4th degree perineal tears compensation claim advice


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Regardless of how successful the delivery has been, a due mother can, unfortunately, suffer birthing injuries which may have a significant effect on her quality of life thereafter.

Clinically referred to as third or fourth degree perineal tears (or alternatively, lacerations) a 3rd degree tear is one which occurs in the vaginal tissue, perineal skin and associated muscles which also extend into the anal sphincter, whilst the focus of this particular brief guide – namely the 4th degree perineal tear – takes effect in the uncomfortable way, shape and physical form of a rip which compromises the anal sphincter and the tissues which lie directly beneath it.

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Is there any way of knowing/pre-empting a 4th degree perineal tear so that clinical staff can prepare to treat or avoid it?

Sadly not. In terms of factoring in any perceivable risks, there are no pre-determined measures or procedures which will inform healthcare professionals in advance whether or not they’ll experience a tear of this very nature during childbirth. That said, there are certain aspects crucially related to the delivery of a new-born baby from a mother’s perspective which will assess, or at least go some way to establishing just how likely a 4th degree perineal tear might be. These include the following more commonly linked elements:

  • Should the labour be induced
  • If it’s the mother’s first vaginal delivery
  • In the event of the pregnant woman having an epidural
  • If the baby weighs over 4kg
  • If a long second stage has played out
  • Should the foetal position describe the back of the baby’s head as being positioned up against the mother’s back
  • If shoulder dystocia presents (where the baby’s shoulder becomes trapped above the mother’s pelvis)
  • If the distance between a vaginal opening and anus is shorter than average
  • In the event of a midline episiotomy
  • Should the use of forceps be required during delivery

Note: Not all perineal tears are problematic, and the majority of cases are resolved within a year.

What are the different degrees of perineal tear?

In total there are four degrees of perineal tear, leading up to the subject discussed hereabouts, the 4th degree. To afford you the fuller picture, in ascending order we have listed the previous degrees of tear below. For the record, the procedure that the midwife (or obstetrician) adhere to with regards to repairing the tear depends on the severity of the grades which follow:

1st degree perineal tear – Described as the most superficial of tears, this involve the skin of the perineum and the tissue around the opening of the vagina, or the outermost layer of the vagina itself; yet doesn’t normally affect muscle groups located close by. These tears, called first-degree lacerations, are often so small that few (or no stitches) are required, and they tend to heal quickly and cause little or no discomfort

2nd degree perineal tear – Second-degree tears/lacerations go deeper, and penetrate the muscles found underneath. These tears need to be stitched closed, layer by layer and it’s fair to say that they will, inevitably cause the individual some level of discomfort. Typically they take a few weeks to heal, with the stitches dissolving on their own during the healing period.

3rd degree perineal tear – This one which occurs in the vaginal tissue, perineal skin and associated muscles together with the anal sphincter

4th degree perineal tear – In a grade 4 tear, the damage extends to the anal canal and possibly also the rectum. Women who suffer a 4th Grade perineal tear face nearly double the risk of developing post-partum faecal incontinence compared to women with only a 3rd grade tear. The lesser grades of tear (1 – 2) may be repaired by a midwife and performed in the delivery room after the successful birth/delivery, however, third and fourth degree tears must always be carried out by an experienced and appropriately trained obstetrician

Note: Whenever a tear occurs during childbirth, it must be assessed by a medical professional and given a grade.

How are perineal tears treated?

Should the extent of the perineal tear require stitches, a local anaesthetic is first injected directly into the areas that need numbing. In the case of an extensive tear the likelihood is that the patient would receive what’s called a pudendal block ; which is an injection of a local anaesthetic directly into the vagina walls, and which effectively bathes the pudendal nerve and numbs the entire genital area. Once this is carried out then the dedicated health practitioner will turn their attentions to stitching the patient up, layer by layer.

Thereafter – and on completion of the surgical stitching – the patient will be instructed to apply ice packs to the area for the next 12 hours or more. Without being too graphic, if the individual has sustained more than a small nick, chances are they’ll be quite uncomfortable and require additional pain-relieving medication at the same time for the next few days.

In the event of perineal tears being effectively diagnosed and repaired, most patients should fully recover within 12 months, although it’s necessary for each stage of assessment and repair to be meticulously documented by the appropriate medical staff.

In what circumstances would I be entitled to claim compensation in relation to a 4th degree perineal tear?

If you believe that the care you received at the time fell below expectations/perceived to be substandard, if the subsequent treatment you were party to was not carried out as described beneath and/or if you still have symptoms relating to your tear then you may be able to claim for compensation.

  • 4th degree perineal repairs should ALWAYS be carried out in a theatre by an experienced obstetrician
  • The appropriate kind of sutures must be used based on the nature of the tear
  • The patient should be prescribed a course of antibiotics and a laxative
  • 6 weeks after the birth, the patient should see the obstetrician or gynaecologist for a review.

As we’ve already intonated above, the pain will subside over an undefined passage of time after corrective measures are undertaken/procedures performed, yet varying levels of discomfort may last for 3 months or more. The following tips are designed to make your life more comfortable should you have endured a 3rd or 4th degree perineal tear during the delivery of your new-born child:

  • Urinating (or having a bowel movement) can be painful. Make sure your practitioner orders a stool softener/laxative so you can start taking it right away and continue taking it for the first few weeks that you’re home
  • Never resist the urge to move your bowels or you could risk become constipated
  • Don’t have sex until you get the green light from a healthcare professional with experience in this area
  • Avoid putting anything, including suppositories or an enema, into your rectum
  • Women with tears into the sphincter (or extending to the rectum) are more likely to have incontinence of gas or faeces later

How to make a perineal tear compensation claim

We wouldn’t let it be said that all complications associated with perineal tears are the result of medical negligence, yet it’s not beyond reason that in some, more extreme episodes, some women suffering from severe perineal tears may experience a total breakdown of their perineum. This worst case scenario could even lead to the onset of urinary and faecal incontinence and may even necessitate the patient having a colostomy.

However it would be misleading to suggest that any situation whereby a woman experienced a perineal tear could cite medical negligence as that would be far from the truth. In 2011 NICE drew up new guidelines on the provision of a caesarean section, which is often advised if it’s determined that the baby due is set to be a large one which could be a precursor to birthing problems for both expectant mother and unborn child. This guide outlines the maternal right of a mother to be able to opt for a caesarean birth in certain scenarios and where certain criteria are met. If these request are declined at the time and subsequently the mother suffers a significant perineal tear injury which could have been prevented by being offered a caesarean, then it could pave the way for the legally justifiable pursuit of claims on the grounds of medical negligence.

Arguably the most recurrent basis for a tear presents in the repair phase. Repairs to the 4th degree perineal should be done in accordance with the guidance in relation to the type of suture and appropriate materials, and this procedure should be fully documented.

If you have been diagnosed with a 3rd or 4th degree tear and the treatment an individual received failed to cover the fundamental bases detailed in a previous paragraph (and the claimant is still suffering from problems) then they may be in a strong position to pursue a claim for personal injury. Another area where claims of this nature could prove to be successful, hypothetically-speaking that is, is during a subsequent pregnancy. If a woman has previously had a perineal tear, regardless of whether there are ongoing problems, this should always be taken into account when considering the method of delivery (namely caesarean) for her subsequent baby.

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