Third Degree Perineal Tear
Sophie Brown, aged 28, suffered a third degree tear during the birth of her first baby, which was overlooked and not properly treated.
On 16th August 2009 Sophie was admitted to the central delivery suite with a history of spontaneous rupture of the membranes, her contractions having started shortly before this.
As labour progressed, vaginal examination revealed the cervix to be 9 cms dilated with the head in the occipito anterior position. About 45 minutes later, the midwife performed a vaginal examination and found the cervix to be fully dilated (thus at 10 cms), but wrote 'Occipito anterior' suggesting that she questioned the findings of the doctor who had examined Sophie 45 minutes earlier.
About an hour and a half later an episiotomy was performed. This is a deliberate incision that is equivalent to a second degree tear. In Sophie's case it was not clear whether she had a medio lateral or mid line episiotomy. In the UK it is usual practice to perform a medio lateral episiotomy as if there is a mid line episiotomy it will materially increase the risk of a third or fourth degree tear.
The baby was born and the head was delivered in the occipito posterior position and not the occipito anterior position as assessed by the registrar.
The summary of labour was recorded as follows -
- 16.8.10 Spontaneous rupture of membranes at 23.00 hours.
- 17.8.10 Labour onset 17.30 hours.
- Cervix fully dilated (10 cms) 15.36 hours.
- Childbirth 15.12 hours.
- Placenta expelled 17.06 hours.
- Baby weight 301.10 grams.
- Head circumference 37 cms.
The perineal repair sheet was filled in as follows -
- Episiotomy - yes
- Indication - to facilitate delivery
- Tear - 2nd degree
- Local anaesthetic - 20 mls of lignocanine 1% (10 mls initially, 10 mls afterwards, etc)
- Repair - 2 - 0 vicryl rapide continuous to muscle and muscle, interrupted and continuous to skin
- Needles correct ...tick
- Swabs correct ... tick
- PR volterol 100 mgs PR (per rectum)
- PV ...tick
- Comments: sutured by Dr. Smith
Perineal tears are classified as follows:
1st degree : laceration of the vaginal epithelium or perineal skin only.
2nd degree: involvement of the vaginal epithelium, perineal skin, perineal muscles and fascia but not the anal sphincter.
3rd degree: disruption of the vaginal epithelium, perineal skin, perineal body and anal sphincter muscles. This should be further sub-divided into :
- 3(a) : partial tear of the external sphincter involving less than 50% thickness.
- 3(b) : tear of the external sphincter involving more than 50% thickness.
- 3(c) : external and internal sphincter torn.
4th degree : any third degree tear with disruption of the anal epithelium.
It became clear during post-natal examinations and tests that in fact Sophie had sustained a severe third degree tear which had not been diagnosed by the registrar at the time she gave birth. Sophie saw various clinicians, to include colorectal surgeons, who all agreed that there was evidence of anal sphincter injury. An endo anal ultrasound was then undertaken which revealed “complete absence of any normal internal or external sphincter anteriorly between 9 and 3 o'clock”.
One colorectal surgeon actually stated in a letter that this was one of the worse injuries she had seen on an ultrasound. Sophie suffered after the birth from faecal urgency, faecal incontinence and passive soiling. These are symptoms that are in keeping with the severe injury of the internal and external anal sphincter.
As it is not possible for an injury of this type to develop spontaneously after delivery, it must have occurred during birth and was missed at the time of the delivery and before the repair of the episiotomy.
According to NICE guidelines (National Institute for Clinical Excellence), systematic assessment of genital trauma after birth should include :
- A further explanation of what the healthcare professional plans to do and why.
- A confirmation by the woman tested effective local or regional analgesia is in place.
- A visual assessment of the extent of the perineal trauma to include the structures involved, the apex of the injury and assessment of bleeding.
- A rectal examination to assess whether there has been any damage to the external or internal anal sphincter if there is any suspicion that the perineal muscles are damaged.
Prior to any suturing, after visual examination of the genitalia, the labia should be parted and a visual examination should be performed to establish the full extent of any vaginal tear. A rectal examination should then be performed to exclude injury to the anorectal mucosa and anal sphincter. The vagina should be exposed by parting the labia with the index and middle fingers of the other hand. In order to diagnose third or fourth degree tears, clear visualisation is necessary and the injury should be confirmed by palpation. By inserting the index finger in the anal canal and the thumb in the vagina the anal sphincter can be palpated by performing a pin rolling motion. Every woman should have a rectal examination prior to suturing in order to avoid missing anal sphincter tears as well as isolated recto-vaginal tears.
However, in this case, the registrar conducted the repair without performing a rectal examination prior to the repair. Indeed there was no evidence that he even performed an examination after the repair. There is no record of a rectal examination having been performed.
In addition, the registrar wrongly diagnosed the position of the foetal head. When the registrar examined Sophie, the cervix was 9 cms dilated. At that point a competent registrar should be able to diagnose the position of the foetal head. In Sophie's case, her baby was not in the occipito anterior position (face looking upwards), but, rather, in the occipito posterior position. Had the registrar diagnosed that, he could have manually rotated the head to an occipito anterior position and thereby reduced the risk of the third degree tear.
In this case it was not negligence that the third degree tear occurred in the first place. At present the occurrence of anal sphincter injury is not considered sub-standard care because it is a known complication of vaginal delivery. However, following the delivery the registrar should have had a high index of suspicion to exclude a third degree tear as Sophie had a number of risk factors, namely, it was her first vaginal delivery, the baby was born in the occipito posterior position, the second stage of labour lasted longer than one hour and a short perineum (the area of muscle covered by skin between the posterior point (fourchett) of the vaginal and the anus) as the midwife recorded this on two occasions.
Conclusion
Had a proper rectal examination been performed by the registrar, the third degree tear would have been diagnosed and the repair would have been conducted in an operating theatre after the delivery, which should have been successful. This means that Sophie would have avoided the need for a second operation to repair the anal sphincter and reconstruct the perineum.
Furthermore, if a primary repair had been performed at the time of delivery, a caesarean section for all future pregnancies might well have been avoided. However, as she required a secondary repair her future deliveries would have to be by caesarean section.
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