News from the OASI Care Bundle Quality Improvement Project Team

By Louise Silverton, Director for midwifery on 23 July 2018 Severe Perineal Trauma

The OASI Care Bundle Quality Improvement Project received funding from the Health Foundation in the summer of 2016 and began implementation in 16 maternity units across England, Wales and Scotland in January 2017. This multi-faceted quality improvement project aimed to reduce rates of obstetric anal sphincter injury (OASI) following childbirth in the UK by standardising practice in a way that is acceptable to women and clinicians.

Between 2000 and 2012, rates of OASI increased in England.1 The long-term consequences of OASI include anal incontinence which can result in significant emotional and medical burden to women and financial burden to the NHS. While the cause of this increase is not singular, it may be linked to changes in practice related to care of the perineum during childbirth.1 There is no way to completely avoid OASI, but this care bundle of interventions brings together evidence-based practice and has shown to decrease OASI rates in both UK and international settings.2,3 Experiences in some maternity units have shown that some of the underlying problems related to this rise in OASI include lack of knowledge about risk factors, variation in practice, inconsistencies in training and skills, and a lack of awareness of the long-term impact of OASI.5,6 

The Royal College of Midwives (RCM) and Royal College of Obstetricians and Gynaecologists (RCOG) set out to address these issues through the OASI Care Bundle as part of a quality improvement project to reduce rates of severe perineal trauma. This included an effort to deliver evidence-based practice consistently, improve clinical skills and increase awareness and knowledge of long-term effects and risk factors of OASI. The Colleges and partner organisations (London School of Hygiene and Tropical Medicine and Croydon Health Services NHS Trust) have used rigorous methods to evaluate implementation of the care bundle. The primary outcome is OASI rates. Qualitative evaluation was also included to see whether the intervention was acceptable to clinicians and women, feasible for those involved, widely taken up in the participating units and sustainable over time.

The project has now finished formal implementation within the participating units and data analysis has begun. It has been a fascinating and exciting journey and we have been inspired by many women along the way who feel that perineal trauma needs to be more openly discussed. We thank them for coming forward with their birth stories over the course of project and their support of our work which aims to prevent more women being affected. We would also particularly like to thank the local champions who spearheaded the project in their units. The findings will be shared through a series of publications and communications in the late autumn, so watch this space!

1Gurol-Urganci I, Cromwell DA, Edozien LC et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG. 2013; 120:1516-25.

2Laine K et al. Incidence of obstetric anal sphincter injuries after training to protect the perineum. BMJ Open. 2012.

3Naidu M et al. Reducing obstetric anal sphincter injuries using perineal support a preliminary experience. Female Pelvic Medicine & Reconstructive Surgery. 20 (Supplement 1):S1-S40, July/August 2014.

4Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOP). Int Urogynecol J 2011;22:1279–85.