Obstetrics – Fourth degree tear not negligent

Abstract

The Claimant went into labour during the afternoon of 6 March 2007 and labour progressed steadily. By 03:00 on 7 March, the midwife noted foetal heart decelerations and called for a medical opinion. A registrar, Dr Gauthaman, attended at 03:15. She noted that the patient was fully dilated and asked her to push. After half an hour there was little progress and Dr Gauthaman therefore decided that an instrumental delivery using Neville Barnes forceps was necessary. Forceps were first applied at 03:58 and William was born at 04:01. Two pulls were used. It was the registrar’s intention to perform an episiotomy before delivery of the head. The first pull brought the baby’s head close to the vaginal entrance, and following another contraction Dr Gauthaman pulled the head to the entrance so that it was resting on the perineum. The registrar intended at this point to make the episiotomy cut and reached for her scissors. However, there was then an unexpected further contraction which pushed the baby’s head through the perineum and caused the tear. The hospital’s guidelines at the time required an episiotomy with a forceps delivery. They stated: ‘‘Episiotomy is to be performed as head is brought down to perineum’’. There was a dispute between the expert obstetricians as to precisely what those words meant. Mr Jarvis, for the Claimant, said they indicated that the episiotomy should be undertaken before the head reached the perineum. He considered that this was good professional practice because to wait until the head is on the perineum risks an unexpected rapid delivery, as indeed happened in this case. The trust’s expert, Dr Erskine, considered that the words ‘‘as head is brought down to perineum’’ included the head being brought through the perineum. Her own practice was to wait until she was drawing the head through the perineum before making a cut.