Incontinence After Giving Birth
If you have developed incontinence after giving birth, you may have an unrepaired perineal tear. Read on to find out more about perineal tears, including risk factors, treatment and the consequences of a delay in diagnosis.
Types of perineal tear
There are four types of perineal tear. They are classified according to the severity of the injury:
A first degree tear is an injury to the vaginal wall.
A second degree tear is an injury to the vaginal wall and muscles of the perineal body.
A third degree tear is the same as a second degree tear but it also involves the anal sphincter. A 3A tear involves less than 50% of the external anal sphincter, a 3B tear more than 50% of the external anal sphincter, and a 3C tear implies the complete division of external and internal anal sphincters.
A fourth degree tear is the same as a third degree tear but also involves the anal epithelium.
Therefore a first degree tear is the most minor type of perineal tear, and a fourth degree tear is the most serious type of perineal tear.
First time vaginal birth
Medical experts agree that a woman's first vaginal delivery is the most traumatic and is more likely to be associated with perineal injury. Statistics shows that 1% of patients having a first-time vaginal birth will suffer a third degree tear.
Other risk factors
There are other factors that put a patient at risk of sustaining a severe perineal injury. Indeed, such tears can affect patients who have previously given birth by way of vaginal delivery.
The factors that increase the likelihood of a 3rd or 4th degree tear are:
- Assisted delivery with forceps or ventouse extraction
- Midline episiotomy (no longer practiced in the UK)
- Larger than average baby (over 10lbs)
- Fast second stage of labour, or prolonged active second stage of labour (more than one hour)
- Previous history of perineal injury
3rd and 4th degree diagnosis and treatment
The management of perineal tears has changed over the last 10 to 15 years. Previously, many 3rd and 4th degree tears were missed or not adequately repaired. Consequently many women went on to suffer persistent problems, particularly with regards to faecal urgency and incontinence.
However, obstetric practice has changed significantly since that time. Obstetricians and midwives are now much better at diagnosing and treating perineal tears, particularly third degree tears.
There are specific guidelines for the treatment of third degree tears. This covers the identification of such tears, repair and follow-up care with pelvic floor physiotherapy and assessment in a colorectal unit.
According to the Royal College of Obstetricians and Gynaecologists, a 3rd or 4th degree tear should be diagnosed immediately after delivery and should be repaired by an experienced obstetrician in the operating theatre. There must be adequate anaesthesia and good lighting.
Recovering from a 3rd degree tear
Because of the improvements in medical care, most women who sustain a 3rd degree tear make a good recovery. It is estimated that 70 to 80% of women who have had a 3rd degree tear regain normal continence levels.
Incontinence after a 3rd degree tear
Some women do experience a level of incontinence after childbirth. This may range from the inability to control wind to faecal urgency to complete faecal incontinence. This normally affects those whose internal anal sphincter has been damaged but has not been repaired.
An internal anal sphincter injury may be left unrepaired because a complication prevented the obstetrician from carrying out treatment. Alternatively the injury might be left unrepaired because it was not diagnosed at the time of delivery.
Delayed or secondary repairs
If a serious tear is missed at the time of delivery, it is likely that it will be diagnosed at a later stage, after a patient has sought medical attention for her symptoms. A suitable course of treatment must then be decided upon.
Sadly delayed repairs are not associated with a good long-term prognosis. Initially a patient may report a good result. Around 60% of patients will have acceptable continence in the first five years after the secondary repair. After this time period the level of continence falls to about 40%.
Often a patient's condition will deteriorate further with age. The menopause in particular can lead to worsening incontinence as the loss of oestrogen makes the muscles weaker. Further treatment can be attempted to help control symptoms. This might include physiotherapy, constipating agents, enemas, rectal irrigation or sacral nerve stimulation/neuromodulation.
Pudendal nerve damage
It is important to note that faecal urgency and incontinence may not necessarily happen because of a missed perineal tear. These symptoms can also occur due to other reasons, such as pudendal nerve damage.
A degree of pudendal nerve damage will arise with every vaginal delivery. It happens because the nerves are fixed in place and cannot move during the active second stage of labour when the perineum descends. Consequently the nerves get stretched and damaged, adversely affecting motor and sensory function. The risk of pudendal nerve damage is increased if there is a prolonged second stage of labour, instrumental delivery and repeat vaginal delivery.
Is a missed tear negligent?
Nevertheless, if a serious perineal tear is missed at the time of delivery, there will be a 'breach of duty'. This means that medical professionals have not delivered an acceptable standard of care. As mentioned above, 3rd and 4th degree tears should be identified shortly after the birth. A failure to recognise the injury will be deemed substandard practice.
It is common for a missed 3rd or 4th degree tear to cause problems such as incontinence. It is likely that such issues could have been avoided with better medical care. If this is the case, the affected individual will be legally entitled to pursue compensation for the damages wrongfully incurred.
Can I claim for medical negligence?
To find out if your 3rd or 4th degree tear has been negligently managed, leaving you to suffer incontinence after childbirth, you simply need to contact us at Glynns Solicitors today. We will be able to tell you whether you have grounds for a claim.
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