Dr Posy Bidwell is an experienced midwife and researcher who was appointed as the Clinical Research Fellow for the OASI Care Bundle Project, a joint initiative between the Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM) that sought to reduce the incidence of severe perineal tears in childbirth between 2016 and 2018. Here she discusses the recently published evaluation of women’s experiences of the OASI Care Bundle and its importance in identifying areas for improvement in maternity care to ensure the best possible outcomes for women.
What a lot of people don’t realise is that many women experience some kind of tearing when they have a vaginal birth. These tears can occur around the labia, clitoris, vagina or within the perineum (the area between the vagina and anus). While these type of tears tend to heal quickly with no long lasting effects, a small number of women experience a deeper and more severe perineal tear that extends into the anus. These are known as ‘third’ or ‘fourth’ degree tears, or obstetric anal sphincter injuries (OASI). The long-term physical and psychological effects can be devastating for women who suffer these injuries. Women who have these injuries can suffer from chronic pain, incontinence, painful intercourse, anxiety and post-traumatic stress disorder, and without immediate access to treatment these effects can persist for months or years afterwards.
The OASI Care Bundle aims to raise awareness of severe perineal tears and reduce the risk of them occurring. It was borne out of discussions between midwives, obstetricians and researchers from the RCOG, RCM and the London School of Hygiene and Tropical Medicine (LSHTM), in response to the reported rise in OASI rates in England between 2000 and 2011. The aim was to introduce a standardised package of care, or “care bundle”, that could be feasibly implemented in maternity units in England, Scotland and Wales to reduce the risk of women suffering a third or fourth degree tear in childbirth. Through a review of the literature on intrapartum interventions that might prevent these injuries, the OASI Care Bundle team identified four commonly-used interventions that, when consistently used together, would likely lead to a reduction. The four interventions are identified in this implementation guide (PDF 1.5mb).
In 2016, the OASI team secured funding from the Health Foundation to trial the OASI Care Bundle within 16 maternity units. The OASI project team consisted of obstetric and midwifery experts who provided ongoing support to clinicians to apply the OASI Care Bundle between January 2017 and April 2018. The clinical results from the project, as published in BJOG in 2020, identified an overall reduction in injuries across all the maternity units from 3.3% to 3.0%, a real-terms decline of 10% that, when adjusted for women’s individual characteristics, amounted to a 20% reduction in the risk of a woman suffering an OASI in childbirth.
While this report showed clearly that the OASI Care Bundle had been successful in a clinical sense, the project team felt it was incredibly important to understand women’s experiences of the care bundle. We’d worked with women throughout the design and implementation of the OASI project to ensure their needs were met and they understood what was involved.
As part of the project evaluation, we recruited 19 women to take part in a qualitative study to explore their birth experiences and perspectives on all four elements of the care bundle. The evaluation found that the majority of women (14 of the 19) had a positive experience of manual perineal protection - a ‘hands on’ approach to reduce the risk of perineal trauma. These women reported that it was a supportive approach, with none reporting it as a negative experience. Similarly, of the 14 women who recalled having the post-birth perineal examination, all felt that it was an acceptable way to diagnose severe perineal tears and were unconcerned by its use. Only two of the 19 women had an episiotomy during their labour which prevented a wider analysis of experiences of this intervention.
An important finding highlighted in the study was that women do not receive enough information about the risk and potential impact of OASI, or about postnatal recovery from perineal trauma. This was summed up well by one respondent, who reported:
“I don’t think people know enough about it generally. I don’t think men know about it. I think it comes as a bit of a surprise to them that there are suddenly stitches, and they aren’t aware of that … people don’t appreciate that you are recovering from lack of sleep, you are sore, you’ve been stitched up. It isn’t really talked about.”
So how, as healthcare professionals, do we learn from these findings? One of the key takeaways is that, on its own, provision of antenatal information leaflets just doesn’t go far enough. We need to emphasise the importance of having a discussion with women about their individual risks and the potential impacts of OASI so that we can empower women to ask questions, clarify doubts, and ultimately, make informed choices about their care. To help ensure women receive the best care and support possible, we have created a Perineal Tears Hub, an online resource that provides information on OASI, postnatal recovery, and where to seek more support. This support is offered by our partners the Birth Trauma Association and MASIC Foundation, both of which were instrumental in guiding the OASI Care Bundle Project and offer a comprehensive range of services to women that have suffered these injuries.
More research is crucial to help us understand women’s experiences of perineal care. The more knowledge we have, the better we can tailor services to care for and support women. The voices of women and our learnings from the OASI Care Bundle Project will go a huge way in helping us to launch the OASI2 project in 2021, as we look at ways to roll out the care bundle to more maternity units. What’s evident though is the need for further research into women’s views and we have plans to interview a much larger cohort of women about their experiences as part of OASI2. Together, we hope to achieve a much better understanding of how women perceive and experience perineal care, so that we can continue to make improvements in this vital aspect of maternity services.
For media enquiries about OASI2 please contact the RCOG press office on +44 (0)7986 183167 or email email@example.com.