Perineal care bundles: clinicians' concerns

Perineal care bundles are a hot topic right now. The past few weeks have seen the publication of two papers relating to the OASI (or obstetric anal sphincter injury) care bundle that has been under trial in the UK.

This is a package of care that was designed to reduce the incidence of birth-related tears that affect a woman’s anal sphincter. That’s because this kind of tear can cause a number of problems after the birth.

In this blog post, which is based on a piece I wrote for my September 2020 Birth Information Update, I am looking at two recent studies that have been published in the UK.

Are perineal care bundles effective, and what do clinicians think?

The first study (Gurol‐Urganci et al 2020) is an evaluation of the bundle itself, and it showed that “the OASI rate decreased from 3.3% before to 3.0% after care bundle implementation.” This is, as the authors acknowledge, a relatively small reduction which needs to be weighed against the potential disadvantages and costs of the package. Which is why I was just as interested in the second recent paper; an exploration of clinicians’ perspectives on the care bundle (Bidwell et al 2020.)

As the authors of that paper note, “We do acknowledge that a researcher of different profile (eg, scientist) might have elicited a somewhat different pattern of responses” (Bidwell et al 2020).

It’s also possible that, if the data had been analysed by people who weren’t involved in the implementation, there may have been a different focus. That’s because we all have pre-existing views on this kind of thing, and I’m happy to acknowledge that I have a perspective on this issue which differs from that of the authors of these papers. I looked at perineal care bundles in an online course, and was struck by the many concerns that have been raised about perineal care bundles (which are in use in Australia and some other countries as well as the UK) by midwives, obstetricians, doulas and others involved in birth.

Professors of obstetrics, gynaecology and midwifery have also raised concerns as well.

One obstetrician wrote:.

“The prevention of severe perineal trauma for 3 in 1000 women who gave birth vaginally in hospitals after the bundle was introduced isn’t really a stunning reduction in incidence. And I wonder if birthing women would accept having their midwife or doctor handling their perineum during birth and later performing a rectal examination as an appropriate “cost” to pay for this reduction. By way of comparison, a recent study focused on nine practice changes, none of which related to the placement of hands during birth, episiotomy use, or rectal examination. Instead they included such elements as monitoring and reporting of birth outcomes, a focus on good inter-professional practice, fetal monitoring education, and employing a midwife co-ordinator. The severe perineal trauma rate fell from 8.7% to 5.2% – 35 fewer cases of trauma per 1000 women. As a bonus, the rates of caesarean section, instrumental birth, and postpartum haemorrhage also fell.” (Small 2020)

Clinicians’ perspectives

It is interesting to see similar concerns reflected in the words of the midwives and obstetricians who took part in the focus groups in Bidwell et al’s (2020) study. For instance, an obstetrician in one of the focus groups in Bidwell et al (2020) echoed the words of many of my colleagues and course participants when questioning the evidence for doing a rectal examination on every woman:

“Because it would be nice to have a number needed to treat sort of thing for that. So if you have to do one thousand PRs [per rectal examinations] to pick up one, is all that indignity worth it? (Obstetrician).” (Bidwell et al 2020).

The reality is that deciding whether “all that indignity” is worth it is not only up to those who make policy recommendations. The job of guideline and policy writers is merely to recommend that something be offered. It is up to the recipients of any type of care to decide whether or not they want an intervention, and yet it is very clear that women are not always being given the information that will enable them to make an informed decision.

The information problem

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Sometimes, information is not being given. But I have also heard stories of clinicians being threatened for giving women accurate information about the way in which the most personal parts of their body will be handled in units which are implementing the care bundle. Other clinicians have expressed concerns about the effect of the bundle on positions that can be adopted for labour and birth, and there is also the sadly ever-present concern that information (especially about submitting to rectal examination) is being given in a coercive, fear-based and sometimes disrespectful manner. Yes, these viewpoints, like those collected by Bidwell et al (2020) are not likely to be representative of all clinicians. But they exist, and that makes them worthy of our attention.

What do women think?

What is even more worthy of our attention are the experiences of those who are receiving this care, although I have not yet seen that question explored by the team who are implementing the care bundle. That doesn’t seem to be their goal though. And to be fair, the authors did state that they were interested in acceptability, feasibility, and sustainability, rather than on learning from the knowledge and experience of clinicians.

A wider perspective?

It’s just that, as someone who spends their own time sharing knowledge and experience with other clinicians and birth workers, I think that so much more could be gained by taking a wider perspective on this. One might think that the fact that the reduction in anal sphincter injury rates in Gurol-Urganci et al’s (2020) evaluation was so small would be cause to consider and evaluate other options (which include a number of individualised, midwifery-focused approaches), but I didn’t spot any discussion of this possibility by the authors of either paper. Perhaps, if we took a range of different knowledge and perspectives into account rather than focusing on one, standardised, intervention-focused care bundle, we might be able to come up with an approach which reduced anal sphincter injuries in a way that was more acceptable, more dignified and more effective.

It’s clear than we need to keep talking about this, at every level.

Bidwell P, Thakar R, Gurol-Urganci I et al (2020). Exploring clinicians’ perspectives on the ‘Obstetric Anal Sphincter Injury Care Bundle’ national quality improvement programme: a qualitative study. BMJ Open http://dx.doi.org/10.1136/bmjopen-2019-035674

Gurol‐Urganci I, Bidwell P, Sevdalis N et al (2020). Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped‐wedge design. BJOG https://doi.org/10.1111/1471-0528.16396