Perineal trauma: the power of partnership
What lessons have been learned from the OASI Care Bundle project aimed at reducing severe perineal trauma, asks Posy Bidwell?
Implementation of the OASI Care Bundle began in January 2016. However, its inception took place in May 2014, at a summit of the RCM and the RCOG to discuss the increase in obstetric anal sphincter injuries (OASI) that had been highlighted in Gurol-Urganci et al (2013).
In September 2015, the RCM, the RCOG and the London School of Hygiene and Tropical Medicine (LSHTM) developed the OASI Care Bundle, which is composed of four elements (see panel, right).
What did implementation of the care bundle involve?
The care bundle was piloted in two maternity units with promising results. Following this, the RCM, the RCOG, Croydon Health Services NHS Trust and LSHTM successfully acquired funding from the Health Foundation to scale it up to 16 units across England, Scotland and Wales as part of a quality improvement (QI) project.
Each participating unit had a primary midwifery and obstetric champion (the number of secondary champions varied according to need). This voluntary role attracted a range of midwives, including those already responsible for training within the unit, or who were passionate about finding new ways to reduce perineal trauma.
Participating units were grouped into four regions, and implementation was staggered so that a new region launched the care bundle every three months. At the start of implementation, champions attended a training day at the RCOG where they learned how to use all elements of the care bundle, including a particular technique for manual perineal protection (MPP).
'Taking part means more evidence, and I think people want to be part of that’
- Labour ward midwife
The training day also included sessions on the evidence behind the care bundle, an introduction to QI, and how they might apply this within their unit. They also heard experiences of women living with the long-term consequences of OASI. Champions were given training and promotional materials, and went back to their units motivated and ready to start.
OASI Care Bundle elements
- Inform the woman about OASI and what can be done to minimise her risk.
- When indicated, an episiotomy should be performed mediolaterally at a 60° angle at crowning.
- Documented use of MPP: for spontaneous births, MPP should be used unless the woman objects, or her chosen birth position doesn’t allow for it. For assisted births, MPP should always be used.
- Following birth, the perineum should be examined and any tears graded according to the RCOG guidance.
The examination should include a per rectum check even when the perineum appears intact.
The main clinical outcome was OASI rates, measured using 18-month patient-level data obtained from the maternity information systems (MIS) of each participating unit. Implementation outcomes were evaluated to assess acceptability, feasibility, coverage and sustainability of the intervention. The evaluation methods are detailed in full in the RCOG’s protocol (Bidwell et al, 2018).
What have we learned?
The OASI Care Bundle has encountered many highs and lows throughout implementation. These emotions are common to any QI journey. Through innovative approaches, we identified barriers and, where possible, implemented enablers to address them (see below).
Enablers of the care bundle
Positive engagement with women: The OASI Care Bundle has women at the heart of the project. There are recent mothers on the project’s advisory group, the RCOG Women’s Network, who were consulted on the women’s information sheet. Women’s stories were included in the project newsletter, and interviews were conducted with women who had received the care bundle as part of their care.
Giving women information about perineal trauma did not put them off vaginal birth. As one woman said: ‘Tearing is a reality and it is better to be informed about it.’
Working together: Prevention of third- and fourth-degree tears is a truly multidisciplinary area, which can make traction difficult. However, it was amazing what the teams achieved, with midwives performing MPP for obstetricians during instrumental births and obstetricians helping train midwives, creating a genuine culture of partnership.
Appetite for change: Midwives within our units reported that they feel upset when women suffer third-degree tears and how they reflect on whether they could have done something differently. They welcomed the opportunity to learn new skills to reduce perineal trauma.
Success stories of the care bundle helped the units to embrace its use. There were reports that MPP was a ‘bit fiddly’, but there was also an understanding that learning a new technique took time. Students in particular were excited about being part of something that would make a difference to women’s outcomes.
Barriers to the care bundle
Freeing up staff for training: Local champions conducted all the training within the units. The aim was to train all midwives and obstetricians within the first three months. This required a flexible approach as there was no dedicated time set aside for training, with sessions conducted on shift or at handover.
The hope was for a ‘train-the-trainer’ approach – but there was a preference for the champions to facilitate training. This placed a heavy burden on the champions, who often had no dedicated time, and the spread of training was associated with being able to maintain positive and passionate attitudes.
Data: Of the 16 units, 10 had different MIS. Their capabilities affected first whether it was possible to add monitoring questions to assess compliance and second, the quality of the final data extract as there was a wide variation in mandatory fields. Some units do not record the category of third-degree tear on their MIS.
It is important at a local and national level to know the number of OASI and severity of tears within a unit, given that this can impact women’s long-term outcomes.
Mixed engagement: Some felt that the women’s information sheet, in particular the diagram of a perineum, was ‘too explicit’ and the content would scare women. Some did not like using MPP and others did not like performing per rectum checks on all vaginal births.
Everyone recognised a de-skilling around episiotomies and perineal management in second stage, including visualising stretch and blood flow.
A comprehensive FAQs section can be found here.
The results of the care bundle were presented in November at an RCM-RCOG event and more publications are planned.
The RCM and the RCOG remain committed to continuing to reduce perineal trauma, and it is essential to keep this topic at the forefront of everyone’s mind.
The short- and long-term consequences of OASI are devastating and include faecal incontinence, relationship breakdowns and post-traumatic stress disorder. Women can be fearful to go out and, as one midwife commented: ‘These women are in their 20s and 30s – you wouldn’t expect them to have to deal with things like that.’
We all need to take responsibility and ensure that we do all we can to protect women’s perineums for the future physical and mental wellbeing of mothers.
Posy Bidwell is a midwife and research fellow at the RCOG
Bidwell P, Thakar R, Seevdalis N, Silverton L, Novis V, Hellyer A, Kelsey M, van der Meulen J, Gurol-Urganci I. (2018). A multi-centre quality improvement project to reduce the incidence of obstetric anal sphincter injury (OASI): study protocol. BMC Pregnancy and Childbirth 18(1): 331.
Gurol-Urganci I, Cromwell DI, Edozien LC, Mahmood TA, Adams EJ, Richmond DH, Templeton A, van der Meulen JH. (2013) Third-and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG120(12): 1516-25.
Priddis H, Schmied V, Dahlen H. (2014) Women’s experiences following severe perineal trauma: a qualitative study. BMC Pregnancy and Childbirth 14: 32.
RCOG. (2014) BJOG study into third- and fourth-degree perineal tearing. See: rcog.org.uk/en/news/rcog-statement-bjog-study-into-third--and-fourth-degree-perineal-tearning (accessed 23 October 2018).