The 4th degree perineal tear after forceps delivery and improper post partum care, amount breach of to duty to care towards patient. Adv. ROHiT ERANDE. ©

The 4th degree perineal tear after forceps delivery and improper post partum care,  amount breach of to duty to care towards patient.

The Doctor reportedly advised the patient to use ‘coconut oil with kapoor at the suture site, but in vain.

The Doctor was asked to pay Rs. 8 lakhs towards compensation.

Adv. ROHiT ERANDE. ©

Case Details : First Appeal No.948/2015. 

Dr. Vartika Mishra, Raipur V/.s Rachana Agarwal.

BEFORE:
	HON'BLE MR. JUSTICE R.K. AGRAWAL,PRESIDENT
	HON'BLE DR. S.M. KANTIKAR,MEMBER

Judgment Link :

http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=0%2F0%2FFA%2F948%2F2015&dtofhearing=2022-02-25

Brief Facts :

1. The Complainant -Patient, Rachna Agrawal  during her pregnancy, since 28.09.2012 was under Antenatal care of Dr. Vartika Mishra - the Opposite Party -Appellant. 

2.  It was alleged that on 23.05.2013, the Opposite Party conducted her forceps delivery, which resulted in to 4th degree tear in the perineum (the area between vaginal canal and anus). It was further alleged that the Opposite Party stitched the skin only, without muscle repairs, therefore the patient lost her control over passing the urine and stool. The Opposite Party did not treat the complications properly. 

3. Thereafter, the Complainant consulted one Dr. Lalit Nihal at Raipur, who performed Sigmoidoscopy and diagnosed 'poor tone' and 'very poor anal squeeze'. Later on, Dr. Rajesh Sainani, the Gastroeterologist at Jaslok Hospital, Mumbai carried out ano-rectal Manomerty, which confirmed 'weak squeeze' of anus. MRI was performed there, it showed thinning of the internal and external anal sphincter, therefore there was loss of control on bowel movements. Thereafter, again,  the patient got operated by Dr. M. G. Norayani and Dr. S. K. Desai at Bombay Hospital for Perineorrhaphy with repair of sphincters and was discharged, but  the patient did not get complete recovery.  

4. It was alleged that she was deprived of marital happiness for 2 years and lost her the chance for normal delivery in future. It was further alleged that the Opposite Party gave only Discharge summary without treatment details. Complete medical record was not issued. Being aggrieved, she filed a Consumer Complaint before the State Commission and claimed Rs. 35 lakhs as compensation.

Defense :

1. The Doctor denied all the allegations and it was submitted that outlet forceps were applied and before applying forceps, episiotomy (a small cut at vaginal opening) was made to facilitate the extraction of the baby along with forceps and prevent stretching of vagina and perineal tear.  There was no perineal tear after the delivery and  the episiotomy wound was sutured and the patient was discharged in stable condition on 26.05.2013.

2. It was alleged that  thereafter during subsequent visits, the patient never complained about incontinence (loss of control on passage of stool and urine) and there was no perineal tear. At 1st time after 6 months, the patient complained about the incontinence; therefore it was impossible to sustain pain for 6 months without any treatment, if 3rd or 4th degree tear was present.

State Commission Finding :

  Based on the averments and evidence, the State Commission partly allowed the Complaint of the Complainant and directed the Opposite Party to pay a sum of Rs. 8,00,000/- to the Complainant as compensation with 9% interest within two months from the date of the order. Also awarded Rs. 10,000/- towards cost of the litigation and Being aggrieved, the Opposite Party filed the instant First Appeal.

Experts Opinion :

The Appellant - Doctor produced two experts opinion.

1. The expert opinion of Dr. Malti Waghela, the retired senior Gynaecologist from M.P. State Medical Services wherein she emphasized that all the reports of investigations point towards repeated trauma to anal region possibly due to anal intercourse and she opined that Forceps delivery cannot be blamed for this condition.

2. The Second Opinion was of  Dr. Palak Gawri about the use of ‘Multiload’ method and according to her opinion the use Multiload method proves  that the instant patient had no such perineal tear.

Both the Experts reports were not accepted by the National Commission. 

Held by the National Commission :

1. The Commission did not accept the Experts opinion. After perusing the record, the Commission Observed that it is pertinent to note that on 22.07.2013 and 27.07.2013, the patient was complaining pain in suture site.  The Per Speculum (PS) examination revealed defect at 12 O’clock position of external anal sphincter. However, the prescription of Dr. Abha Singh dated 23.08.2013 lacks details of patient’s examination. Dr. Abha Singh referred the patient to Dr. Vijayalaxmi, Devikripa Hospital. The reference letter (undated) establishes that the patient suffered perineal tear. It is reproduced as below:

“Date…………………

Dr. Vijay Laxmi,             Devikripa Hosp,

   Please examine Rachna who c/o passing uncontrolled motion. She delivered 6 mths back at same pvt Hosp. & had a bad perineal tear.

Pl. inform me SOS.

(Lost all mobile no., otherwise have called you)”

 

 2. The Commission then referred to the Sigmoidoscopy & MRI reports which in short concluded  the “Complete perineal tear (Post Deliver)… & Thinning of internal and external sphincter”  and the clinical findings of Dr. Rajesh Bhuta, also in short confirmed that “there was unhealed perineal tear and anal sphincter injury”, 

3.      It was held that Considering the entirety of this case, in our view, there was negligence during outlet forceps delivery. In addition, there was failure of duty of care during post-delivery (post-partum) period. The medical record/prescriptions of the Opposite Party including Dr. Abha Singh failed to convince us about proper post-partum care. 

4. It is evident that, the patient was complaining repeatedly about pain in the suture site but both the doctors have simply prescribed medicines, but ignored or not carefully examined the suture site for induration or infection, surprisingly advised to use ‘coconut oil with kapoor’ for about 6 months. The condition of the patient did not improve for a long period, therefore, she consulted several specialist doctors in Raipur and Mumbai viz Dr. Lalit Nihal, Dr. Rajesh Sainani, Dr. Rajesh Bhuta and Dr. Parwez Shaikh. She underwent several in investigations like Signmidoscopy, Anal Manometry and MRI, which collectively affirms perineal tear. Finally, in Mumbai, on 30.12.2013, the patient underwent Perineorrhaphy repair of sphincters operation at Bombay Hospital. However, the recovery was 60-70% only.

5.     It has been held long back by Hon. Apex Court that the doctor owes to his patient certain duties which are: (a) duty of care in deciding whether to undertake the case, (b) duty of care in deciding what treatment to give, and (c) duty of care in the administration of that treatment.  A breach of any of the above duties may give a cause of action for negligence and the patient may on that basis recover damages from his doctor.

6. It was held that the patient was a young woman and in primi gravida (first pregnancy) and for her sufferings ran from pillar to post to various hospitals in Raipur and Mumbai. In the present case, the patient developed 4th degree perineal tear after forceps delivery, which squarely attributed to the failure of duty of care, thus, medical negligence.  

7. Lastly confirming the State commission order, it was observed that the patient did not get post-partum care as per accepted reasonable standards.  Moreover, we cannot ignore sufferings of the patient, physical and mental trauma, in addition she lost her chance for normal (vaginal) delivery in future.

This case emphasizes the duties of every doctor towards the patient and breach of such duties call for the legal action. It is to be also noted that expert opinion much less any other opinion, is never binding upon the Court. 

The postpartum care is no doubt necessary. Had there been no tear, then use of coconut oil with camphor would have gone unnoticed and which might be advised by others as well alongwith other medicines.

No doubt, the intention of Doctor was not to cause any harm to the patient, but proved breach of care has costed her Rs.8 lakha

The court can draw its own conclusion contrary to expert opinion, considering the other facts and record of the case. Again, the good record keeping has no alternative, which every Doctor should learn from this case.  

Thanks and Regards

(Adv. ROHiT ERANDE) ©

Pune.