Third and fourth-degree perineal tears — obstetric anal sphincter injuries (OASI) — are serious complications of vaginal delivery that require immediate recognition and expert repair. When a significant tear is not identified, or is repaired incompetently, the consequences can be permanent: faecal incontinence, urinary incontinence, sexual dysfunction, and chronic pain that affects every aspect of a woman's daily life. In some cases, the tear itself was preventable. This guide explains when episiotomy and birth tear management amounts to negligence.
Classification of perineal tears
| Degree | Structure involved |
|---|---|
| First degree | Skin only |
| Second degree | Skin and perineal muscle — does not involve the anal sphincter |
| Third degree (3a, 3b, 3c) | Involves the external anal sphincter (3a: < 50% thickness; 3b: > 50%; 3c: full thickness) and/or internal anal sphincter |
| Fourth degree | Involves the anal sphincter complex and the anorectal mucosa |
Third and fourth-degree tears (OASI) must be identified and repaired by an appropriately trained clinician in theatre, with the patient under effective anaesthesia.
Common types of negligence in OASI claims
Failure to identify a third or fourth-degree tear
A midwife or doctor who does not adequately examine the perineum after delivery may fail to identify an OASI. Failure to carry out a systematic assessment — including digital rectal examination to check anal sphincter integrity — is the most common negligent omission. An unidentified OASI that is not repaired causes permanent incontinence in a significant proportion of affected women.
Inadequate repair
Even where the tear is identified, a repair that is performed by a clinician without adequate training in OASI repair, or that fails to restore anatomical continuity of the internal and external sphincters, will result in poor functional outcomes. Repair must be performed by a suitably trained surgeon following RCOG guidelines, using appropriate suturing technique and material.
Negligent episiotomy
A mediolateral episiotomy — a surgical cut to widen the vaginal outlet — is used to facilitate delivery in certain circumstances. An episiotomy that extends into or through the anal sphincter — a "button-hole" injury — is a serious complication. Where the extension was caused by incorrect technique or by performing an episiotomy at too acute an angle, and the result is sphincter injury, a claim may arise.
Failure to identify and treat OASI in a subsequent delivery
A woman with a previous OASI who presents for a subsequent delivery should be assessed for residual sphincter defect. Failure to counsel and offer caesarean section where there is a pre-existing sphincter defect, and the patient then suffers a further tear, may give rise to a claim.
Failure to identify and treat consequences of unrecognised tear
Where a woman presents with post-natal incontinence that is not investigated, the missed OASI may not be identified for months or years. Delayed repair of OASI has significantly worse outcomes than immediate primary repair.
What harm results from an unrecognised or poorly repaired OASI?
- Faecal incontinence (inability to control bowel)
- Urgency and frequency of defecation
- Urinary incontinence or urgency
- Dyspareunia (painful sexual intercourse)
- Chronic perineal pain
- Psychological harm: depression, PTSD, social isolation, relationship breakdown
- The need for further surgery: secondary sphincter repair, colostomy in severe cases
SCRIPT 60 — Hysterectomy Negligence Claims
Frequently asked questions
Can I claim if my anal tear was not identified after childbirth?
Yes — if a competent midwife or doctor examining your perineum after delivery would have identified the tear and the failure to identify it led to permanent incontinence or other harm.
Can I claim if my episiotomy caused a tear into my anal sphincter?
Yes — if the injury resulted from a technique below the required standard, such as an incorrectly angled episiotomy cut.
How long do I have to bring a claim?
Three years from the delivery, or from the date of knowledge — when you knew or ought reasonably to have known that the tear caused your symptoms. If the tear was not identified at the time, the date of knowledge may be later.