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3rd & 4th Degree Childbirth Tears | Orange City Medical Malpractice Attorney

Evaluation of Fourth Degree Perineal Tear Birth Injury for Medical Malpractice

This case study simulates the first phase of a medical malpractice case evaluation using the example of a fourth degree perineal tear suffered during childbirth.

The case involves a 28-year-old first time mom of average height and weight who went to the hospital after her water broke. Thirteen hours later, contractions had not begun so doctors induced labor with Pitocin. In less than two hours at 4:56 p.m., mom’s cervix became fully dialated.

After only 45 minutes of pushing labor, the doctor suggested he could assist the mother if she was tired. She agreed to assistance so the obstetrician performed an episiotomy (after receiving consent) and used a vacuum to pull the baby from the birth canal.

Though the baby was on his side with his tilted down toward his shoulder and mom’s bottom, he came out with one pull. Weighing in at 6 pounds 2 ounces, he was perfectly healthy. Mom however was not. She suffered a fourth degree perineal tear through her rectal sphincter muscle, which doctors repaired immediately.

However, the repair was unsuccessful and the mother required four subsequent surgeries including a colostomy because her bowel movements had become uncontrolled.

The fact pattern mentioned above is a good example of the narrative type of information attorneys receive at the exploratory stages of a lawsuit. More information is always required especially in medical malpractice cases. A thorough evaluation of the medical record must be preformed.

However, the initial evaluation would proceed along these lines:

Medical science has chronicled the increased risk of third and fourth degree tears caused by episiotomies combined with forceps and vacuum delivery so doctors are well aware of them and should proceed with caution.

Some potential acts of negligence that should be explored in this case include the potential that the obstetrician decided to use the vacuum too early instead of letting mom push the baby out, pulled too hard or botched the repair. What is of special interest in this case is that the mom began the “pushing” phase of labor at about 5 p.m. which is of course known as “quitting time” – a time that is approaching “dinner time.”

Operative deliveries such as those with forceps or vacuums are usually reserved for abnormal situations including emergency situations and times when the baby is in distress. If this doctor used an operative method simply because he was tired of waiting and wanted to get home for dinner, that could be a breach of the standard of care. Interestingly, national statistics show an increase in c-sections at times approaching shift changes at hospitals so this theory is not farfetched. In addition, the mom was allowed to push for less than an hour when two is normal.

The short pushing time is important for another reason. The pushing phase helps the woman’s perineum thin out and become more elastic so a longer, slow controlled pushing phase protects the perineum from tears. That phase was artificially shortened in this case which means the perineum was not as ready as it could have been. Nurses can help prepare the perineum by massaging it during labor, and that is something that would require further investigation in this case.

As for the potential for a negligent repair of the fourth degree tear, much more investigation would need to be performed to determine if the doctor used the proper retractor equipment if performing the repair alone; if the rectal mucosa was repaired with the correct layering of interrupted stitching with re-enforcing running or running locking stitching; if the sphincter was repaired correctly with the correct methods and clamping.


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