Postnatal care of woman with perineal tear – HDC decision

The following case was published on the Health and Disability Commissioner's website today.

Postnatal care of woman with perineal tear

16HDC00911

Deputy Health and Disability Commissioner Rose Wall today released a report finding an obstetric consultant and a midwife in breach of the Code of Health and Disability Services Consumers’ Rights for failing to provide appropriate postnatal care to a woman with a perineal tear.

The woman’s baby was delivered via instrumental delivery. Following delivery, a registrar remained with the woman and started to repair the woman’s perineal tear. The registrar queried whether the tear was a fourth-degree tear, and discussed her concerns with a senior registrar. The senior registrar then examined the woman, decided that the tear was second degree only, and began repairing it. The senior registrar then became concerned that “the tear to the skin possibly involved the anal mucosa” and discussed her concerns with the obstetric consultant who had performed the instrumental delivery. The obstetric consultant examined the woman and repaired the tear. The obstetric consultant recorded that the tear was to the anal margin but did not involve the sphincter, and that the per rectum examination post-suturing was normal with no sutures felt.

The woman’s lead maternity care (LMC) midwife carried out four postnatal visits, during which a number of times the woman reported faecal discharge at the front of her underwear. The midwife did not view the woman’s perineum until 16 days post-partum. The midwife then queried an infected perineum and requested an obstetric registrar review.

Findings

The Deputy Commissioner was critical that, considering the concerns raised by two registrars, the obstetric consultant, as a consultant, did not identify that the tear was more significant. Accordingly, the obstetric consultant did not provide the woman with an appropriate standard of care.

Ms Wall considered the LMC midwife, by failing to carry out a visual perineal examination earlier, did not provide the woman with an appropriate standard of care.

Recommendations

Ms Wall recommended the obstetric consultant and the midwife provide written apologies to the woman.

Ms Wall recommended the obstetric consultant audit the outcome of deliveries in which she had been involved over the previous three months, and provide HDC with a copy of the audit report. She recommended the LMC midwife provide evidence to HDC confirming attendance or enrolment at a course relating to perineal tears.

The Deputy Commissioner also recommended that the Medical Council of New Zealand review HDC’s report of the case and that the Midwifery Council of New Zealand consider undertaking a review of the midwife’s competence.