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OASI Care Bundle Update, January 2017

Welcome from the project team

Welcome to the first OASI Care Bundle update. We are very excited that the first four participating sites have now begun rolling out the care bundle and look forward to sharing updates about the project with you.

Over the course of the project, an estimated 32,800 women will be potentially eligible for the care bundle within the 16 participating sites. The first region’s four participating sites (Birmingham Women’s Hospital, Royal United Hospital Bath, Royal Gwent Hospital and Warrington Hospital) have attended a Skills Development Day at the Royal College of Obstetricians and Gynaecologists. Over the past six months, the project team has been working with these sites to set up the project .They will begin roll-out this month and the remaining three cohorts will begin roll-out every three months throughout 2017. We wish them every success with rolling out the care bundle and look forward to hearing about their experiences throughout the project.

The second region will begin roll out in April 2017 and will be informed shortly of this. We will work closely with them, as we did with the first units, to set up the programme and support them in making any adjustments which are specific to their needs.

We look forward to sharing these updates with you over the next year and look forward to hearing about your experiences. 

Vivienne Novis – Clinical Lead for Midwifery 

Vivienne Novis, the Clinical Lead for Midwifery on the OASI Care Bundle Project, talks about how she became involved and why she is interested in this clinical topic.

I trained as a nurse in 1981 and as a midwife in 1987, and since then practised as a staff midwife and a labour ward co-ordinator until 18 months ago. Then due to health issues (worn out “midwife” joints mainly), I applied for a secondment to lead my Trusts Perineal Management Project.

The project came about as a successful bid for funding to the NHSLA Incentivisation scheme which offered Trusts the opportunity to make bids, linked to their claims profile, to run projects aimed at reducing harm and avoiding litigation. The project was supported by Sign Up to Safety.

Getting ready for the interview I revised what I knew about 3rd/4th degree tears and, sadly, although I was a very experienced midwife and labour ward Co-ordinator, it was pitifully little.

In my world, the midwife came out of the delivery room, told me she thought her lady had sustained a 3rd degree tear, I called the relevant doctors to confirm, prepare her for theatre and off she went down the corridor to theatre for the repair. As far as I was concerned the case was completed and, although unfortunate, no harm was done.

Then I started looking in detail at the subject, and importantly at the most recent work/statistics nationally and internationally.

I discovered the rate of 3rd/4th degree tears had risen three-fold over approximately 15 years, and that uro-gynaecologists and colo-rectal surgeons in the UK had raised the alarm. They were trying to bring about changes in practice based on the evidence from Scandinavia who seemed to have experienced a similar rise in 3rd/4th degree tears, but were ahead of the UK in taking action to address it. Most notably, I read the work of Katariina Laine, a Norwegian obstetrician. She and her team realised that a change in the way midwives used their hands at the moment of birth in the Nordic countries may be responsible for the increased rates whereas in Finland, where rates were stable, traditional practices had been maintained

Although I’d lived/worked through the HOOP trial in 1998 my practice was already ingrained, having been mentored by very experienced labour ward sisters who dare I say were of more advanced years! I’d continued to practice what I now found out was called “the Ritgen manoeuvre”, and as a labour ward co-ordinator I was confident in performing episiotomy if the case called for it.

Next, I looked at outcomes and started reading women’s stories on Netmums  and the Birth Trauma Association. I attended the endo-anal follow up clinic and I think that was when I truly began to realise that something was terribly wrong and that a trip to theatre wasn’t the end of the story. The women posting on these sites were deeply traumatised, suffering embarrassing and debilitating symptoms both physical and psychological. Their relationships with their partners, children, friends and colleagues were altered and in many cases the seriousness of their symptoms had not been understood by health care professionals.

I began to understand the personal cost to women and their families and the financial cost to the NHS.

So our local project began 18 months ago based on reducing the chance of 3rd/4th degree tear by using a “hands on “ technique at the time of birth and communication with the women about achieving a slow controlled birth of both the baby’s head and shoulders. Deskilling around performing episiotomy was addressed and the Episcissors-60 were introduced. Robust diagnosis of tears was maintained with 100% per rectum examination for all vaginal births.

Great efforts have been made to mitigate the event when it does happen including providing multi-disciplinary written information for those women who do sustain tears, and ensuring that every single woman receives a timely follow up appointment from a uro-gynaecologist and input from a women’s health physiotherapist.

I manage the incident reporting for the 3rd/4th degree tears and see every midwife whose woman has sustained the injury. I encourage them to reflect upon the case and check that they have a thorough understanding of risk factors and strategies for prevention.

The midwives and obstetricians have had excellent engagement with the project and the rates of tears are now sitting at approximately 2.5% (of total births) from a pre-project figure of almost 4%.

The local project tempted me to apply for the secondment to the RCOG/RCM OASI Care Bundle project and, much to my amazement, I got the job!

I was keen to participate because the OASI Care Bundle has been honed down to the four most important and very simple elements. In the longer term I believe this work could bring a real change of practice in the UK. I am pleased to be involved with a project that has gone the extra mile to ensure all voices are represented, bringing obstetricians, midwives and women together, working in partnership, to improve outcomes and reduce harm. 

OASI Care Bundle Pilot- our experiences in Plymouth

Heidi Hollands, RM, MMid, BSC. Research Midwife Champion 

Heidi Hollands is the Research Midwifery Champion at Plymouth Hospitals NHS Trust, one of the pilot sites for the OASI Care Bundle. Heidi shares her experiences of the Care Bundle programme.

OASI has been a specialist interest for me since 2010. In 2013, I received training by Katariina Laine on Manual Perineal Protection and am involved in OASI days as well as presenting on the subject both nationally and internationally. I have been involved in the OASI Care Bundle programme from the start, training both at my own unit as well as at the other unit for the pilot in 2016. 

At Plymouth, we rolled out training in several different ways, through a targeted training day, a preceptee midwives training session and through ad hoc training which targeted Band 7 midwives in particular. To keep the momentum going I found it helpful to distribute emails internally, provide training materials and share OASI email updates within my unit. 

Over the three month pilot period, there were 877 births within our unit. During this time, attending clinicians filled out just 15% of pro formas. The Project Team have taken this on board and a more feasible data collection method (monitoring stickers or adding fields to the MIS) will be used in the Scaling Up project. However, those pro formas which were filled in did illustrate a high rate of compliance to the Care Bundle interventions and there was definitely no lack of enthusiasm for taking up the programme in our unit! Throughout the roll out period OASI rates fluctuated, as expected, but we saw an overall decrease.

The work does not end here and a continued approach to keep up momentum is definitely needed to maintain enthusiasm and compliance in order to reduce OASI rates and keep them that way!

Women’s experiences – Birth Trauma Association 

We at the Birth Trauma Association are delighted to have been invited to be the part of the OASI Care Bundle Project Team. It represents a chance to make a real change and to make a huge difference to women’s lives, and to give every woman the best start on her journey into motherhood.

The statistics behind the project tell us that the rate of OASI has tripled over the last decade, with long-term consequences including anal incontinence and dyspareunia. These outcomes incur significant costs to the health service, in terms of ongoing treatment costs and also expensive litigation costs. But more than this, the impact of OASI on a woman can be life-changing and devastating.

At the BTA, we speak to women every year whose lives have been turned upside down following a severe perineal tear. The emotional aftermath of an OASI and the impact on a new mother’s mental health cannot be underestimated. A traumatic birth massively increases a woman’s risk of developing post-natal depression and post-natal post-traumatic stress disorder, with symptoms including mood swings, flashbacks, nightmares, hypervigilance and intrusive bad memories. Mothers tell us that chronic pain and acute emotional distress stemming from their OASI badly affects their ability to build a strong maternal bond with their baby. Attempts to breastfeed can fail, as women can find it extremely difficult to find a comfortable position in which to sit and feed their baby.

It is common for relationships with husbands and partners to become difficult; not only can physical pain from an OASI make it difficult to resume a sex life, women also tell us that fear of causing more pain, or embarrassment about their injuries make them shy away from intimacy.

Women can easily become socially and emotionally isolated from friends and supportive networks, as incontinence and pain make them afraid to leave the house. Confidence and self-esteem is badly affected and women often tell us that they are ashamed to tell other people about their injuries – sometimes even too embarrassed to tell a doctor or other healthcare professional about the full extent of the difficulties they are having - and so suffer in silence. Women can later find it difficult to resume careers, in part because of physical problems but also due to the associated long-lasting mental health problems. There is barely an aspect of a woman’s life which is not affected by the impact of an OASI.

As a healthcare professional, you have the opportunity to make an enormous difference. The successful implementation of this Care Bundle is about so much more than improving patient outcome statistics or reducing associated medico-legal costs. It represents a chance to make a real change and to make a huge difference to women’s lives and to give every woman the best start on her journey into motherhood.