New Delhi: Holding negligence against the treating Gynecologist in providing Post-partum care to a patient who lost her control over passing urine and stool following forceps delivery, the National Consumer Disputes Redressal Commission (NCDRC) directed the treating doctors to pay Rs 8 lakh as compensation to the patient, as the State Commission had earlier directed.
During the forceps delivery, the patient had developed 4th degree perineal tear and due to the lack of post-partum care, she also lost her chance of normal vaginal delivery in future, the NCDRC bench held.
"It is pertinent to note that the patient was a young woman and in primi gravida (first pregnancy). She, after delivery, 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. Also, she 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," read the order.
The history of the case goes back to 2013 when the complainant had approached Dr. Vartika Mishra for childbirth. Dr. Mishra conducted forceps delivery resulting in 4th degree tear in the perineum i.e. the area between vaginal canal and anus. The complainant alleged that the doctor had stitched the skin only without muscle repair and as a result the patient lost her control over passing the urine and stool.
Following this, the patient approached another doctor at Raipur, who performed Sigmoidoscopy and diagnosed 'poor tone' and 'very poor anal squeeze'. Later, the patient approached several other doctors including a Gastroeterologist at Jaslok Hospital, Mumbai, who carried out ano-rectal Manomerty confirming 'weak sqeeze' of anus. MRI was also conducted which showed thinning of the internal and external anal sphincter.
Later, the patient got operated by doctors at a Bombay Hospital for Perineorrhaphy with repair of sphincters and was discharged on 04.01.2014. However, the patient did not get complete recovery. It was alleged that she was deprived of marital happiness for 2 years and lost her the chance for normal delivery in future. Aggrieved the complainant approached the State Commission claiming Rs 35 lakhs as compensation.
On the other hand, the treating doctor, Dr. Vartika Mishra denied any negligence on her part. 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.
While considering the matter, after taking note of the avertments 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.
Being aggrieved, the doctor approached the NCDRC bench. The doctor argued before the top consumer court that due to prolonged 2nd stage of labour, delivery by the use of forceps was decided. Therefore to facilitate easy forceps delivery, episiotomy was performed and after delivery the episiotomy wound was sutured. The patient was discharged with follow-up instructions. The doctor further referred to the prescription on record which mentioned complaining pain at the suture site and further mentioned that 'no perineal tear and the episiotomy scar was healthy'.
It was further submitted by the doctor that the patient had later consulted Dr. Abha Singh who recorded the increase in patient's weight and there was no complaint of incontinence. She advised "Multiload" and prescribed few medicines. The contention of the doctor also included the fact that the State Commission had completely overlooked importance of episiotomy and the affidavits (opinion) given by Dr. Malti Waghela and Dr. Palak Gowri.
After taking note of the submissions, the top consumer court perused the opinion of Dr. Malti Waghela, the retired senior Gynaecologist from M.P. State Medical Services. Referring to one review article "Complete anal sphincter complex disruption from intercourse: A case report and literature review", she opined that for 6 months after delivery the complainant must have sustained repeated injury to the anal region which resulted in incontinence. Forceps delivery cannot be blamed for this condition. She also emphasized that all the reports of investigations point towards repeated trauma to anal region.
Another expert doctor referred to the use of 'Multiload', which is a contraceptive device like (CuT) applied to the patients who are free from infections involving cervix, vagina, uterus and adjacent organs. It should be avoided in the patients having any abnormal communication between rectum and vagina. According to her, the use of Multiload proves that the instant patient had no such perineal tear.
At this outset, the NCDRC bench also referred to the medical records and clinical findings of all the doctors and hospitals where the patient had been treated later. The Sigmoidoscopy report mentioned, "Fecal incontinence with Complete perineal tear," and the MRI report at the Jaslok Hospital mentioned, "Thinning of internal and external sphincter".
Another doctor, who had examined the patient had opined in his report, "On examination there is no muscle felt between vagina and rectum. There is very poor tone and very poor squeeze power. This is conf. with MRI + anorectal menometry. There is complete sphincter damage most likely post forth degree tear. This will require surgery with sphincter reaper with muscle sling success rate 60-70% and the long term prognosis is guarded)."
Referring to these reports, the top consumer court noted, "Therefore, on collective reading of the above paragraphs (i to iii), it establishes that there was unhealed perineal tear and anal sphincter injury."
Expressing surprise over the expert opinions, NCDRC noted, "We are rather surprised with the opinion of Dr. Malati Waghela about repeated anal trauma possibly due to anal intercourse. It is also not clear from the prescription of Dr. Abha Singh, dated 23.08.2013, whether "Multiload" was inserted in the uterus or not. Nothing is forthcoming about the details of clinical or gynaecological examination of the patient. It was the deficiency in service from Dr. Abha Singh."
Holding negligence in providing post partum care, the Commission noted, "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. 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," further noted the NCDRC bench.
NCDRC also referred to the concept of duty as specified by the Supreme Court in the case of Dr. Laxman Balkrishna Joshi vs. Dr. Trimbark Babu Godbole and Anr. and A. S. Mittal vs. State of U.P.
In these cases, the top court had mentioned 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.
Therefore, affirming the order of the State Commission, the NCDRC bench noted, "It is pertinent to note that the patient was a young woman and in primi gravida (first pregnancy). She, after delivery, 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. Also, she 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."
To read the NCDRC order, click on the link below.
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