Beyond the Tear: What Davison v Leitch Tells Us About Function After OASI

A third- or fourth-degree tear may occupy only a few lines in the maternity record. For some women, its consequences extend into continence, mobility, intimacy, work, motherhood and confidence long after the obstetric episode has ended. Davison v Leitch is a useful reminder that, in maternal injury litigation, the diagnosis is only the beginning of the evidential story.

The medical record can make childbirth injury look deceptively contained. There is the delivery. The tear is classified. A repair is undertaken. Follow-up is arranged. In clinical shorthand, a complicated event is compressed into a sequence of recognisable entries. For the woman living with the consequences, the experience may be considerably less tidy.

Obstetric anal sphincter injury, OASI, describes a third- or fourth-degree perineal tear involving the anal sphincter complex. RCOG reports that these injuries occur in around 6% of first vaginal births and in fewer than 2% of women who have previously given birth vaginally. Most women recover without long-term complications, but some experience continuing bowel-control difficulties, pain, sexual problems or psychological effects.

What those statistics cannot convey is how such symptoms behave in an ordinary day. That is where litigation often becomes more difficult.

When the diagnosis does not explain the loss

The distinction is illustrated starkly by Davison v Leitch [2013] EWHC 3092 (QB).

Sarah Davison sustained a serious obstetric injury during the delivery of her first child. A mid-line episiotomy caused a third-degree tear affecting both the internal and external anal sphincters. The severity of the injury was not immediately recognised and she later required further surgical treatment. By the time the case came before Mrs Justice Andrews, liability had been admitted and the trial was principally concerned with quantum. The consequences extended far beyond the fact of the tear itself.

Before her injury, Mrs Davison had been a highly successful equity sales trader. Her work involved long hours, pressure, travel and a crowded trading-floor environment. The court ultimately accepted that the continuing effects of her injury meant she could not return to that form of work and that her residual earning capacity was dramatically reduced. Damages exceeded £1.5 million, with loss of earnings forming the largest component. The point is not the size of the award. It is the distance between the clinical label and the functional consequence.

“Third-degree tear” describes the injury. It does not explain why somebody may avoid a crowded workplace, structure a journey around toilet access, lose confidence travelling, experience pain with activity, alter an intimate relationship or become unable to return to a previously successful career. Those questions require a different kind of clinical enquiry.

From anatomy to everyday function

This is the area in which specialist pelvic health Physiotherapist and Expert Witness Imogen Williams works clinically. Imogen has more than 16 years’ physiotherapy experience and specialises in complex pelvic health and musculoskeletal rehabilitation. Her current practice includes bladder and bowel incontinence, pelvic floor dysfunction, prolapse, chronic pelvic pain, pelvic girdle pain and rehabilitation following obstetric anal sphincter injury and other childbirth-related trauma. She continues to work actively in this field alongside her Expert Witness practice.

That active clinical context matters. Pelvic health is not static. Symptoms interact with recovery from pregnancy and childbirth, changing physical demands, return to work, caring for a baby, future pregnancy, psychological trauma and the expectations women place upon their own recovery. Two women with apparently similar obstetric injuries may therefore present very differently. One may recover progressively and return to normal activity. Another may continue to experience urgency, leakage, pain, reduced exercise tolerance or fear associated with leaving home.

The expert question is not simply:

What symptoms are present?

It is:

What do those symptoms mean for this particular person’s function?

The support hidden inside “managing”

The language used by claimants can sometimes obscure rather than reveal the extent of the problem. A woman may say that she is “managing”. That might mean symptoms are relatively minor. It might equally mean that she knows every available toilet on her commute, avoids certain foods before travelling, no longer exercises in the way she once did, carries spare clothing, declines social invitations and plans family outings around the risk of bowel urgency. On paper, she may still be working. Clinically, the cost of remaining at work may be substantial. A specialist assessment has to understand that distinction. The same applies to apparently simple activities such as lifting a child, walking with a pram, driving, sitting through a meeting or returning to sexual activity. Technical ability to perform an activity does not necessarily mean it is being performed normally, comfortably or without consequence.

That is the value of looking at function rather than diagnosis alone.

The private nature of the evidence

There is another difficulty particular to pelvic health litigation. The symptoms are often intensely private. Anal or faecal incontinence, difficulty controlling wind, sexual pain, vaginal symptoms, fear of odour or leakage and the psychological consequences of traumatic childbirth may not be volunteered readily to treating clinicians. RCOG expressly recognises that a minority of women experience continuing problems with bowel or wind control after OASI and that specialist treatment may include physiotherapy or surgery. It also recognises the psychological impact that severe tears and traumatic birth can have. The absence of repeated references in the records therefore does not necessarily establish the absence of symptoms. Nor does that mean that a retrospective account should simply be accepted without scrutiny.

The expert must do something more difficult: explore the history sensitively, compare it with the contemporaneous records and treatment history, understand the clinical plausibility of the presentation and explain how the reported symptoms translate into everyday restriction. That is where specialist experience becomes particularly important.

What specialist pelvic health physiotherapy actually involves

It is easy for a legal file to reduce rehabilitation to a phrase such as “pelvic floor physiotherapy”. The reality is more nuanced.

Assessment may encompass continence, pelvic floor strength and coordination, scar tissue, pain, bowel and bladder function, movement, activity tolerance and the interaction between physical and psychological symptoms. RCOG advises pelvic floor exercises following OASI and identifies specialist physiotherapy as part of treatment for women who continue to experience anal incontinence.

The medico-legal question is not simply whether physiotherapy exists.

It may be necessary to consider:

• what treatment has already taken place;
• whether it was genuinely specialist pelvic health rehabilitation;
• what response occurred;
• whether further intervention remains clinically reasonable;
• what improvement can realistically be expected;
• and what limitations are likely to remain despite appropriate treatment.

That distinction can be important when assessing prognosis and future loss. The existence of another treatment option is not the same thing as evidence that full recovery will follow.

Different experts, different questions

Maternal injury claims can involve several overlapping disciplines. That makes clarity about expert boundaries particularly important.

The obstetric management of labour, the decision to perform an episiotomy, the recognition and repair of a tear and whether the maternity care fell below an appropriate standard may require evidence from obstetricians, midwives or other suitably qualified liability experts.

The breach identified in Davison, for example, arose from the obstetric management surrounding the mid-line episiotomy and subsequent handling of the injury. The case has since been discussed professionally as an example of substandard episiotomy technique resulting in OASI.

A specialist pelvic health Physiotherapist answers a different set of questions. For Imogen, those questions may concern:

• the claimant’s present pelvic health presentation;
• continence and pelvic floor function;
• pain and physical restriction;
• the rehabilitation already undertaken;
• whether further specialist treatment is appropriate;
• likely functional recovery;
• residual symptoms;
• and the effect of those symptoms upon everyday activities and participation.

That distinction matters.

A good expert does not expand their role simply because another issue is clinically interesting. They understand where their expertise begins, where it ends and which questions require another discipline.

Davison and the importance of context

The value of Davison for solicitors handling maternal injury claims is therefore not that it establishes a formula for assessing OASI. It does not. What it demonstrates is how quickly the consequences of an obstetric injury can move beyond the maternity record. Mrs Davison’s injury ultimately affected questions of employment, earning capacity, working environment and long-term life trajectory. That makes the case particularly relevant to the clinical perspective Imogen brings to expert work. The medical question may begin with the sphincter injury. The evidential question becomes broader:

What has changed because of it?

That may involve work. It may involve mobility. It may involve caring for a child. It may involve intimacy, exercise, travel, confidence or the practical ability to participate spontaneously in ordinary life. The expert report becomes most useful when it explains the chain clearly:

injury → symptoms → functional consequences → rehabilitation → prognosis.

Why the questions asked by solicitors matter

This is also why some clinical understanding within the legal team can materially improve the evidence obtained. Solicitors do not need to become pelvic health clinicians. They do benefit from recognising when seemingly innocuous wording may need further exploration.

“Occasional bowel urgency” can cover a considerable spectrum of experience.

“Had physiotherapy” says very little about the type, duration or effectiveness of treatment.

“Returned to work” does not establish that the claimant has returned to her pre-injury level of function.

“Independent with childcare” does not necessarily describe the physical or psychological cost of performing that role.

Those distinctions have formed part of the pelvic health and OASI training Imogen provides to solicitor teams. Imogen’s sessions are grounded in the cases and clinical presentations she sees in practice: helping lawyers understand the anatomy and terminology, but more importantly helping them recognise the functional questions that can otherwise remain buried in a medical record.

The purpose is not to teach solicitors to practise medicine. It is to make the legal instruction better informed.

From solicitor training to better evidence

A recent session delivered by Imogen to the Fieldfisher team centred on this gap between the recorded injury and what may follow from it in real life. The discussion moved beyond the classification of third- and fourth-degree tears into the issues that tend to matter later in a claim: bowel and bladder symptoms, pain, physical activity, return to work, sexual function, psychological effects, rehabilitation and prognosis. It also considered the respective roles of the different experts who may become involved. That is an important practical point in complex maternal-injury litigation.

The better the legal team understands the clinical landscape, the easier it becomes to identify the right expert, formulate a focused instruction and avoid asking one discipline to answer questions properly belonging to another.

Imogen’s training is therefore not simply about OASI as a clinical diagnosis. It is about how to recognise the evidence that sits behind it.

A different conversation for the injured person

There is also a separate need that arises outside the Expert Witness process. Women living with persistent symptoms after birth injury may have gone through multiple clinical encounters and still feel that they do not fully understand what is happening, what specialist rehabilitation may offer or which questions they should be asking. Harrison Associates also provides access to Imogen for clinical consultation with injured claimants where appropriate.

That is distinct from her role as an independent Expert Witness.

A claimant consultation is not an expert assessment for litigation, and the two functions must remain clearly separated. But a specialist clinical conversation can help an injured person understand the pelvic health and rehabilitation landscape, make sense of terminology and identify matters that may warrant discussion with her own treating clinicians. For a woman whose symptoms are private, complex and sometimes poorly understood even within general healthcare, simply having the opportunity to discuss them with someone working routinely in specialist pelvic health can be valuable.

The tear may be recorded. The consequences have to be understood.

There is an understandable tendency in litigation to organise maternal injury around the obstetric event. That is where the breach may have occurred. It is where the records are often most detailed and it is where the injury itself is first described. But the litigation may ultimately turn upon what happened afterwards.

Davison v Leitch is an unusually clear illustration. A third-degree tear became a case about much more than anatomy. It became a case about work, confidence, environment, psychological health and the trajectory of a highly successful professional life. The same principle applies even where the consequences are less financially dramatic.

A clinical diagnosis tells us what happened to the body. Specialist functional evidence helps explain what that injury has come to mean for the person living with it.

For Imogen Williams, who continues to assess and treat women with complex pelvic health conditions alongside her Expert Witness practice, that distinction is central and for solicitors handling maternal injury claims, it suggests a deceptively simple question worth asking early:

Do the records tell us what the injury was — or do they also tell us what it has changed?

Further support

Women affected by severe perineal tears or OASI may also find independent information and peer support through organisations including The MASIC Foundation, the Birth Trauma Association and Bladder and Bowel Community. The Royal College of Obstetricians and Gynaecologists also provides detailed patient information on recovery following third- and fourth-degree tears.

Clinical contributor: Imogen Williams

Imogen Williams is a Physiotherapist and Expert Witness with more than 16 years’ clinical experience, specialising in complex pelvic health and musculoskeletal rehabilitation. Her current practice includes pelvic floor dysfunction, bladder and bowel incontinence, pelvic pain, prolapse and rehabilitation following obstetric anal sphincter injury and other childbirth-related trauma. She undertakes independent claimant and defendant Expert Witness instructions and remains actively engaged in specialist clinical practice.

Imogen also provides clinician-led Pelvic Health, OASI Tears and Birth Injury Rehabilitation training for solicitor teams, as well as separate specialist consultation sessions for injured claimants where appropriate.

Case reference

Davison v Leitch [2013] EWHC 3092 (QB), Mrs Justice Andrews, 18 October 2013. The claimant sustained a third-degree tear affecting the internal and external anal sphincters during the delivery of her first child; liability was admitted and the subsequent trial addressed the consequences and quantum of her injury.

How Harrison Associates supports solicitors in maternal injury claims

Harrison Associates provides specialist clinical expertise for solicitors handling complex maternal and birth injury claims.

Our Expert Witnesses provide independent opinion on the functional consequences of injury, rehabilitation, prognosis, care and future needs. In pelvic health cases, this can include the longer-term impact of OASI, continence problems, pelvic pain, physical restriction and the rehabilitation already undertaken or reasonably required.

Imogen Williams, Specialist Pelvic Health Physiotherapist and Expert Witness, remains actively engaged in clinical practice alongside her medico-legal work. She also delivers Pelvic Health, OASI Tears and Birth Injury Rehabilitation training for solicitor teams, helping legal professionals understand the clinical issues that may sit behind the maternity record and formulate more focused instructions.

Separately from Expert Witness work, specialist clinical consultation may also be available for injured people who need help understanding their pelvic health presentation and rehabilitation options, where appropriate.

To discuss an Expert Witness instruction, solicitor training or specialist pelvic health input, contact Harrison Associates.

Contact