Perineal tears are tears that occur to the perineum – those soft tissues between the vagina and the anus. Tears occur as a result of vaginal childbirth, typically during the final moments before a baby is delivered.
The vaginal opening becomes stretched during childbirth and particularly on a first vaginal delivery, it can tear or may need to be cut in a procedure called an episiotomy. An episiotomy is designed to enlarge the vaginal opening while deflecting any further tear away from the delicate muscle structures around the anus.
Such tears are very common and usually are not severe in nature. Sometimes however they are severe, resulting in a tear that runs towards and even through those important muscle structures around the anus that allow us to control both wind (flatus) and faeces. When this happens, it is essential that the full extent of the tear is identified quickly and that it is repaired with both care and skill to ensure a good outcome for the mother.
Perineal tears are classified into 6 different categories ranging from the least serious to the most serious in terms of harm or injury to the woman.
1st and 2nd degree tears are less serious and tend not to lead to long-term consequences simply because they do not extend into and cause damage to the muscles that control the anus.
3rd and 4th degree tears cause the most harm and affect the functioning of the two muscles that encircle the anus. These are the External Anal Sphincter muscle (EAS) and the Internal Anal Sphincter (IAS).
3rd degree tears are divided into three sub categories depending on severity.
3a is where the tear extends less than 50% into the EAS.
3b is where the tear extend more than 50% into the EAS
3c is where the tear goes through the EAS and extends into the IAS.
A 4th degree tear extends through the full thickness of both the EAS and IAS and on through the anal mucosa so that the vagina communicates directly with the anus.
Unless 3rd and 4th degree tears are identified immediately after the birth, and repaired competently by a properly trained obstetrician or colorectal surgeon under theatre-type conditions, there is a significant risk that the woman will be left with life limiting loss of anal sphincter control. Without proper examination and diagnosis of the correct degree of tear, followed by prompt and skilled repair, the woman is likely to lose a significant degree of control of flatus and/or faeces from an injury like this and her life can be changed radically.
What are the medical negligence issues?
While perineal tears occur in the normal course of a well-managed childbirth, they can also arise due to the poor or negligent management of childbirth. Harm can also occur if a proper examination of the perineum is not conducted so as to identify the full extent and depth of the tear and when this happens such as when a junior or less experiences doctor is assigned to repair a tear, then the repair may be superficial and fail to repair the vital muscle tissues deeper within the tear. If this happens, the woman may miss out on the opportunity to have the tear repaired properly and go on to suffer long-terms, even life-long issues of incontinence with faeces or flatus or both together with serious consequences for her self-confidence, ability to work, function outside the home. In many cases, a person with these injuries will also experience painful sexual intercourse or be unable to partake of their normal intimacies due to the fear of embarrassment.
Where legal issues arise, these have tended to relate to:
What are the common features of cases related to 3rd and 4th degree perineal tears?
What steps do we take to establish if there is a strong cause of action?
An important part of our job for our client is to ensure that they are kept safe and that any cause of action identified by the medical experts is a strong one.
To achieve this level of safety for our clients, while acknowledging that in the litigation process around medical negligence, there is no such thing as certainty, we rely on leading independent medical experts to build the case.
We begin by taking up all relevant medical records relating to all pregnancies and any treatment received following the tear that is the subject of investigation. We examine these records to establish a timeline of events and also to identify what studies have been done such as manometry or endo-anal ultrasound that will give objective evidence of the degree of damage to those anal sphincter muscles. We are also interested in the documentation or recording of symptoms and when those symptoms of injury were first noted.
Then, if there remains a basis for enquiring further and if our client instructs, we will seek an expert review of those records and an estimate of the cost of that review. Such reports are time-consuming and leading experts will usually reflect the time spent in their fees such that an initial report can often cost €2,000 to €2,500. If that opinion is critical of the care given to the extent that no other medical practitioner of similar specialist or general skill would be guilty of this standard of care if taking ordinary care, then the criteria for negligence will be met where the injury complained of has been caused by that poor standard of care. The test has its complexities but it is our job to apply it correctly and advise our client what the expert opinion means in terms of negligence. It may be that the expert can show how the situation that arose was not caused by any want of care or skill and where this is the case, some comfort can at least be derived from knowing that the consequences were not avoidable. If on the other hand the expert report is critical to the degree that negligence is uncovered, then our client will be advised on the options including taking legal action.
We previously published a case study relating to a 4th degree perineal tear case here.
Over the past ten years, Cian O’Carroll Solicitors have represented many women with perineal tear injuries and have succeeded in each case by taking care to ensure there was top class expert opinion confirming that the woman had been treated to a negligence degree – not just a poor standard of care. We rely on leading experts to determine for our clients whether they have been failed by their case because it is the medical profession that ultimately decides what the correct standard of care for patients is, not judges or legal practitioners like us.
Here is a brief note referring to some of our recent cases relating to perineal tears:
+ In April 2020 Cian O'Carroll Solicitors achieved a €125,000 settlement at mediation just days prior to a specially fixed trial date. The case related to a 3rd degree tear that arose in the course of a complicated labour. The criticism of the hospital related to the failure to identify the need for and perform a caesarian section and subsequently causing delay before the resulting perineal tear was sutured.
+ In July 2019 Cian O’Carroll Solicitors represented a 33 year old woman who had suffered a 3C tear 7 years earlier during the delivery of her son. When she instructed us, she has been suffering severe and career limiting symptoms of incontinence and urgency whereby she needed to be near toilet facilities in order to feel confident. She also had ongoing vaginal and perineal pain that influenced her choice of clothing but also caused great harm to her intimate life with her partner.
Having considered the relevant medical records and obtained an independent medical expert review, it became clear that while the quality of medical care during the delivery was very good, after the delivery there was a failure to examine her properly and as a result the true extent of the tear was missed. But for that failure, she would have had a more extensive repair and on the balance of probability would have made a good recovery from this very serious tear.
While negligence was denied in the case, after just under two years, the case came on for trial when it settled outside court for the sum of €450,000, the majority of which was in respect of care and future care in particular to help make her future more manageable.
+ In February 2019 Cian O’Carroll Solicitors achieved a €360,000 settlement for a woman who had suffered a 4th degree tear during a forceps delivery at The Coombe when a junior doctor, albeit supervised by a consultant, failed to perform an episiotomy to protect her perineum. The plaintiff went on to suffer quite severe symptoms of incontinence together with psychological harm, loss of mobility and difficulties in performing her normal work both inside and outside the home.
Liability was denied in the usual way up to the trial of the action however the matter settled shortly before trial.
€7.25m Settlement approved for boy who suffered traumatic brain injury and induced autism at birth in landmark case
Cian O’Carroll Solicitors acted for Lisa Marie Murphy in her High Court medical negligence case concerning the traumatic circumstances of the birth of her son Finn Phillips in July 2005 at the National Maternity Hospital and his subsequent diagnosis of autism, behavioural problems and developmental delay that settled for €7.25 million in mid -June 2019.
Having read the maternal birth injuries post on Cian O’Carroll Solicitors’ website in November 2016, Lisa decided to try to get answers on whether there was substandard or negligent medical care provided to Finn at birth that caused his autism. Cian O’Carroll Solicitors commenced a detailed and complicated medico-legal investigation that ultimately resulted in identifying a strong medical negligence case for Finn against the National Maternity Hospital. Numerous medical experts were retained to identify and support Finn’s case. The crux of Finn’s case was that during labour and the instrumental vacuum delivery he was unnecessarily subjected to a prolonged period of asphyxia (lack of oxygen), excessive traction and trauma (from the vacuum delivery) that ultimately caused his subsequent developmental delay, behavioural problems and autism. Finn suffered hypoxia (lack of oxygen) at birth evident by a low APGAR score, a left sided focal seizure at 8 hours of age and MRI scan on day 5 of life that showed evidence of cephalohaematoma and subdural haematoma (a collection of blood outside the brain). Cephalohaematoma is a collection of blood outside the skull that can occur in 13% of vacuum deliveries. 19 medico legal reports, in total, were required to fully prepare Finn’s case for trial in the High Court.
The National Maternity Hospital had its own medical experts to refute Finn’s case. Negligence, the cause of Finn’s autism from birth negligence, his current and future requirements were fully disputed. The Hospital argued that the decision to proceed with the vacuum delivery was appropriate. The Hospital further argued that the cephalohaematomas almost certainly contributed to Finn’s early discomfort and early neonatal clinical concerns, but these subsequently resolved. Normal cord gases and normal brain imaging at day five of life and at age two went against an acute ischaemic (restriction in blood supply) event. According to the Hospital there was no evidence of intercranial injury with respect to brain functioning. Therefore, Finn's developmental delay and probable autism were unlikely to be related to peripartum delivery events. The Hospital further maintained that Finn’s autism could be due to an underlying possible genetic disorder.
Despite this strong defence put forward by the Hospital, Lisa and Finn successfully brought a “test case”. It was the first case of its kind in Ireland seeking to prove the alleged negligence in the circumstances surrounding Finn’s birth caused his subsequent development of autism, behavioural problems and developmental delay. Cian O’Carroll Solicitors retained 17 experts on Finn’s behalf to prove his case. However, Finn’s case was fully defended by the Hospital from the very start right up-to the mediation in June 2019 that resulted in the settlement of €7.25 million. The settlement was, however, made without an admission of liability. Meaning, the Hospital did not admit Finn’s case whereby any birth negligence caused his subsequent development of autism. It was, nevertheless, possible to reach a detailed settlement with the Hospital and this €7.25 million will ensure that Finn’s needs are met for the rest of his life.
Our work on the recent CervicalCheck case on behalf of Vicky Phelan shows the potential for complex litigation to proceed quickly through the courts. Our team took the case from initial instructions to trial where it settled after three days at hearing for €2.5m. The case also provided a platform from which our client rocked the Health Service that had treated her so badly and has began a process of reform that will save many lives and stand as a legacy to her strength of will and her courage.
This complex breast cancer misdiagnosis case resulted in a settlement for damages of €325,000 immediatley before trial for the 13 year old son of Dorota Sliwa who had died from her breast cancer in October 2015
DCU lecturer (26) died from carbon monoxide poisoning during a house fire in Limerick
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