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A tear during delivery

01 January 2014

Mrs J, 37 years old, was pregnant with her third child. She had an uneventful forceps delivery with her first child and a spontaneous vaginal delivery with her second.

She had been previously diagnosed with irritable bowel syndrome, but endoscopies had revealed no evidence of any other disease. The GP records showed that she had colicky pain with constipation and diarrhoea, but no history of faecal incontinence. This pregnancy had been uneventful and she went into spontaneous labour at 39+5 weeks.

At 5.15pm she was 4cm dilated and, as the contractions had reduced, she was started on an oxytocinon drip. She had an epidural sited and was found to be fully dilated at 9.45pm. As the head was ‘high’ she was given an hour for it to descend and started active pushing at 11pm. The baby’s head had come down to station 0 and appeared to be in the correct position (occipito-anterior) with only minimal caput and moulding.

Dr A, an experienced specialty trainee, was called after Mrs J had been pushing for one and a half hours. She documented that there was no ‘head’ palpable abdominally (cephalic 0/5) and vaginally confirmed the midwife’s findings. She advised Mrs J that she would need to carry out an operative delivery and documented fully in the notes that a verbal consent had been obtained. She deflated the foley catheter, which had been put in place when the epidural was sited.

Dr A then applied a silicone ventouse cup over the ‘flexion point’ on the baby’s head. She increased the pressure to 0.2kg/cm2 and checked there were no maternal tissues under the cup. She then increased the pressure gradually to 0.8kg/cm2 and, with good maternal effort, pulled along the pelvic axis. Despite using the correct technique, the cup slipped off and the suction was lost.

She re-examined the patient and still felt the baby was in the correct position, and that “the head had descended well to station +1”. Dr A decided to use the Neville Barnes forceps to complete the delivery. The blades were easily applied and, using the ‘Saxthorph-Pajot’ technique, the baby’s head was delivered with one pull.

Dr A felt the perineum was stretching out well, and did not carry out an episiotomy. The patient was noted to have a second degree tear. Dr A carefully examined the perineum and anal canal following the delivery and documented that the “anal sphincter was intact” and there was no evidence of any sphincter damage, and repaired the tear routinely.

The patient made an uneventful recovery and, when she was seen by her GP for her six-week check up, it was documented that “she had no problems with her bladder or bowels”.

Unfortunately, 12 months following the birth, Mrs J was referred to obstetrics and gynaecology consultant Mr B, with signs suggestive of utero-vaginal prolapse, menorrhagia and lack of bowel control. An endo-anal ultrasound found only minimal scarring of the external sphincter, and the internal sphincter appeared intact. A clinical neurophysiologist also assessed the patient and felt “there was evidence of bilateral chronic pudendal neuropathy with poor muscle function on the right and left side”.

Mrs J underwent a vaginal hysterectomy and posterior pelvic floor repair, and her symptoms improved significantly with dietary modifications and bio feedback.

Mrs J made a claim, as she was advised that if Dr A had carried out an episiotomy and avoided the use of ‘double instruments’ her symptoms would have been avoided. She felt that a diagnosis of a third degree tear had been missed and, as a consequence, this had had a major impact on her life.

Expert opinion on these issues was sought. Although it was acknowledged that an episiotomy is often required in a forceps delivery, the perineum was stretching well and it was felt that the episiotomy was not essential in this case.

The contemporaneous notes confirmed that the anal sphincter was intact despite the second degree tear that was observed. The endo-anal ultrasound and neurophysiology tests also confirmed no signs of marked sphincter damage, and the cause of the bowel problems was felt to be due to pudendal neuropathy.

The ventouse cup displaced due to the caput on the baby’s head, and the fact that there had been some active descent during traction meant that it was deemed acceptable to use a second instrument to achieve the vaginal delivery. The case was successfully defended.

Learning points

  • The use of sequential instruments is associated with an increased neonatal morbidity; however, the operator must balance the risks of a caesarean section following failed vacuum extraction with the risks of forceps delivery following failed vacuum extraction. In the UK, the Royal College of Obstetricians and Gynaecology (RCOG) has published Guideline No 26 Operative Vaginal Delivery (2011)
  • Recognition and documentation of the correct technique in the notes (eg, ‘Saxthorph-Pajot’ technique for forceps delivery – where the operator’s dominant hand applies horizontal traction, whilst the other hand gently presses downwards on the shank of the forceps) suggests that the accouchere has adequate experience to carry out the procedure correctly. In the UK, the RCOG does support the “restrictive use” of episiotomies for instrumental deliveries and leaves it to the clinical judgment of the operator, but certainly when undertaking a forceps delivery they are often required in multips and almost always on primips. 
  • Careful documentation of the technique and assessment for perineal damage is essential, and use of endo-anal USS may help with the definitive diagnosis at a later stage.  
  • The expert opinion was logical and evidence-based and, with careful documentation and adherence to good medical practice, such cases can be discontinued before they are taken to court.