When most people find out they are pregnant it is one of the happiest days of their lives and they focus on the joy that their new baby will bring. The majority of women put off thinking about the birth for as long as possible and then create a wish list aimed at producing a birth with minimal pain and intervention which is over in the shortest possible time. However what most women omit to consider is that both pregnancy and birth can be a dangerous time in a woman’s life and there are many things that can go wrong.
We are often approached by families asking them to help in devastating circumstances when they have either lost a child at birth or their child has experienced a significant injury as a result of something going wrong during delivery. These are the extreme cases and, fortunately, they do not occur for most women giving birth. However even if your birth goes well you can still sustain injuries which can have a life altering affect and which could be the subject of a successful medical negligence claim.
One such injury is a perineal tear. In the 1970's it used to be standard practice during birth for women to undergo an episiotomy just before delivery as it was considered that this produced a better result than allowing women to tear. Fortunately medical thinking has advanced in the last decade or so and episiotomies are no longer routinely performed unless there is a clinical need such as an instrumental delivery. However it is still quite common for many women to tear during delivery.
There is no categorical way to know who is going to tear and who isn't, but there are some recognised risk factors such as:
- A baby who weights over 4kg
- A long second stage
- A occipitoposterior position
- Shoulder dystocia
- A midline episiotomy
- Forceps delivery.
The fact that a woman tears is not in itself a problem. The problem arises in relation to the way in which it is repaired. If this is not done correctly then it can have significant consequences for the woman and result in an injury for which you may be able to claim compensation by way of a medical negligence claim.
There are four grades of tear:
- Grade 1: injury to skin only and although the underling muscles are exposed they are not torn
- Grade 2: injury to perineal muscle but not to anal sphincter
- Grade 3: injury to the perineum involving elements of the anal sphincter but where the rectal mucosa is intact
- Grade 4: injury to the perineum where the anal canal may be torn and the tear may have spread to the rectum.
Statistics and guidance
The Royal College of Obstetricians and Gynaecologists (RCOG), estimates that 85% of women who have a vaginal delivery will have some degree of perineal trauma and 60 -70% will require some form of suturing.
Woman who suffer a fourth degree tear are almost twice as likely to report post partum faecal incontinence as women who suffer a third degree tear.
The RCOG has set out guidelines for the management of third and fourth degree tears.
Every tear should be adequately assessed post delivery to ascertain the severity of the tear, particularly to ascertain if the tear involves the anal sphincter.
For a third or fourth degree tear it is recommended that they should be repaired in theatre with either regional or general anaesthetic. This allows the anal sphincter to relax so that the torn ends can be retracted and brought together without tension.
A third or fourth degree tear should always be repaired by an appropriately trained obstetrician. Inexperienced attempts at anal sphincter repair may contribute to maternal morbidity, especially subsequent anal incontinence.
Following a third or fourth degree repair it is recommended that women are given broad spectrum antibiotics for 5-7 days as well as a laxative. After about 6 to 12 weeks women should be offered physiotherapy and they should be reviewed by an experienced obstetrician and gynaecologist.
The provision of antibiotics is important as the development of infection will pose a high risk of anal incontinence and fistula formation if the repair breaks down.
If a perineal tear is correctly assessed and competently repaired then the prognosis is good with 60-68% of women asymptomatic within 12 months. The most common remaining symptoms for women are incontinence of flatus or faecal urgency.
It is important that previous obstetric history is taken into account when a woman finds herself pregnant again. It is possible that a previous sphincter injury may mean that there is a risk of developing anal incontinence or worsening symptoms. If a woman is symptomatic at the time of a subsequent pregnancy it may even be appropriate to consider a caesarean section to avoid such an outcome.
Types of claims
As lawyers, we see many different types of potential medical negligence claims for women who have sustained some form of perineal tear during delivery.
It would be very unusual to be in the situation where the very fact that a woman tore is negligent. We often have enquires from women who have been fearful their whole pregnancy that they are going to have a big baby and therefore feel that they are going to struggle with a vaginal delivery. While having a big baby does carry with it increased risk of tearing or other complications, which may result in tearing, the risk of having a big baby is not, in isolation, usually a reason to offer a woman a caesarean section. However at the end of 2011 NICE brought out new guidance on the provision of a caesarean section. In this guidance there is a section which refers to the maternal right to choose in certain situations where certain criteria are met. As such it may be that in the future we see more cases where women have had their request for a caesarean section refused and then find themselves sustaining a significant perineal injury, which could have been avoided, had a caesarean section been performed. It may be that for those women they will be able to pursue a successful claim for medical negligence.
It is also not negligent for a baby to suffer a shoulder dystocia, which is where the babies head is delivered but their shoulders get stuck above the pelvis. This situation is almost entirely unpredictable and unavoidable as well as being quite unusual. This is a very dangerous situation for both mother and baby and in such a situation delivering a live baby is the highest priority and it is very unlikely that you could bring a successful claim for suffering a tear in such circumstances.
The most common basis for a tear comes in the repair situation. Repairs are, in the main, carried out in a calm and controlled setting and as such there should be no reason as to why they can not be carried out in a competent manner by appropriately trained and practiced obstetricians.
It is appropriate for a first or second degree tear to be carried out by an appropriately trained and qualified midwife in the delivery room.
However, if there is a risk that a woman has sustained a third or fourth degree tear, then the repair should be carried out in a theatre, in sterile surroundings and by an appropriately trained obstetrician. The tear should be carefully assessed and that assessment should be documented. The repair should be done in accordance with the guidance in relation to the type of suture and appropriate materials and again this should be fully documented. The woman should then be given antibiotics and laxatives and she should have her 6 week post natal check with an obstetrician. If you have been diagnosed with a 3rd or 4th degree tear and this is not the treatment that you received and you are still suffering from problems then you may have a claim for medical negligence.
The other area where a perineal tear may be the cause of a medical negligence claim is during a subsequent pregnancy. If a woman has had a perineal tear, regardless of whether there are ongoing problems, that should be taken into account when considering the method of delivery for her subsequent baby. If a woman is not counselled appropriately or is denied an option such as a caesarean section then, again, there is a possibility that if she goes on to sustain a further perineal injury as a result she may have a claim for medical negligence.
Although most perineal tears heal well and become asymptomatic there are a number of women who are not so lucky. This is not always as a result of negligence. Due to the nature of the area of the body where the wound is located it is almost impossible to keep any wound in this area truly clean. As such it is not uncommon for a perineum to become infected, inflamed and painful. However even if this does occur it is still more common than not for women to eventually make a full recovery.
As lawyers, we have, however, acted for clients who have not been so lucky. We have had clients who have experienced complete breakdowns of their perineum leading to urinary and/or faecal incontinence and in some cases even ending up with a colostomy to give the area time to heal.
For these woman they find themselves, at what should be the happiest moment of their lives, living with significant physical consequences of the delivery whilst also trying to care for a new born baby. It is sad to think that for many of these women if only more care had been given to the repair of their perineal tear they would not be in that situation.