Cheng Shi Ying Cherissa v Khoo Chong Kiat and another

Cheng Shi Ying Cherissa v Khoo Chong Kiat and another was a medical negligence trial in Originating Claim No 235 of 2023 in the General Division of the High Court. Ms Cheng sued her obstetrician, Dr Khoo Chong Kiat, and Royal Clinics of O&G Pte Ltd, the company that formally employed him, over the birth of her first child at Mount Elizabeth Novena Hospital.

Labour was induced on 2 May 2020. Dr Khoo performed a cervical sweep that evening and ruptured the membranes. Ms Cheng said he performed a second sweep on the morning of 3 May 2020 after telling her a caesarean was needed; Dr Khoo denied this, saying he only examined her and found her fully dilated. With the baby crowning and signs of foetal distress, he performed a mediolateral episiotomy and applied manual fundal pressure, and the baby was born healthy at 10.35am. While repairing the episiotomy he found a 0.5cm rectovaginal buttonhole tear, which he repaired in two layers.

Ms Cheng said he told her he saw faecal matter in her vagina; he denied it. Days after discharge she passed faecal matter through the vagina, a rectovaginal fistula was diagnosed, and it was surgically repaired on 28 October 2020. She claimed the incident caused postpartum depression, post-traumatic stress, uterine and bladder prolapse and financial loss, alleging failures of consent, negligent management of labour and a negligent repair.

1. Whether Dr Khoo failed to obtain informed consent for the sweeps, episiotomy, fundal pressure and repair
2. Whether applying manual fundal pressure was negligent or caused the tear
3. Whether the two-layer repair without a colorectal surgeon fell below the standard of care
4. Whether a caesarean should have been performed because labour was prolonged

On consent, the court accepted that Dr Khoo explained the sweep beforehand, and Ms Cheng admitted at trial agreeing to let him try to widen the cervix. Although telling her before the cut would have been good bedside manner, Singapore doctors are not required to take formal consent for an episiotomy or fundal pressure in routine vaginal delivery, especially when hurrying a distressed baby. It accepted that she was told of the tear before the repair; the omissions from the discharge summary and handover form, and the late timing of his note, did not make his account unreliable.

On fundal pressure, the court preferred Dr Khoo's expert, long in Singapore practice, over Professor Korda, who had not practised clinical obstetrics since 1998 and admitted no direct knowledge of Singapore practice. Given maternal fatigue and foetal distress, with instrumental delivery riskier for the perineum and a crash caesarean inappropriate once the head was crowning, the pressure was not negligent. Nor did it likely cause the tear, as the baby was already well within the birth canal.

On the repair, the court found there was likely no faecal soiling at delivery: both defence experts thought leakage through so small a tear very unlikely after the enema, and the hospital's own records showed none. Consulting a colorectal surgeon was therefore unnecessary, and a colostomy would not have been relevant for a tear that was not third or fourth degree. A two-layer repair met the standard because the tear was much smaller than those in the cited articles, and enlarging it carried greater risks. Any omission of a vaginal check was not shown to have caused the fistula.

On labour, a first stage over the average was not necessarily prolonged, and proceeding naturally at full dilation was reasonable. The court added that damages would in any event have been limited and found no loss of earning capacity.

The court dismissed the action, finding that Ms Cheng had failed to prove her case against either defendant. Dr Khoo was not negligent and did not commit battery, so the company was neither vicariously liable nor in breach of contract. Costs were to be argued later.