Impractical for doctors to obtain explicit consent for each act in medical procedure: High Court Judge
Source: Straits Times
Article Date: 08 Apr 2025
Author: Nadine Chua
The judge noted from testimony that doctors in Singapore are not required to obtain formal consent for episiotomy or manual fundal pressure, which are routine procedures for natural birth.
A woman who sued her doctor over claims that she was not consulted for procedures during childbirth had her claims dismissed by the High Court.
In a written judgment published on April 3, Justice Choo Han Teck said Dr Khoo Chong Kiat should have exhibited a good bedside manner by explaining to the woman that he was about to perform an episiotomy – a surgical cut in the area between her anus and vagina – during childbirth.
“However, medical procedures often involve numerous steps and routine actions,” Justice Choo added.
“Requiring doctors to obtain explicit consent for each individual act within a medical procedure is impractical and would place an unreasonable burden on them.”
The woman had claimed in a medical negligence suit filed in 2023 that Dr Khoo did not seek her consent before carrying out cervical sweeps, manual fundal pressure and the episiotomy, and when repairing a tear she sustained during childbirth.
Doctors apply manual fundal pressure around the upper region of the uterus to assist with delivery.
The judge noted from testimony provided by Dr Han How Chuan, senior consultant obstetrician and gynaecologist and urogynaecologist at HC Han Clinic for Women, that doctors in Singapore are not required to obtain formal consent for episiotomy or manual fundal pressure, which are routine procedures for natural birth.
Justice Choo said that Dr Khoo’s failure to tell the 32-year-old woman before conducting both procedures is not a breach of the standard of care as a medical practitioner.
He also noted that the doctor had explained to the woman the purpose and process of the cervical sweep before proceeding with it. In a cervical sweep, a finger is used to induce labour.
In her suit, the woman said Dr Khoo had also failed to consult a colorectal surgeon before repairing the tear she sustained during childbirth. The woman said she excreted faecal matter from a 0.5cm tear she sustained during childbirth on May 3, 2020.
She said she continued to excrete faecal matter from her vagina for months after the delivery procedure performed by Dr Khoo, who practises at CK Khoo Clinic for Women & Laparoscopy.
The woman said the doctor’s alleged negligence by not providing appropriate treatment caused her to suffer from major depressive disorder and other financial losses.
Dr Khoo was represented by Senior Counsel Kuah Boon Theng, while the woman was represented by Mr Cumara Kamalacumar.
Dismissing her claims, Justice Choo noted the absence of medical diagnosis for the woman’s claims of urinary incontinence and faecal urgency.
The woman had claimed that Dr Khoo told her he noticed “poop” in her vagina and said he would stitch her up after delivery.
The judge said: “However, she did not actually see or know if she had bowel movement during the delivery.
“Dr Khoo maintains that there was no faecal matter in the vagina at the time of delivery.”
Justice Choo said the woman merely felt the sensation of the baby descending the birth canal, which was similar to the sensation of passing motion.
In his testimony, Dr Han said it was very unlikely for faeces to come out through the “small buttonhole” tear.
A colorectal doctor, who testified for Dr Khoo as an expert witness, said it was unlikely that faeces leaked into the vagina as the woman had received an enema before delivery.
Justice Choo noted that medical records at Mount Elizabeth Novena Hospital also did not indicate that there was faecal soiling during delivery.
“In the circumstances, it is unlikely that Dr Khoo observed faecal soiling on May 3, 2020.
“His decision to repair the tear without consulting a colorectal surgeon was therefore appropriate and reasonable.”
The woman did subsequently pass faecal matter through the tear on May 5 and the next day because she had diarrhoea, presumably as a result of consuming a laxative.
After examining her, Dr Khoo told her the repair had broken down and formed an abnormal connection between the vagina and the rectum.
After consulting colorectal surgeons, the woman had another procedure to repair the tear six months after giving birth.
Justice Choo said Dr Khoo should have noted down the tear the woman sustained, and its repair procedure, in the handover form and clinical discharge summary, since they were not part of routine deliveries.
However, the judge said medical notes and reports are prepared to document critical facts about medical management and not intended to be a foolproof shield against potential litigation.
“It is impossible for doctors to make contemporaneous notes of every step of every procedure they perform throughout the day as multiple events often occur simultaneously in medical practice,” said Justice Choo.
The woman had claimed $36,000 for her loss of earning capacity, saying that she “had no choice but to resign” from her role at a funeral service company founded by her father-in-law, as she took frequent medical and hospitalisation leave after the incident.
The woman said this caused her relationship with her manager and brother-in-law to deteriorate, but the man later clarified that her medical condition “was in no way related to the company’s decision” to terminate her employment.
He said the woman’s position no longer existed after the company was restructured in 2021. In fact, the woman was offered another role, which she rejected.
The judge said the woman was able to earn the same or higher income in the various jobs she tried out after she left the funeral service company.
He added that she left those jobs “not due to any disability or long-term effects from the injury sustained during her delivery, but because she found that the roles were ‘mundane’, ‘not as meaningful’ or ‘not a good fit’ for her”.
“She is now a homemaker, but she admits that she can work and has been looking for a new job. There is thus no loss of future earning capacity at all.”
In concluding his judgment, Justice Choo said many of the woman’s expenses would have been incurred even if she had not sustained the injury during delivery.
In a statement following the judgment, Dr Khoo told The Straits Times: “I’m pleased that the High Court has dismissed the claim.
“I have always strived to put my patients’ interests first, to try to achieve the best outcomes for both mother and baby.”
He added that he hopes the woman will find closure and wishes her the best.
Nadine Chua is a crime and court journalist at The Straits Times.
Source: The Straits Times © SPH Media Limited. Permission required for reproduction.
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