Nearly six in ten women who experienced serious perineal tears during childbirth and brought a claim had their injuries initially misdiagnosed, a new report from NHS Resolution reveals.
The thematic review by NHS Resolution, in collaboration with the Royal College of Obstetricians and Gynaecologists, examined a decade of clinical negligence claims relating to obstetric anal sphincter injuries (OASI) – severe tears affecting the perineal muscles during childbirth.
Analysis of 237 claims between 2011/12 and 2021/22 found that 58% of women had their injuries graded as less severe than they actually were, with most initially assessed as second-degree tears when they had in fact sustained third- or fourth-degree injuries requiring specialist repair.
The average delay before correct diagnosis was 294 days – nearly 10 months – during which women experienced debilitating symptoms including faecal incontinence (80% of cases), pain (74%), and psychological trauma (47%).
The total cost of closed claims during the period reached £40.6 million.
Key findings:
• 61% of claimants had assisted births, with forceps used in 54% of all cases
• Only 65% of women received the recommended rectal examination before suturing
• 19% of women required surgical repair of the anal sphincter; 12% needed a temporary colostomy
• First-time mothers accounted for 84% of claims.
Megan Bidder, Director of Safety and Learning at NHS Resolution, said: “While an OASI can be an unavoidable complication of childbirth, immediate diagnosis and proper repair offer the best chance of good outcomes. This report identifies clear areas where care can improve – from safer assisted births to better training in systematic examination techniques.”
Professor Ranee Thakar, President of the Royal College of Obstetricians and Gynaecologists, said: “It is vital that maternity teams are supported with the right tools and training to identify and manage perineal tears promptly and effectively. The RCOG has worked with partners to develop an evidence-based care bundle that reduces the risk of perineal tears during childbirth and improves detection when they do occur. We are calling on every maternity unit to implement these interventions so that fewer women experience avoidable harm during birth.”
The report identifies six priority areas for improvement:
• Safer assisted vaginal births – ensuring obstetricians are properly trained in instrumental delivery techniques and appropriate use of episiotomy
• Better supervision – providing adequate support for trainee doctors and midwives performing complex deliveries
• Accurate diagnosis – training all clinicians to perform systematic vaginal and rectal examinations using the “pill rolling” technique
• Enhanced education – raising awareness of symptoms, risk factors and the significant impact on women’s lives
• Awareness of complications – recognising rare but devastating complications like rectovaginal fistula
• Consistent pathways – developing national guidance for managing women with missed injuries.
Dr Katherine Barton, National Obstetric Clinical Fellow at NHS Resolution and lead author, said: “Many of these injuries could be better managed with improved training and earlier recognition. Women deserve care that ensures every birth injury is properly identified and treated from the outset.”
NHS Resolution and RCOG are sharing these findings to support maternity teams in delivering safer, more compassionate care and reducing both the incidence and impact of these injuries.
