Targeted intervention to reduce severe tearing in childbirth ‘promising’, studies reveal

on 17 September 2020 RCM Maternity Services Wellbeing Of Women Safety RCOG - Royal College of Obstetricians and Gynaecologists OASI - Obstetric anal sphincter injuries

Two new evaluation papers exploring the impact of the Royal College of Obstetricians and Gynaecologists’ and Royal College of Midwives’ OASI Care Bundle have been published in BJOG: An International Journal of Obstetrics and Gynaecology and BMJ Open

Third- or fourth-degree perineal tears, also known as an obstetric anal sphincter injury (OASI), can occur in 6 out of 100 births (6%) for first-time mothers and less than 2 in 100 births (2%) of births for women who have had a vaginal birth before. These injuries can have severe, life-long implications for a woman’s mental and physical health. The OASI Care Bundle, a Health Foundation-funded quality improvement project, aimed to reduce the rate of these severe perineal tears in 16 maternity units in England, Scotland and Wales between January 2017 and March 2018.

The OASI Care Bundle consisted of four components that, when used together, aim to reduce the risk of women suffering a severe perineal tear during childbirth. Implementation of the OASI Care Bundle within each maternity unit was led by obstetric and midwifery champions. Introduction of the care bundle was supported by multidisciplinary training and an awareness campaign to highlight the impact of these injuries to women.

The care bundle was evaluated for clinical effectiveness as well as barriers and enablers to uptake. The clinical results, published in BJOG, compared 28,000 singleton vaginal births that took place before implementation of the care bundle with 27,000 singleton vaginal births that took place after implementation of the care bundle. The authors found that the OASI Care Bundle reduced rates of severe perineal tearing from 3.3% to 3.0%, without affecting rates of caesarean section or episiotomy. The estimated reduction in severe perineal tearing was 20% when women’s characteristics were taken into account.

A qualitative study to explore healthcare professional’s perspectives of the bundle in terms of acceptability, feasibility and sustainability, published in BMJ Open, found that engagement through awareness-raising and training is key to clinical buy-in and successful implementation.

The study also found that the adoption of the OASI Care Bundle can require changes in behaviour and practice from clinicians, which takes time. Furthermore, training gaps were identified, particularly around instrument choice and appropriate episiotomy use, all highlighting the need for continuous professional development.

The barriers and successes identified by the qualitative evaluation and results of the OASI Care Bundle will be used to inform the next phase of the work. The second phase, “OASI2”, will commence in the autumn of 2020 and will involve 10 of the original units that participated in the first phase of the project, in addition to 20 new maternity units. OASI2 will evaluate and compare different approaches to the implementation of the OASI Care Bundle to support wider adoption and sustainability.

Dr Ipek Gurol-Urganci, OASI Care Bundle Evaluation Lead and first author of the BJOG paper, said:

“The gradual roll out of the OASI Care Bundle in 16 NHS hospitals in the UK demonstrated that the risk of an obstetric anal sphincter injury can be reduced by 20%.

“Working closely together with midwives and obstetricians in the participating hospitals, we found that this care bundle makes child birth safer while women’s choices of how they want to give birth are fully supported.”

Dr Posy Bidwell, RCOG OASI Care Bundle Clinical Research Fellow, OASI2 Clinical Midwifery Lead and first author of the qualitative study published in BMJ Open, said:

“The findings of the qualitative study are extremely important in our continuing effort to improve the bundle and prevent cases of severe perineal tears.

“The presence of in-house champions was fundamental to the success of the project as they were able to create awareness and encourage people to attend training. It was really positive to see midwives and obstetricians working closely together to help improve perineal outcomes for women. Visual senior support was also key.

“Throughout the project we have engaged with women and have identified an overall need for a greater awareness about severe perineal tearing. We anticipate that a third paper will follow, exploring women’s perspectives on the OASI Care Bundle, which will be instrumental in helping to further improve work to improve perineal outcomes for women.”

Dr Ranee Thakar, RCOG Vice President for Global Health and Clinical Lead for both projects, said:

“Obstetric Anal Sphincter Injuries (OASI) can have a devastating effect on a woman’s quality of life. We are delighted that the OASI Care Bundle has demonstrated a reduction in OASI rates without affecting caesarean section rates or episiotomy use.

“This quality improvement project is a joint initiative of the two colleges (RCM and RCOG) with support from the LSHTM, highlighting the importance of multidisciplinary working. We are also indebted to the local champions from the selected units for their hard work and dedication.

“Although we still have some way to go to further reduce cases of OASI, we will work hard to learn from these studies and improve the care bundle for all women. OASI2 will continue to ensure that women are at the heart of this initiative and that women’s choice is at the forefront of all conversations and decisions about their care.”

Louise Silverton, CBE, Royal College of Midwives representative for both projects, said:

“Reducing the OASI rates is absolutely key to ensure women have the safest possible birth, with the best possible outcome. It took some time to decide which components should be included in the care bundle as it was important to understand the evidence for each.

“We’ve examined this project in huge detail to show where we can continue to make improvements. As we commence with the second phase of the project we have a greater understanding of what support is needed to implement the care bundle and help guarantee its success.

“We need to work together with one voice so that we can improve outcomes for women. By continuing to do this, we can only get better. Birth complications can be very distressing and can affect women’s mental health. Therefore, each and every woman prevented from suffering these injuries is a huge achievement.”

Mother of two, Karen, from Hampshire suffered a fourth-degree vaginal tear whilst giving birth to her first child, said that the injury had affected her physically, psychologically and emotionally:

“After a healthy pregnancy, I had a very difficult labour. My daughter went into distress very quickly which led to a forceps delivery. Up to this point, and during the forceps delivery, I had not been given any pain relief other than gas and air. As you can imagine, it was excruciating. But the pain did not stop there. After a few days of experiencing discomfort, the pain increasingly worsened, to the point that I could not sit down, and I was readmitted to the maternity ward. I found out that I had a fourth-degree tear which had developed into a fistula. This has been missed by the healthcare professional as they did not perform a quick, routine rectal examination following my forceps delivery - a simple thing that could have saved me years of pain, embarrassment, anxiety, depression and anger. Since then, I have undergone three operations, had panic attacks, felt socially isolated and I have had to have counselling to help me process the trauma. This has not just affected me, but it has impacted my children, my partner, my family and friends.

“The OASI project is so important. Even if it stops only one woman experiencing what I have gone through, it is worth it. The online video resources are particularly helpful to empower women with information about tears.”


Note to Editors

For media enquiries, please contact the RCOG press office on +44 (0)20 7045 6773 or email [email protected]

BMJ Open, Exploring clinicians’ perspectives on the ‘Obstetric Anal Sphincter Injury Care Bundle’ national quality improvement programme: a qualitative study (September 2020)

BJOG, Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped‐wedge design (August 2020)

The OASI Care Bundle Project was a scaling up programme that developed and piloted an intervention package, including a care bundle and guide, a multidisciplinary skills development module for health care professionals, and campaign materials (such as leaflets and newsletters designed to raise awareness) to reduce the rate of obstetric anal sphincter injury.

It was a collaboration between the RCOG, Croydon Health Services NHS Trust, the Royal College of Midwives (RCM) and the London School of Hygiene and Tropical Medicine (LSHTM), with funding provided by The Health Foundation.

The OASI Care Bundle developed an information hub on perineal tears and episiotomies in childbirth and a series of videos of women who discuss their experiences.

These resources are based on the RCOG Green-top Clinical Guideline The Management of Third- and Fourth-Degree Perineal Tears and expert opinion

To find out more about the project, please see here:

About the RCOG

The Royal College of Obstetricians and Gynaecologists is a medical charity that champions the provision of high quality women’s healthcare in the UK and beyond. It is dedicated to encouraging the study and advancing the science and practice of obstetrics and gynaecology. It does this through postgraduate medical education and training and the publication of clinical guidelines and reports on aspects of the specialty and service provision.

About the RCM

The RCM is the only trade union and professional association dedicated to serving midwifery and the whole midwifery team. We provide workplace advice and support, professional and clinical guidance and information, and learning opportunities with our broad range of events, conferences and online resources. For more information visit the RCM website at

About the Health Foundation
The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. We supported the OASI Care Bundle as part of our Scaling Up programme, which funds teams to take successful interventions or approaches and deliver them at scale, to improve health care in the UK.