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Is it ok that we don’t talk about the chance of suffering a perineal tear in labour?

Health care lawyer Despina Kavadas looks at the stories behind perineal tear statistics

Mother and daughter
Despina is an experienced medical negligence solicitor who has specialised in this field since qualifying in 2002.
During my two pregnancies (in 2008 and 2012), nobody mentioned to me that there is a risk of sustaining a tear during a vaginal delivery, and when I specifically asked for a caesarean section, I was told of the risks of that mode of delivery, but none of the risks of a vaginal delivery, including the incidence and nature of perineal tears. I am hoping that six years on things have changed .
According to the RCOG’s report on this subject some 3% of deliveries result in a 3rd/4th degree tear. The figure is closer to 6% in first time mothers. The Office for National Statistics (ONS) calculates that there were 679,106 live births in England and Wales in 2017, so about . 20,373 severe tears happen each year, not all of which will involve negligence. 
Given the incidence and the cost to society, let alone the emotional and physical injury to the mothers who have suffered 3rd and 4th degree perineal tears, it is in everybody’s interest (the healthcare system, mothers and the public generally) that there is awareness about the incidence and the consequences of 3rd and 4th degree perineal tears. 

Perineal tear risk factors

  • A long labour
  • A ventouse or forceps delivery
  • Women who have been pushing for longer than recommended

Perineal tear case study

A look at one of our perineal tear claim cases illustrates the presence of a number of the risk factors that mothers face in labour which can result in severe injury if not recognised and dealt with appropriately.
Our client, known as Mrs L, was in labour for over 18 hours, and spent nearly two hours pushing. Medical staff attempted a ventouse delivery unsuccessfully, followed by a forceps delivery.  During delivery Mrs L suffered a fourth degree tear in which her internal and external anal sphincters were damaged.  Mrs L suffered persistent symptoms of faecal incontinence and incontinence of flatulence.  She was diagnosed with post-traumatic stress disorder and suffered from panic attacks and flashbacks as a result of her injuries.
The case centred upon the hospital trusts’ failure to perform an episiotomy at the time of the first pull of the forceps, failure to identify damage to and repair the internal anal sphincter, and failure by the consultant to attend Mrs L within a reasonable timeframe when the major obstetric haemorrhage alert was made.
The case was settled successfully but for Mrs L her injuries will affect her for the rest of her life.

Mothers need to know

Perineal tears should no longer be a taboo. The consequences of a 3rd and 4th degree perineal tear are far reaching. Mothers need to be armed with knowledge during their pregnancies so that they know what to expect, make an informed decision about how to proceed with their delivery and get the help and support they need should they suffer a perineal tear. There needs to be greater support for mothers, increased public awareness and better education for medical professionals. 
There are a number of support groups and charities, but in order for these to be effective the public needs to know they exist. Clients who approach Leigh Day and who have suffered perineal tears do not know about the various support groups. For example, the MASIC foundation is a charity which aims to help mothers with anal sphincter injuries following childbirth, and which campaigns to influence change in healthcare policies to avoid these injuries, improve their detection and where possible improve the rate of repairs after birth, so more women are spared the indignity of anal incontinence.

Other support groups are Birthrights, who are dedicated to protecting human rights in childbirth, Birth Tear Support who have their own closed facebook page, and who offer support and signpost mothers to other groups such as the Birth Trauma Association
Women should be informed about all aspects of their pregnancy and delivery, including the possibility of suffering a 3rd or 4th degree perineal tear during a vaginal delivery.  This subject is too important to be ignored. The emotional and economic consequences of having these tears are immense. 
I think that there needs to be more education, information and communication so that we can eradicate the stigma associated with tears, we can prevent them occurring in the first place, and when they do occur, they can be identified quickly and accurately and the mothers are signposted to appropriate support networks.

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