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:
- Failure to proceed by caesarean section where it was required.
- Failure to perform an instrumental delivery (using either vacuum method or forceps or both) in a competent manner and thereby causing excessive and unnecessary pressure on the perineum during the delivery causing a tear.
- Failure to perform an episiotomy either competently or at all. An episiotomy performed at an inadequate angle may fail to protect the muscles around the anus and thereby cause or contribute to the injury.
- Failure to examine the tear competently in order to identify the full extent of the tear. Where this happens, a more complex tear may be missed altogether and the opportunity to repair it will be missed.
- Failure to repair the tear in the correct manner and in accordance with the established required procedures. The Royal College of Obstetrics and Gynaecology (RCOG) has set out very clear guidance on how to manage and repair such tears and failure to adhere to these guidelines will tend to give rise to objective criticism.
What are the common features of cases related to 3rd and 4th degree perineal tears?
- These injuries tend to be deeply private and while severe, can often be hidden by the injured party.
- The injury will tend to affect every aspect of the woman’s life. Such injuries can lead to social isolation due to the fear of embarrassment or even humiliation due to difficulties controlling wind or bowel movements. With such a fear, the person may avoid social occasions or be unable to maintain their work, their career. The injury will often lead to changes in self-image, a loss of confidence and sometimes an inability to wear some types of clothing without pain or discomfort. Intimate relationships are often deeply affected with either painful intercourse or a fear of loss of wind or bowel control a constant presence.
- The injury tends to be long-term, even life long because the repair and treatment options, while they exist, tend to be difficult and far from certain. In addition the condition associated with serious injury to the anal sphincter muscles is known to get worse for many women following menopause due to loss of muscle tone and onset of further pelvic floor weakness.
- Whether some or all of these changes occur to a person, the consequences are great and for that reason the damages tend also to be substantial. All of our cases have merited damages in excess of €100,000 with the majority in the range €250,000 to €450,000.
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 October 2019, Cian O’Carroll Solicitors successfully concluded a a High Court medical negligence case whereby our client suffered a 4th degree anal sphincter tear during the delivery of her first daughter at a regional hospital some 13 years earlier. Our client’s case settled before trial for compensation in the sum of €112,500.00. Our client was in her early 20's at the time of giving birth to her first daughter. The perineal injury she received resulted in our client sustaining severe pain, inconvenience, discomfort, and distress. She had a difficult recovery and a long stay in hospital. Further surgical investigation and surgical intervention in the form of repair of recto-vaginal fistula was carried out. She developed faecal incontinence. Like many mothers, our client never questioned her injuries after the birth of her first daughter. She was caused to believe that her injuries were just an unfortunate consequence of a complicated delivery. Approximately 10 years after the birth of her first daughter our client began to read up on her on-going injuries and contacted our office when she began to suspect that her care may have been negligent. A medico legal investigation promptly commenced that led to independent expert evidence identifying the true nature and extent of her injury. Expert opinion was strongly of the view that the management of her labour had been negligent. Her High Court case quickly progressed. The HSE argued throughout the High Court proceedings that our client’s case was out of time or 'statute barred' because it was more than ten years since the birth but we were confident that based on our successful Supreme Court case of Green v. Hardiman, we could show that she did not have sufficient knowledge of harm having been caused to her by the neglect of the hospital until shortly before the proceedings were issued. Ultimately the action was successfully concluded in less than two years with an out of court settlement.
+ 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.