Obstetric Anal Sphincter Injury: SP -v- Luton & Dunstable University Hospitals NHS Foundation Trust

Negligently acquired Obstetric Anal Sphincter Injury (OASI), that occurred during the birth of her second child, which left permanent bowel and bladder symptoms and injuries to her vagina - case settled in January 2024 - £85,000.

The Claimant (C) instructed Andrew Taylor a Partner in Birchall Blackburn Law, who is a Law Society Accredited Clinical Negligence expert to deal with a claim against L&D UH NHS FT, for injuries and consequential losses arising from a negligently acquired OASI (Obstetric Anal Sphincter Injury), that occurred during the birth of her second child in October 2018, which left permanent bowel and bladder symptoms and injuries to her vagina.

The use of forceps without an episiotomy caused serious life changing injuries

C was admitted at 39 weeks gestation, with regular contractions. Due to foetal heart rate decelerations C was transferred to theatre. The CTG showed a prolonged deceleration and Neville-Barnes forceps were applied at 05.16 hours and the baby was delivered at 05.17 hours with one pull. An Episiotomy was planned but not conducted, even though it was originally erroneously documented as having been performed. C states that she was told by the midwives that they could not find the scissors to perform an episiotomy, before the clinic fellow, supervised by a senior registrar, applied the forceps, with a negligently and forceful extraction. The use of forceps without an episiotomy caused serious life changing injuries to C that will be permanent.

Fourth degree perineal tear involving the rectal mucosa

Suturing was conducted in theatre, by the clinical fellow. The Trust advised that the repair was initially considered complete and included repair of a ‘third degree’ tear of the anal sphincter, bilateral vaginal tear, and labial tear. Unfortunately, however, after the initial repair was completed, it was realised that there was a likely ‘fourth degree’ perineal tear involving the rectal mucosa and this therefore had to be repaired. There was no description within the medical records as to where the rectal mucosa and/or anal epithelium was injured and how long the defect was. Estimated blood loss for the delivery and repair was 1,000ml. The average amount of blood loss after the birth of a single baby in vaginal delivery is about half of that (500ml).

C subsequently developed right foot numbness and weakness. An MRI scan was reported not to show any spinal cord compression or haematoma. Likely nerve root damage from regional anaesthesia was suspected although not proven. Physiotherapy and neurology follow up was arranged.

Faecal urgency, incontinence, and dyspareunia

Six months after the labour, C was reviewed and the tear was considered to have healed but C had faecal urgency and incontinence, as well as dyspareunia (Difficult or Painful sexual intercourse). It was noted that a Postnatal follow up had not been organised at discharge, which was also a breach of duty, given her injuries. C was referred to a pelvic floor clinic, a colorectal surgeon for endo-anal ultrasound and manometry and the community continence service.

Had to undergo a Fenton’s Procedure

C was seen by a Colorectal Surgeon in May 2019. She was very tender in the anterior wall of the anus and/or rectum so they were unable to perform endoanal ultrasound or manometry. The impression was of anal fissure. She was also seen in pelvic floor clinic. The vagina was excessively scarred and tender and particularly around the perineal area. An Endoanal scan demonstrated a deficient external anal sphincter anteriorly (12 to 2 o’clock) and thin internal and external anal sphincter also anteriorly scarred at 11 to 1 o’clock. C had to undergo a Fenton’s Procedure (surgery performed to remove scar tissue or an area of tightness around the entrance to the vagina).

C suffered ongoing symptoms of pain on intercourse as well as faecal and urinary urgency.

Mismanagement of labour and a failure to offer a C-Section

Evidence was obtained from the Claimant and Andrew Taylor and his team began obtaining notes and medical records. Unfortunately, the Trust advised that some investigations that the Claimant underwent were unable to be located including follow-up appointments with the colorectal department. Expert evidence was obtained from Obstetrics & Gynaecology Expert to assess whether there was also a mismanagement of labour and a failure to offer a second C-Section, which would have totally avoided the injuries. An expert in Colorectal Surgery was also instructed.

Failure to perform an episiotomy and use of excessive pull on forceps

A Letter of Claim was sent to the Trust in August 2021. A Letter of Response was received in January 2022, whereby the Defendant made limited admissions in relation to the failure to perform an episiotomy and that an excessive pull-on forceps was used, and the Claimant was invited to disclose their Schedule of Loss and medical evidence in order to consider settlement. The Trust however reserved their right to challenge causation in respect of the alleged injuries and this remained an issue throughout. C submitted a Letter of Challenge in response to the Letter of Response regarding breaches that hadn’t been admitted and the Trust conceded and accepted liability for the tear occurring and all the symptoms that could be proven as arising from the tear. Birchall Blackburn Law were successful in recovering an interim payment at that stage of the case, to enable C to undergo private medical treatment and investigations, as there has been significant delays with NHS appointments, due to the Covid 19 pandemic.

Confirmed irreparable damage to internal sphincter

C underwent anorectal physiology testing which confirmed irreparable damage to her internal sphincter that will likely cause permanent residual symptoms at the minor end of the spectrum, and C remained in work. With regards to the urological issues, despite facing challenges over some symptoms, that could have arisen because of a non-negligent assisted delivery, i.e., USI (Urinary stress incontinence), her OAB (Over Active Bladder), was caused by the negligent and forceful pull on the forceps. Fortunately, following the Fenton’s procedure, C made excellent recovery and didn’t require any psychological support or specialist counselling, although this was considered as part of the overall evaluation of the case.

Following negotiations, the case settled in January 2024 in the sum of £85,000.

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