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Tag Archives: Birth trauma

Bundles for perineal care: the impact on midwifery practice

When attempting to solve difficult problems in healthcare, professional organisations are increasingly making use of bundled approaches to care. A care bundle consists of collection of interventions which are believed to work interactively to address the issue in question. Using several interventions at once, at a whole of population level, is considered to be a more effective approach than the application of single interventions. There is however little evidence to support this assumption (Lavallee et al., 2017).

In maternity care, severe perineal trauma (sometimes called obstetric anal sphincter injury or OASI) is an issue that has received attention in both the United Kingdom and Australia. Tearing of the tissues at the opening of the vagina is common at birth. Typically, these tears are small and heal well without impacting on the function of the pelvic floor. Less often, tearing can be more extensive and extend to include the muscles around the anus (categorised as a third-degree tear) or into the anal passage (categorised as a fourth-degree tear). Trauma involving the anal sphincter muscles and / or anal passage can result in long term problems controlling the passage of wind and bowel movements. Recognising the extent of the trauma is important, as appropriate surgical repair and physiotherapy enhances the likelihood of restoring the normal function of the muscles.

Concerns have been raised that severe perineal trauma has become more common in recent years, though some argue that it is simply that clinicians have become better at recognising when it has occurred (Thornton & Dahlen, 2020). A bundle designed to prevent and identify severe perineal trauma was introduced in the United Kingdom in 2016 (Gurol-Urganci et al., 2021) in the hope that the rate of severe perineal trauma might be reduced. Another perineal care bundle was introduced in Australia in 2018 (Women’s Healthcare Australasia, 2019), with slight differences to the interventions included. In Australia the bundle consisted of:

  • Applying warm compresses to the perineum during birth
  • Applying manual pressure to the fetal head and the woman’s perineum during birth
  • Performing an episiotomy (a cut made at the opening of the vagina) for all women giving birth for the first time when instrumental birth is being conducted (vacuum extraction or forceps assisted birth), and when an episiotomy is done, ensuring that the angle of incision is at least 60 degrees from the vertical
  • All women having two people assess their perineum after vaginal birth, and
  • This assessment included a digital rectal examination, even when the perineum appeared intact.

High quality research evidence is only available for the first of these practices (Aasheim et al., 2017). Outcomes from the United Kingdom perineal bundle were reported after the Australian bundle was rolled out (Gurol-Urganci et al., 2021), finding a small but statistically significant reduction in the incidence of severe perineal trauma, occurring in 3 less women per 1000 following the introduction of the bundle. What is not known is how the bundle impacts on midwifery practice nor has there been research to understand the bundle from the perspective of birthing women.

Recently published research from Transforming Maternity Care Collaborative researchers Dr Jyai Allen, Dr Kirsten Small, and Dr Nigel Lee of the University of Queensland set out to examine the impact that the Australia perineal bundle had on midwifery practice (Allen et al., 2021).

Midwives working in Queensland hospitals where the bundle had been introduced were recruited, with twelve midwives from five hospitals being interviewed. Midwives were asked about the approaches to perineal care they used prior to the introduction of the bundle and how this had changed with the introduction of the bundle. The findings were presented relating to three themes:

  1. Design and implementation of the bundle,
  2. Changes to midwifery practice, and
  3. Obstetric domination and midwifery submission.

Participants expressed confusion about whether the bundle was a research project or a quality improvement measure. Emotive appeals rather than the presentation of sound evidence for the elements of the bundle was used in education sessions supporting the introduction of the bundle. Some midwives readily accepted all the changes to practice that occurred with the introduction of the bundle, with others used a variety of approaches to “get around” aspects of the bundle they considered inappropriate. When midwives did comply with all elements of the bundle there was a sense that this was done from a position of relative powerlessness to provide alternative approaches to practice.

Midwives described concerns about the standardising effects of the bundle, which prevented them from being able to provide individualised care. The practices outlined in the bundle were considered easiest to apply when women had an epidural and were confined to bed for birth. Meeting the bundle requirements (particularly maintaining manual perineal support) was not always possible when approaches such as waterbirth or upright, forward leaning postures where used. Midwives were concerned that the bundle therefore favoured forms of care (such as restricting women to the bed for birth) which made it easier to comply with the bundle requirements.

Overall, the bundle appeared to reflect and reinforce technocratic obstetric ways of knowing and acting. Midwives were therefore placed in a position where they were required to frame their practices in relation to an obstetric view of the ideal approach to preventing severe perineal trauma. Providing care consistent with midwifery philosophy, such as individualised care that supports physiological processes would be seen as non-compliant behaviour. To avoid this, future bundle development should include consultation and collaboration with women and midwives, and routine evaluation of the bundle should include research to examine the impact of the bundle on midwifery practice and women’s experiences of their births.

References

Aasheim, V., Nilsen, A. B. V., Reinar, L. M., & Lukasse, M. (2017). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews, 6, CD006672. https://doi.org/10.1002/14651858.CD006672.pub3

Allen, J., Small, K., & Lee, N. (2021, Jan 20). How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis. Women and Birth, in press. https://doi.org/10.1016/j.wombi.2021.01.012

Gurol-Urganci, I., Bidwell, P., Sevdalis, N., Silverton, L., Novis, V., Freeman, R., Hellyer, A., van der Meulen, J., & Thakar, R. (2021). Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design. British Journal of Obstetrics and Gynaecology, 128(3), 584-592. https://doi.org/10.1111/1471-0528.16396

Lavallee, J. F., Gray, T. A., Dumville, J., Russell, W., & Cullum, N. (2017). The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implementation Science, 12(1), 142. https://doi.org/10.1186/s13012-017-0670-0

Thornton, J. G., & Dahlen, H. G. (2020). The UK Obstetric Anal Sphincter Injury (OASI) Care Bundle: A critical review. Midwifery, 90, 102801. https://doi.org/10.1016/j.midw.2020.102801

Women’s Healthcare Australasia. (2019). The how to guide: WHA CEC perineal protection bundle. https://women.wcha.asn.au/sites/default/files/docs/wha_national_collaborative_how_to_guide_21.1.20.pdf

 

Psychological trauma regarding birth and helpful responses – Podcast

This week is Birth Trauma Awareness week. There is increasing recognition that a significant proportion of women describe some aspect of their birth as traumatic. This week provides an opportunity to focus on what can be done to prevent, and respond appropriately to, women’s experiences of their births as a form of psychological trauma.

Professor Jenny Gamble, Director of Transforming Maternity Care, recorded a podcast with Annalee Atia from Pregnancy Birth and Beyond earlier this week. In the podcast Professor Gamble explained that women may experience their birth as traumatic if they feel that there was threat to their life or safety or their baby’s (or babies’) life or safety. About 30% of Australian women report that their birth was traumatic and have some trauma symptoms at 4-6 weeks after birth.

All women should be asked about their birth experience and provided with sufficient time and empathy to be able to talk about it. The process of care is key to whether women experienced birth as traumatic. Technically poor care, failures of communication, care with coercion and without consent, and excluding the woman from decision making contribute to experiencing the birth as traumatic.

Human intent in the harm or threat experienced is significant in the development of traumatic stress and PTSD. If women feel their trust was betrayed or that they received treatment with callous disregard they are more likely to experience birth as traumatic.

The podcast explains helpful early responses for maternity care providers and others. For some women, following the trauma and the struggle to cope and work through the impact of their birth experience, report positive change and growth. These women are beacons of hope and often an empathetic ‘home’ for others experiencing adversity.

You can listen to the Podcast here. Other events held during Birth Trauma Awareness week are hosted on the Facebook page of the Maternal Mental Health Matters Australia 2020 group, along with helpful resources for people who have been affected by birth trauma.