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Childbirth is exceptionally safe in United Kingdom, thanks to the progress made over decades in safety and quality of care. Despite this, perineal trauma in the form of anal sphincter injury is increasing in incidence. The reported rate of OASIS (Obstetric anal sphincter injuries) in singleton, term, cephalic, vaginal first births in England has tripled from1.8% to 5.9% from 2000 to 2012. The overall incidence in the UK is 2.9%, with an incidence of 6.1% for first birth compared with 1.7% for women having subsequent birth.
The NHSLA 10-year report on maternity claims identified perineal trauma as being the fourth highest indication for claims, with £31 million in legal pay outs. It accounts for nearly 9% of all maternity claims and is superseded by claims related to the management of labour (14.05%), Caesarean section (13.24%) and cerebral palsy (10.65%).
(Ref: http://www.nhsla.com/safety/Documents/TenYearsofMaternityClaims2012.pdf)
The National Patient Safety Agency (NPSA) stratification considers OASIS as moderate to severe harm and its definition is outlined below.
Moderate: Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving NHS-funded care.
Severe: Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving NHS-funded care.
(Ref: http://www.npsa.nhs.uk/corporate/news/npsa-releases-organisation-patient-safety-incident-reporting-data-england/)
Recently, a High Court Judge awarded £1.6 million in damages for ‘claim for damages arising from a serious obstetric injury suffered by the Claimant, Mrs Sarah Davison, during the delivery of her first child, whilst under the care of the Defendant, a Consultant Obstetrician’. (Davison v Leitch EWHC 3092, Court of Appeal- Queen’s Bench Division).
There are two national ‘guidance’ over standard of care regarding perineal injury and its management. They are from the Royal College of Obstetrician and Gynaecologists as a Green top guideline, number 29, ‘The Management of third and fourth degree perineal tears’, dated June 2015.
(Ref: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf).
This guidance was revised after the above- mentioned judgement and now incorporates detailed evidence based guidance for prevention and management of such injuries.
The other relevant guidance is under ‘intrapartum pathway’ developed by NICE and published first in December 2014. It has outlined ‘interventions to reduce peirneal trauma.
(Ref: https://pathways.nice.org.uk/pathways/intrapartum-care#path=view%3A/pathways/intrapartum-care/care-in-second-stage-of-labour.xml&content=view-node%3Anodes-interventions-to-reduce-perineal-trauma.)
Though the above two guidances largely concur, there remains some difference in the guidance above regarding the ‘angle of episiotomy’ and potential ‘hands poised’ approach for vaginal birth. This could lead to differences in expert opinion based on interpretation of such guidance.
Guidance does not have a legal status in English Law. However they are evidence-based documents prepared by learned Societies and Organisation with credible background. Many Maternity units will have their own ‘protocol’ based on such documents. It would be prudent to examine case records meticulously with contemporaneous national guidance to determine any liability issues.
There is no validated risk scoring system to predict OASIS and occurrence of such is not necessarily considered ‘negligent’. However failure to detect such injuries and perform primary adequate repair of OASIS has formed the bulk of successful litigation and claims.
In light of recent Montgomery ruling (Montgomery v Lanarkshire Health Board, (Ref: https://www.supremecourt.uk/decidedcases/docs/UKSC_2013_0136_Judgment.pdf), the medico- legal aspects of ‘consent’ has attracted great attention. The duty of care is not only to avoid or avoid exposing any personal injury or its risk, it is also an entitlement for the patient to decide whether or not to incur the risk. The Court effectively concluded that the ‘Bolam test’ is no longer appropriate in consent cases.
At present, normal vaginal birth is not ‘consented’ but it could open a debate whether such needs to be the practice. Some Maternity units have started ‘consent’ process for operative vaginal deliveries, which (operative deliveries) are known to increase the risk of OASIS. The validity of such consent process while under analgesics and extreme physiological duress is still to be tested in the Court of Law. The Montgomery ruling recognises that such discussion is unlikely to take place in emergency situations, which are often the case during childbirth scenario.
Considering the above, the question to answer in case of an OASIS could be the adequacy of information for patients and consideration of avoidance of such risks for health care providers in selected cases.
There are now gathering evidence in strategies to reduce the incidence of such injuries. This includes use of specialised scissors, episiotomy techniques and role of improvement of sustained targeted training for the health care providers. One also needs to keep in mind the already published evidence and guidance in proper management of such injuries, once detected.
Normal childbirth should be safe and an experience to cherish. While incidence of ‘harm’ is rare, the increase in incidence of OASIS together with is devastating consequence in some women is real. The medico-legal profession needs to take cognizance of the evidence-based guidance, which are available as established standards of care.
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