in place, the doctor was annoyed and I heard him say "just stay still". I heard him say that I was at 1 cm. He mumbled something about breaking my water while he was there. I said "No, please don't. I'm not ready".

He broke my water. I did not consent. I wanted a natural membrane rupture. He looked at me while I was attempting to pull myself together and he told me "you need to take an epidural." At this point I had heard it enough that I yelled "I don't want an epidural". He left the room annoyed. 

Within 3 minutes my midwife was in my room. I was unable to leave the bed, she stood so close to me. And for what felt like 30 minutes she lectured me on taking the epidural. One point she made that stood out to me was the idea of a "walking epidural" that I could still get up and move around and pace while labouring. I just kept telling her I did not want one. She left my room. My mom helped me to the bathroom. My new nurse came in and told me that the doctor would be starting my pitocin drip immediately. I told my nurse that I couldn't feel my baby move. 4 different nurses attempted to insert an IV into my hand. Each nurse collapsed my veins. The last nurse to try was previous nurse. She made a comment about me not liking her, "I know you don't want me in here so I'll try to be quick".

I had to wait for an anesthesiologist for the IV. I was forced to lay in the hospital bed on my back. While waiting I commented again that I still couldn't feel the baby move. Through my uneven contractions I waited for them to set up the monitor to listen for baby. I kept telling my mom how scared I was. We asked the new nurse about pain management options. She explained that I could try morphine. She mentioned that I wouldn't be weak if I did take the epidural. She was calm and helped me to feel heard. Her shift ended and a new nurse was in. A shot of morphine was administered and I felt like I couldn't breathe. I was gasping for air. She looked annoyed, ignored my concerns and told me to suck on a candy. She got me hooked up to the monitor and tried to insert my IV.

The morphine never touched my contraction pain. I expressed that I would be open to the epidural. When 4 hours after my water was broken, an anesthesiologist came in to do my IV and epidural then and there. He told me I would feel a bee sting and a pinch. He exclaimed that he inserted it wrong and had to try again. I counted six. Six times I felt something enter my back. Each time hurt worse than my contractions. The final time I remember screaming from the pain. He got it in the right spot. They laid me down and that is where I stayed for 6 more hours, on my back completely numb from my chest to my toes. I couldn't feel my baby move. I couldn't feel my contractions. And part of me felt numb to my own emotions.

In that 6 hours my nurse checked my cervix. I was only 2 cms. She inserted a catheter. I wasn't allowed to get up and walk like implied I could earlier. At some point I fell asleep. I remember being woken up to roll over at nurses request. I fell back asleep. I remember waking up at 2:30 am. My doctor looked at me and informed that I was 2 cms and that I needed a c-section because they felt like I wasn't progressing and stated baby's heart rate was not reassuring.

I cried. I requested to be put under because I didn't want to be awake anymore. I didn't want to remember it. I did not want to be awake knowing I was being cut open. 
My anxiety peaked. 

When mom stepped out to talk to the doctor about letting me be put under he said, "this is not my first rodeo, lady" and walked away. It was the anesthesiologist who explained that it's not preferred to use a GA once a patient has had an epidural, but he consented because my anxiety was so high already. 

My midwife and doctor all promised my mom and I that we would be together until I was put under but they sent her out of the OR before I was asleep. 

While on the table before being put under, I heard the doctor say "this needs to be treated as an emergency" and I felt what might have been blankets being tossed onto my stomach. 

I woke up from my c-section to be told that I had a boy. They would not answer me as to where he was or if he was okay. I asked at least 3 times. It wasn't until I asked if he was alive that they answered that he was okay. I asked if my mom was with him and they said that they "could not find my mom".

My mom had originally been told to wait in the delivering room where we had spent the day, but when she went back, a nurse was packing our stuff. She took my mom to my new room and told her to wait there. They couldn't find her because there had been no communication of this.

They never updated my mom on my status and would not answer her questions until she started crying and panicking. She only knew my baby was born because she overheard a nurse communicate "baby is born and is in NICU". My mom was given attitude when she asked if my baby was okay and why he was in NICU - "it's just a nursery".

My delivering doctor informed me that I didn't widen at all and claimed that baby was stuck. He instructed me to have a scheduled c-section at 39 weeks if I chose to have another baby.

They made me name my baby before I met him. They promised me that I would see him within the hour as they took me to my room. When the hour was up, I asked my new nurse where my baby was and she told me another hour and I would get to see baby. That hour went by and I got another new nurse. I asked to see my baby. When she told me it would be a few more hours because the doctor needed to assess him. I lost it. I was done being lied to. I wanted my baby then and there.

The supervisor visited me and my mom spoke for me. My nurse brought a wheel chair. I had to be able to stand and walk to a wheel chair before I could meet my baby.

When I could finally get out of the bed and into the chair I was brought to him. I watched the nurse lift my baby out of an incubator and hit his head on the edge. I held him for an hour before I was talked into going back to my room.

My mom suggested I try to sleep. When they finally released my baby to me, I wanted to try and breastfeed but I didn't know how and so my nurse grabbed my breast and shoved my babies face "just put it in there" I struggled to figure out how to latch my baby. I had no support from the nursing staff.

Over the next 3 days I asked every nurse if I had his latch right. My baby wasn't gaining weight and lost 12%. They forced me to give him formula for 24 hours. They never once changed my bandages or gauze. When I showered on day 3 after my c-section is when the bandages were removed even though I had asked about a bandage change on day one.

I was kept longer than necessary because my baby wouldn't drink the formula. My Aunt is a lactation consultant. She came in and helped me with a latch and showed me how to tell that baby was nursing and getting milk. She told me my nurses were wrong to instruct me to time his feed and to tickle his chin to make him nurse faster. 

When I was discharged from the hospital I was placed back in the care of the midwives with instructions to book with the Ob/Gyn at 6 weeks. My midwives pushed formula because baby wasn't gaining fast enough. One of my midwives made a comment about how I was the strangest case of cholestatis she had ever seen. I asked "so I did have cholestatis then?" Her response "technically no. Your bile acid levels were normal." 

My c-section site developed an infection. I developed a UTI at the same time. My midwifes were unable to prescribe me antibiotics for my c-section site, only my UTI. l needed to contact my family doctor for antibiotics.

I've since requested a copy of my records from the hospital. My records showed that the doctor had performed a cervix check prior to waking me up to announce me needing a c-section. I have no memory of this cervix check. I was asleep, He apparently requested consent from me while I was asleep.

My records also showed that my baby was resuscitated at birth - no one told me. I was 12 weeks postpartum when I learned all of this. My results show no signs of cholestatis. The hospital will not release all of my records to me. I asked twice and offered to pay for the additional papers.

I saw a different Ob/Gyn. He informed me that I never had cholestatis based on my results. He told me that my delivering doctor did not let me try long enough and he told me that I could try for a VBAC and that he personally would oversee my next pregnancy and even encouraged going with midwifery care.

I felt betrayed, embarrassed, assaulted, abused, mocked, belittled. I was failed by my medical team. I was robbed of my experience. 

I have made my doctor aware of how I feel. I'm working with a CBT to work through PPD and PPA. No one is helping with coping from the stress and trauma of my delivery and after care experience.

RVH called me for a follow-up phone survey. I made it known that I was unhappy with my care. I expressed my concerns regarding an infection in my c-section site and the response was along the lines of "it happens".

I was 23 years old. I am a single first time mom. I wanted a homebirth, in a pool, in my livingroom. I have a fear of hospitals and a fear of doctors. I have struggled with depression since I was a teenager. I live every day with fibromyalgia and mild degenerative disc disease (I didnt want to risk the epidural causing more back problems). I was 225lbs when I became pregnant and I was only 235 when i gave birth. I am a college graduate and I work with adults with disabilities. I worked my whole pregnancy and kept myself in overtime so I could give my baby the best I could.



Submitted by K.M.