Hello everyone
Firstly I'd like to thank all of you for your kind words and support for Mr Bubble. We have been to hell and back over the last ten days and he has had to keep it together for the sake of our two older DS's.
I'm not sure where to begin....
On Wednesday 16th February we went to hospital for induction of labour. I'd had a sweep the previous week at 38 weeks (twins) and was booked for induction a week later. We chose to go in for an overnight induction as I had been induced overnight with my previous pg and the wards were a lot quieter and I felt we had got more one to one care. Oh how I regret that decision now.
The previous day I had hurt my shoulder, a muscular 'pull' after turning badly. Bear in mind that I was carrying fifteen and a half pounds of babies and unsurprisingly was experiencing backache and general discomfort.
We arrived at the hospital and were put in a room on the post natal ward. A midwife appeared, checked my BP, pulse and temp. and set up CTG tracing. My pulse rate was 110bpm at this point my usual pulse rate is 80bpm. I explained to her about the shoulder pain and she said she would get me seen by one of the obs team and written up for some analgesia. I was finding it very difficult to lie on my left shoulder and was on my back during 25 minutes of CTG tracing. Both babies wre tachycardic (fast pulse) Twin 1 (Elijah) at 166bpb and Twin 2 (Bo) at 176bpm these pulse rates were at a time when neither baby was moving.
A House Officer arrived, looked at the traces and went to consult with a Senior SHO, the Seior SHO came to see me but seemed preoccupied with my shoulder pain. As a nurse I know that she was concerned that I may have been having a PE (pulmonary embolism)I didn't, however, have any shortness of breath and my observations were otherwise normal. My oxygen stauratin levels were 98 - 99 percent. We agreed that the pain was likely to be muscular in origin and I was given some oral pain relief. The time was now 9.30pm.
Referring to the babies heartrates I said " I think we need to get these babies out now" and explained that although I had been given a choice and elected to try for a vaginal delivery I now felt that a CS would be a safer option. I was ignored by both the MW and the doctor and on reading my notes later this and later requests for CS were not documented. I know now that at this point I should have insisted on seeing the on call consultant but hindsight is a wonderful thing and they seemed so unfazed by the CTG traces in front of them. As I've said I am a nurse not a MW and I truly believed that they knew what they were doing. They kept referring to my 'tachycardic babies'. My babies were already dying at this point. Throughout my notes I kept finding the phrase "continue CTG tracing and review" No one, it seems was willing or able to make a decision. I again asked for a CS and was told by the doctor that "It says for induction of labour on your notes" What a deeply intelligent statement So, cases are treated on a decision made in an antenatal clinic 2 weeks previously rather than on a clinical situation unfolding in front of you are they?"
I'm sure that some of you are reading this and thinking "Why didn't she DO anything" Some of you may know that this pregnancy has been fraught with difficulties in communication, trying to see comm MW's, delayed consultant appointments. Mears commented a few weeks ago how appalling it was that I was having to self direct my own care during what is a higher risk pregnancy. Read on sistas.
By this time it was around 11.30pm. Mr Bubble had been told that I would be induced in the early hours and that he should go home for some sleep and they would 'phone him. He left under the impression that everything was OK, babies were tachycardic but 'Hey, no big deal, we're professionals'
I was left alone with the monitoring belts in place, twin 2 was moving a lot, deaththroes with hindsight and the belts kept losing trace. I was just about to call for a MW when the fire alarm went off. A false alarm and half an hour later the MW came in. She reattached the belts and fifteen minutes later a MW from labour ward arrived to hold the belts in place.
With hindsight everyone on duty that night seemed to be obsessed with gathering evidence of how well they had monitored the situation instead of doing anything about it.
I was then moved to labour ward and a locum senior registrar arrived. Again I asked for a CS but was told that they were going to do an amniotomy to try and start labour. I asked why as twin 2 was in dire straits and would get more distressed but was told that they would take me to theatre if things didn't improve. I was 4cm dilated at this point. Surprise, surprise, things went from bad to worse. Mr Bubble was called and they had attached a scalp electrode to Elijah. He was deccelerating and taking a long time to recover. I begged them to take me to theatre and the Registrar said we would wait until my DH arrived. I said "forget that, we need to go now" and we did.
We got to theatre and the anaesthetist attempted for twenty minutes to site a spinal block. I could see the CTG tracing going from bad to worse and told him to give up and give me a GA to get the babies out. When I fell asleep there were two, albeit distressed taces visible.
I now know that the anaesthetist failed to intubate me and had to crash call the on call consultant to do it for him. There was a delay of 35 mins between me going to theatre and the CS.
When I woke up I was back in the room on labour ward with my DH and assorted weeping MW's
Elijah had been delivered with an APGAR of 3 rising to 7 and then 9. Bo was stillborn and though they attempted to resus him for 30 minutes he was dead.
The rest is a blur. At some point the anaesthetist came in to set up a PCA pump (patient controlled analgesia). He was the one who had failed with the spinal block and intubation. The poor man was shaking and nearly in tears. I hold no anger towards him, I'm believe that if he'd been successful earlier we would have saved Bo but I should have been in theatre at 10pm the previous evening as a serious case, not at 4.30am the following morning as a crash situation.
We await the results of Bo's postmortem. We'd initially rejected the idea as I didn't want his little body to be subjected to any more trauma. If we are to get any answers, however, we need to know everything. I'm aware that he was already in distress when we arrived that evening. Part of me wants to hear that there was a problem which caused his death which had nothing to do with the total negligence of the hospital, that he would have died anyway. I'm haunted by the feeling that if I had protested and shouted I would have had a CS earlier and he would be alive.
As a nurse I know that an important part of my role is to act as an advocate for patients. I feel badly let down that not one MW stepped in and said "this is wrong."
The consultant obs on call is reportedly furious that he had not been made aware of the situation until 3.30am even after he had phoned the unit from home at midnight to check that all was well. What the f**k was going on?
The care after the event was good. I was looked after by two MW's in particular who were fantastic and I have written to the head of midwifery services to tell her so. There is an ongoing enquiry and we have a meeting with those involved in 6 weeks.
And Elijah? He is beautiful and we are so glad that he made it. He was in SCBU for a while but has passed all his tests with flying colours. It is the most bizarre feeling to be smiling at him one minute and crying our hearts out the next.
Our 4 year old DS saw Elijah in SCBU. He looked at him and announced in a loud voice "So, thats not the dead one, Bo, then?" And in the next breath - "Can we bury Bo in grandma's garden with the cat?". Talk about smiling through your tears.