Is it time for women to be adequately consented prior to childbirth on the severe tear risks that can occur during a natural birth?
The devastating and potentially life-long consequence of sustaining a childbirth tear is not a topic of conversation most women wish to speak about. Symptoms that clients have reported to us include urinary and fecal incontinence, bladder and bowel prolapse, difficulty going to the toilet, vaginal bleeding, difficulty having sex and fear about a future pregnancy together with the psychological trauma associated with all of that. In addition, such an injury can adversely impact on a mother’s day to day life, her ability to work and socialise.
- In 2014 the HSE published guidelines on the management of obstetric anal sphincter injury (the medical term for 3rd and 4th degree tears associated with childbirth – the most severe type of tear). It estimated that over 85% of women who have a vaginal delivery will sustain some degree of perineal trauma.
- The HSE’s Clinical Report in Obstetrics and Gynaecology published in August 2016 indicates there were 46,437 vaginal deliveries in 2014 and of those 891 or 1.9% suffered perineal tears(1) – the report defines perineal tears as tears in the vaginal tissue, perineal skin, and perineal muscles that extend into the anal sphincter and/or go through the anal sphincter and the tissue underneath it.
- The State Claims Agency (the manager of the Clinical Indemnity Scheme) in their report published in October 2015 on the National Clinical Incidents identified 3,676 perineal tears (3rd and 4th degree tears including breakdown of the perineum) during the 4-year period 2010 to 2014.
The RCOG published its guidance for the management of third and fourth-degree perineal tears in June 2015. It states all women having a vaginal delivery are at risk of sustaining obstetric anal sphincter injuries (OASIS). They should therefore be examined systematically after the baby is delivered, including a digital rectal examination, to assess the severity of damage, particularly prior to suturing. Unfortunately, in our experience such examinations do not appear to happen all of the time.
Of course, not all childbirth tears will equate to negligence. Yet, those cases that do arise from substandard care tend to reveal errors such as the injury being caused by the pushing being too long in the second stage of labour; an inadequate episiotomy; women who have had forceps deliveries including where the forceps were misapplied. Research suggests delivery by instrument raises the risk of an anal tear. There are other factors too such as the average age at which women give birth (the risk of damage from a natural delivery increases with age) and large babies. The problem is usually made worse if the damage is not noticed quickly after the delivery. In some cases, we have seen when the injury is noticed it is ineptly repaired or problems can arise when the medical team classify a 3rd or 4th degree tear as a 1st or 2nd degree tear.
Given the debilitating injuries that such tears can cause it is no wonder that Hans Peter Dietz, a Professor of Obstetrics & Gynaecology at the University of Sydney has called for women to be consented and informed of the risks prior to childbirth. In one of his articles he has stated ‘since the mid-90s, Australian law has required doctors to disclose material risks of proposed treatment. Medical practitioners have had two decades to adapt, and, by and large, patient autonomy is acknowledged and respected by obtaining ‘informed consent’. While problems with obtaining consent do surface in medico-legal litigation, practitioners are generally aware of the need to do so and usually comply with requirements. However, not in obstetrics. Here, even if material risk of a serious adverse event in an attempt at vaginal birth in a given case is over 50% (as it would be in the case of a 35-year-old primigravida at 41 + 3) obtaining informed consent is the exception rather than the rule. This degree of paternalism is not just unethical and immoral. It is illegal – and it needs to change.’(2)
So how is it the case that a mother’s body can be damaged beyond repair without her being informed of the risks? Is it the case that women are not being told of the potential trauma of vaginal births for policy reasons? For example, caesarean sections might be seen as being costly and could be viewed as putting an unnecessary pressure on an already stressed health care system. But at what cost? Women who are accessing maternity services ought to have the best information regarding potential risks of childbirth irrespective of policy considerations. This is not happening currently. For example, on the HSE website it gives mothers to be details regarding a natural birth and births by C-section. In the natural births section, it doesn’t set out the risk attached to an instrument delivery whereas the risk of undergoing a C-section is set out. Elsewhere on the website the HSE states regarding forceps delivery ‘some women may experience slight tearing of the perineum area during childbirth.’(3) That statement may be true for ‘some’ women but not for all women who undergo assisted delivery via forceps. For those women that acquire a 3rd/4th degree tear from a forceps delivery and are left with for example pelvic organ prolapse, the reference to a ‘slight’ tear is hugely misleading. Just because a woman is pregnant does not mean she has less authority over her body. It is now high time women were adequately informed of the risk of tears during labour and appropriately consented on these potential severe complications prior to childbirth.
Contact us at Cantillons Solicitors at +353 (0)21 -4275673 or firstname.lastname@example.org if you would like more information.
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