3rd Degree Tears
A third degree tear must be diagnosed and treated in the hours following the birth. A failure to achieve this standard of care will amount to medical negligence. If this has affected you or your loved one, please get in touch with us today to discuss a compensation claim.
Risk factors of third degree tears
The Royal College of Obstetricians and Gynaecologists (RCOG) estimate that 9% of women in the UK will suffer a severe tear every year. A 'severe tear' is classified as either a third or fourth degree tear, both of which involve the perineum and anal sphincter complex.
A third degree tear can affect any women giving birth by way of vaginal delivery. Nevertheless, a number of retrospective studies have identified certain risk factors that increase the chance of a third degree tear occurring. These are:
- Larger than average baby, with a birth weight over 4kg
- First time giving birth by vaginal delivery
- Epidural analgesia
- Second stage longer than one hour
- Shoulder dystocia
- Forceps delivery
Forceps delivery
The risk of sustaining a third degree tear is particularly high if a forceps delivery is performed.
Forceps blades, when applied to the foetal scalp, always increase the diameter of the presenting part in comparison to the maternal pelvis. It is well documented that by comparison to a ventouse delivery, obstetric forceps are more likely to be associated with significant maternal perineum and vaginal trauma.
For this reason, the ventouse was advocated as the instrument of first choice in 1989, as it reduces the chance of maternal pelvic floor injuries. The downside to this approach was an increase in the risk of a failed operative delivery and of sequential use of instruments – i.e. ventouse followed by forceps. This has inherent additional risks to the mother and infant.
Therefore, the most recent RCOG recommendations suggest that a careful, well-trained operator will select the instrument best suited to the individual circumstances.
Rectal examination to diagnose perineal trauma
After a vaginal delivery, medical practitioners must assess the extent of perineal trauma. This can be achieved with a thorough examination of the vagina, as well as a digital rectal examination.
The digital rectal examination is especially important as it is the only way to diagnose a third or fourth degree tear, both of which involve the anal sphincter. Without performing a digital rectal examination, the clinician will have no way of telling whether or not a third degree tear is present.
Despite this, it is surprising how many patients are not given a digital rectal examination. For some, this means that their third degree tear remains undiagnosed. Most will instead be told that they have suffered a superficial injury – i.e. a first or second degree tear – and sutured accordingly. As a result, the outer skin will be intact, but underneath will remain a significant defect that has been left untreated.
A failure to perform a digital rectal examination would be considered to be representative of a poor standard of clinical care.
Consequences of a missed 3rd degree tear
If a third degree tear is not diagnosed and treated, the patient in question will go on to develop problems with faecal urgency, faecal leakage, faecal incontinence and incontinence of wind (flatus).
Such symptoms will of course be extremely upsetting, particularly while trying to care for a new born baby. Having to face these problems will be all the more troubling when they could have been avoided with the proper medical care.
Indeed, if a patient's third degree tear had ben correctly identified and repaired in a timely manner, on the balance of probabilities she would not have gone on to experience complications. Furthermore, it is probable that she would not have required further treatment, such as surgery.
Treating a missed 3rd degree tear
If a 3rd degree tear is diagnosed in the weeks, months or years following the birth, a suitable treatment plan must be devised. There are various treatments available, including sacral nerve stimulation, biofeedback and secondary anal sphincter repair.
Unfortunately, however, the longer a third degree tear remains untreated, the harder it is to repair. RCOG says that 'women should be advised that the prognosis following an EAS [external anal sphincter] repair is good, with 60-80% asymptomatic at 12 months. Most women who remain symptomatic describe incontinence of flatus or faecal urgency.'
Sadly, the longer-term assessment is not as good, with just 30-40% reporting a satisfactory outcome after five years. Therefore symptoms may improve in the short-term, but it is likely that a patient's condition will deteriorate within five years of a secondary repair. This will decline further with age, especially with the onset of the menopause.
Caesarean sections after missed 3rd degree tear
If a woman does develop complications due to a missed third degree tear, she may not be able to give birth naturally in the future. This means that any future deliveries will have to be made by way of elective Caesarean section. This is supported by RCOG, which states that all women who have sustained an obstetric anal sphincter injury in a previous pregnancy and who are symptomatic should have the option of an elective C-section.
Claiming compensation
If a third degree tear is properly diagnosed and treated, on the balance of probabilities, a patient will avoid:
- Ongoing symptoms of faecal urgency/incontinence, and incontinence of flatus
- Secondary treatment, such as a surgical anal sphincter repair
- The need to give birth by way of Caesarean section in future
If the aforementioned complications do arise because a third degree tear is missed, there will be grounds for a medical negligence claim. This is because any reasonably competent obstetric practitioner should be able to identify a third degree tear – this includes midwives and doctors. Once diagnosed, a repair should be performed by an experienced surgeon. Any reasonably competent colorectal/obstetric surgeon should be able to repair a third degree tear to an acceptable standard.
Therefore when a third degree tear is missed or poorly repaired, the level of care will be deemed substandard. When a substandard level of medical care causes a patient to suffer avoidable injury – such as faecal incontinence – she will be legally entitled to pursue a claim for the damages wrongfully incurred.
Contact us today
If you would like to talk to a solicitor about claiming compensation for a third degree tear, please contact us today. We specialise in third degree tear claims and will be able to advise you further.
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