NHS Resolution has recently published a thematic review investigating Obstetric Anal Sphincter Injury (OASI) experienced during childbirth. The report examines settled claims in order to identify recurring trends which hopefully will help guide safer maternity practices and prevent harm caused by OASI.
OASI is a severe third or fourth-degree perineal tear which damages the anal sphincter muscles during vaginal birth. It is especially common in women having their first child by vaginal delivery. When a tear is identified at delivery, it should be repaired immediately by a suitably trained clinician. If a third- or fourth-degree tear is not surgically repaired, the mother may face many long-term symptoms such as faecal incontinence, pain and discomfort, sexual dysfunction and pelvic floor issues, which understandably often lead to serious psychological problems.
Classification (Grades 3a-4):
- 3a: <50% of the external anal sphincter (EAS) is torn.
- 3b: >50% of the EAS is torn.
- 3c: Both EAS and internal anal sphincter (IAS) are torn.
- 4th Degree: Extends through the anal sphincter and the anorectal mucosa (anal epithelium).
Numerous OASI claims have been submitted by women facing the consequences of poor care after childbirth, and as a result, the NHS is having to pay an estimated annual cost of £6 million.
Some sobering statistics;
- 237 claims were submitted between 2011/12 and 2021/22,
- 187 were settled costing a total of £60 million in damages and costs
- 149 were settled with damages paid amounting to £40.6 million. This is a significant cost to the NHS budget. The review also highlights the way in which diagnosis of OASI was missed.
- 58% of claims where damages had been awarded revealed that they had been wrongly diagnosed perineal tears; the majority of women had been graded as having second-degree perineal tears and only later diagnosed as more advanced OASI.
- Additionally, it took an average of 294 days for a diagnosis; some women even waited years. This long delay contributed to the decision women made to bring claims against the NHS.
- The longer the wait became, the more serious the symptoms became with 80% of women suffering faecal incontinence, followed by 77% suffering from faecal urgency and 74% in pain. A woman’s overall quality of life, mental health, and work life can all be significantly impacted by these symptoms, which frequently manifest concurrently.
The report also highlights a correlation between assisted vaginal births and the levels of women suffering from OASI. 61% of women who had an OASI had assisted births, 54% of these births involved using forceps, and an episiotomy occurred in 70% of the deliveries using forceps. Although assisted births are sometimes unavoidable, the report concluded that there appears to be a lack of supervision and training in providing the best support. By closely monitoring clinicians and training them appropriately for safe assisted vaginal births, it is hoped that there will be a reduction in perineal tears. More specifically, there needs to be more awareness of symptoms and risk factors as well as training in early diagnosis and management of OASI in postpartum mothers. This, in turn, may lead to improved diagnosis and management of OASI and provision of safe and compassionate services.
There is some good news though – initiatives like the OASI Care Bundle hope to reduce trauma, support women’s birth choices, and provide clinician training.
The NHS Resolution OASI review ultimately concludes by highlighting the serious human and financial consequences of delayed diagnosis and misdiagnosis of severe perineal tears in postpartum mothers. The report shows that consistent attention to professional guidance, immediate examination post birth, and appropriate treatment remain crucial, on top of the use of OASI Care Bundles. Strengthening healthcare administration, supervision and training has the potential to limit future claims and reduce long-term suffering in women.
The full report can be found here – Learning from Obstetric Anal Sphincter Injury claims within the NHS in England: A thematic review
This article was drafted by work experience student, Charlotte Ardant-Carpentier and edited by Sarah Stanton – Partner | Medical Negligence.
