Most women who give birth vaginally do so safely and without any long-term health issues. However, according to NHS data, around 4% of women suffer third- or fourth-degree tears during childbirth. In some cases, complications can result in severe and life-changing maternal injuries.
Sadly, Tees Law’s specialist Medical Negligence team knows only too well the devastating impact of such cases. One example is Niamh who experienced a third-degree tear following a vaginal birth. This was despite Niamh having expressed a preference for planned caesarean section. Her claim against Kingston Hospital NHS Foundation Trust is based on breaches of duty before, during and after delivery.
Lack of informed consent
Niamh became pregnant in early 2018.
At 16 weeks, she met with a male registrar and explained that she expected she would need to have a C-section because all the women in her family had given birth that way. In addition to her family history, Niamh’s very slight build further suggested that C-section would be the best method to deliver her baby. Niamh recalls: “the registrar looked me in the eye and said that ‘we would very much support a vaginal birth at this stage’. lt felt to me from the outset like it was going to be a battle to get a c-section and that I was being told that I didn’t need one, despite my family history. To be told so early on that I would need to have a vaginal delivery, made me really anxious.”
Later on at her booking appointment, Niamh also explained her family history of c-sections to the midwife. The midwife referred Niamh to Birth Options to discuss the mode of delivery. There, she was told that a vaginal birth would be much better for the baby. She was also informed that a vaginal birth would allow her to get back to her daily routine sooner. Additionally, she was warned of the risks of having a C-section, including the potential to lose a lot of blood.
Throughout the antenatal process, Niamh repeatedly asked about having a C-section. At 26 weeks, it was noted that she felt “very anxious about [the] birth and uncomfortable within the hospital”. She expressed doubts about her ability to give birth vaginally but was nevertheless encouraged to pursue this route. In the end, based on the medical assurances she had received, Niamh agreed to proceed with a vaginal birth.
An assisted delivery
A week before Niamh went into labour, an ultrasound scan revealed that her baby was back-to-back, a position that increases the risk of complications during delivery. At this point, Niamh asked again if this meant she should have a C-section. She was told that the baby would likely turn around and there would be no problem.
In October 2018, Niamh went into labour spontaneously at 40 weeks. The baby remained back-to-back, and Niamh could not deliver so she was taken to theatre for assisted delivery. A C-section was not offered to Niamh. Instead, the baby was delivered after three pulls of the ventouse and four pulls of the forceps. Her daughter, Darcey, was born safely, but the instrumental delivery caused Niamh to sustain a Grade 3 tear, along with significant and irreparable muscle damage.
Niamh bled heavily for 16 days after giving birth. She suffered faecal urge symptoms and abdominal distension, and her haemoglobin levels fell to 52 grams per litre. On day 5, she was given an X-ray but was refused a CT or MRI scan. The X-ray didn’t reveal anything and despite her symptoms, Niamh was told there was nothing untoward. Niamh pressed for a CT or MRI scan but continued to be refused. Finally on day 9, after having to wait a full weekend and only after continuing to press further, an ultrasound was performed, which failed to detect any medical issue.
Finally, a CT scan was arranged and Niamh was subsequently diagnosed with a pelvic haematoma requiring surgery.
After this, she was unable to pass urine. Several attempts at trial without catheter failed, but instead of being referred to uro-gynaecology, she was discharged with a catheter.
Niamh was in and out of hospital several times during November 2018 to attempt a trial without catheter (TWOC). Eventually, Niamh sought her own private consultant and on the consultant’s medical advice, went back to the NHS to request a suprapubic catheter.
Niamh was re-admitted in late November 2018 and underwent further surgery to insert the suprapubic catheter into her stomach, a procedure which she found extremely distressing.
Niamh’s catheter was not removed until the start of January 2019. During this time, she experienced coccyx, groin and deep pelvic pain, as well as faecal urgency. Since then, Niamh has continued to suffer from psychiatric injury. She has been diagnosed with PTSD and also suffers chronic coccyx pain, which causes her to wake up in pain. She also suffers urgency of continence and has not been able to return to work.
Failures at every stage
There were medical failures at every stage in Niamh’s story. In antenatal meetings, she was not properly counselled as to the pros and cons of C-section compared to vaginal delivery. Having expressed concern regarding the risks of giving birth vaginally, specifically in relation to her family history of C-sections, Niamh was assured that this was the best method of delivery. At no point was she presented with a balanced picture of the benefits and risks of each option. If she had been warned of the risks associated with vaginal delivery, she would have chosen a C-section.
Although she knew there was a small risk she could tear, Niamh was not warned this could lead to difficulties with continence. Moreover, she was warned of the dangers of C-section and the potential disruption this could cause to her recovery, but she was not provided with an equivalent risk assessment of vaginal delivery. For example, she was informed that she could suffer excessive bleeding with a C-section but was never told that this could also happen with a vaginal delivery. Niamh was also not informed about the risk of requiring instrumental assistance.
During labour, there was an opportunity to perform a C-section yet Niamh was not offered the option of a C-section. Furthermore, once assisted delivery with ventouse and forceps had been chosen, there was a failure to manage the delivery in such a way as to avoid the tear.
Finally, Niamh experienced negligent postnatal treatment. There was a delay in escalation, imaging, identification and treatment of the haematoma. Had the haematoma been diagnosed and treated earlier, the extent of the infection would have been less severe. Because of the failure to treat in a timely manner, her episiotomy wound broke down twice and wasn’t able to heal properly which has resulted in the formation of extremely painful scar tissue.
An all-too-common problem
Ultimately, had Niamh been able to go ahead with her preference for a planned C-section, she would have avoided the third-degree tear, haematoma and the rest of the consequences that have resulted from her instrumental delivery. Unfortunately, Niamh is not alone in suffering injury and long-term complications from a vaginal birth that should have been avoided.
Official NICE guidelines state: “For women requesting a caesarean section, if after discussion and offer of support… a vaginal birth is still not an acceptable option [Trusts should] offer a planned caesarean section.” Yet a report by Birthrights in 2018 revealed that only 26% of Trusts offered C-sections in line with NICE best-practice guidance.
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