Damage to anal competence during childbirth is a common source of medical malpractice litigation. This is not surprising, given that one in eight women develops incontinence or urgency[1].
PRACTICE POINT Anal sphincter damage following vaginal childbirth is on a continuum from symptomless loss of anal power to disabling fecal incontinence |
Neurological injury and its recovery was previously documented[2] and the relative contributions of harm to nerves and muscles varies from woman to woman[3].
Anal ultrasound now provides a means of studying the occult sphincter damage, which occurs in up to a third of mothers[1], to determine risk factors and potentially trigger improvements in obstetric technique[4].
A woman's first vaginal delivery causes a significant fall in anal pressure, according to a large prospective study[5] of normal childbirth in Australia.
PRACTICE POINT Negligent
causes of severe anal damage include unwarranted hurry in the delivery
of a healthy fetus: |
In the individual case, it is often difficult to determine how much of the resulting incontinence was preventable by standard obstetric practice.
(Third Degree) tearing of the anus leaves 5 out 6 women with permanent sphincter defects, and 1 in 2 with symptoms, in spite of standard and successful repair immediately after delivery[1].
Risk has been found to be increased by the use of forceps[6], midline episiotomy and Asian race[7]. Obstetric inexperience in instrumental delivery was not a factor.
After routine repair of lacerations which also include the rectal lining (Fourth Degree), 1 in 20 will become infected and/or split open and require rerepair[8].
PRACTICE POINT There may have been clear contravention of Clinical Practice Guidelines in the choice of delivery method |
These and other risks of vaginal delivery must be balanced against the many increased risks of Cesarean Section, including infection and maternal death. It is to achieve minimal risk that professional bodies, notably the American College of Obstetricians and Gynecologists, and the (Canadian) Society of Obstetricians and Gynecologists, have developed guidelines for method of delivery in various clinical situations.
Copyright © 2008 Electronic Handbook of Legal Medicine