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27LEGAL MEDICOMAGAZINESponsored by:that increase the risk of perforation include cervical stenosis, acute anteversion or retroversion, lower-segment fibroids or intrauterine synechiae and operator inexperience. Uterine injury without the use of an electrical source can usually be managed by observation of signs of vaginal or intraperitoneal bleeding, but if an electrical source has been used, laparoscopy is advised to rule out bowel injury.SterilisationThe most common reason for litigation is conception post-sterilisation. This could be for one of the following reasons:• A luteal phase pregnancy which was not identified at the time of surgery.• An actual failure because the procedure was inappropriately or inadequately performed. • Recanalisation of the fallopian tubes post-procedure. If pregnancy occurs within 12 months of sterilisation it is likely to be a failure of the technique whereas after 12 months it is more likely to be recanalisation. There are also recorded cases of litigation because of failure to perform procedures concurrently for which the patient has consented, such as removal of an IUCD. More serious is non-consented tubal sterilisation performed at caesarean section (CS), or regret related to sterilisation done at the time of CS when the patient was consented immediately before the procedure. Medico-legal law relating to maintenance of the child born after sterilisation is controversial. In the McFarlane1 ruling it was held that parents of healthy children born after sterilisation were not entitled to the costs of bringing up the child. However, a valid claim can be made following the birth of a child with disabilities, based on the additional cost of raising a child with those disabilities (Parkinson2).HysterectomyFailure to detect ureteric injury is the most common cause of litigation related to this procedure. Damage to the bladder and bowel are probably more common but are not generally considered to be negligent, especially if the procedure is difficult due to scarring from a previous surgery. A successful claim for compensation is unlikely when the injury is recognised and has been appropriately repaired. A missed bladder injury may lead to a vesico-vaginal fistula and a missed bowel injury could result in sepsis or peritonitis. These will frequently be classed as negligent. It may be argued that some occur because of ischaemic necrosis in the bladder base, and these may be defensible. Therefore, timing of onset of the leakage is important. Early leak is probably a result of direct injury whereas later leak is a sequel of ischaemia. Litigation may also be related to unnecessary hysterectomy or an oophorectomy. Questions relating to the indication for surgery can arise particularly when a hysterectomy is associated with complications and less invasive options such as an intrauterine contraceptive device or endometrial ablation have not been offered or discussed.UrogynaecologyLitigation related to urogynaecology cases are centered on the use of meshes and related complications. Clinicians undertaking synthetic meshes for the treatment of pelvic organ prolapse should familiarise themselves with NICE guidance on the use of meshes interventional procedure guidelines https://www.nice.org.uk/guidance/ipg581.General gynaecologists must also be aware that without a sufficient workload, continuing to perform complicated urogynaecology procedures is fraught with the risk of litigation.Time barClaims should be brought within 3 years of the injury or the date of knowledge of the alleged negligence. Where the injured person is a child, the 3-year period will only begin when they have reached their 18th birthday. In practice that means that a child has until their 21st birthday to bring a claim. In cases of claimants who lack capacity there is no time limit, as is often the case in birth injury cases. If an adult dies as a result of their medical treatment, their personal representatives or dependants may bring a claim within 3 years of the date of their demise. References1. McFarlane v Tayside HB [1999] 3 WLR 1301. 2. Parkinson v St James' [2001] 3 All ER 97.