Over the past few years, several countries have introduced packages of interventions known as ‘perineal care bundles.’
These bundles are groups of interventions which policymakers hope will address the rising rates of anal sphincter injury (severe tears to the perineum and/or anal area) which are sustained by some women during birth.
This is a really important area, as perineal and anal sphincter injuries can cause lifelong health issues.
The argument for perineal care bundles
Let’s start with the arguments FOR perineal care bundles.
As the RCOG notes in the guide for the implementation of perineal care bundles in the UK:
“In England, the rate of obstetric anal sphincter injuries (OASIs) has tripled over the last decade from 1.8% to 5.9% among singleton, term, cephalic, vaginal first births. (1) The overall incidence of OASI in the UK is 2.9% (range 0—8%), with an incidence of 6.1% and 1.7% in primiparous and multiparous women respectively.”
“The main risk factor for anal incontinence amongst childbearing women is OASI. A systematic review
demonstrated a wide variation in the prevalence (2.2—36.7%) of anal incontinence in the short term, which can get worse over time.”
“Short-term complications of OASI include pain, bleeding and infection, which can result in urinary retention and constipation. These complications can lead to multiple attendances in hospital or community services.”
“Long-term complications of OASI include anal incontinence, chronic pain, dyspareunia and urinary incontinence which have been shown to have a detrimental psychosocial impact requiring further counselling. In some circumstances, the trauma of sustaining an OASI and its complications affects subsequent births where a vaginal birth is forsaken for an elective caesarean, with associated additional costs.”
“Medico-legally, the total value of negligence claims relating to OASIs, between 2000 and 2010 was estimated to be £31.2 million. The specific negligent acts related to failure to consider a caesarean section, failure to perform or extend an episiotomy, failure to diagnose the true extent and grade of the injury, inadequacy of repair and failure to perform a repair. Furthermore, the long-term healthcare costs can be significant, with ongoing imaging, outpatient, community and surgical follow-up required for further treatment.” (RCOG 2018).
Perineal care bundles were introduced in an attempt to address these issues.
Outlining the controversy
However, the introduction of the bundles has been controversial, for a number of reasons.
Some people are questioning whether we have good enough evidence to justify introducing these.
One aspect of the controversy concerns the way that midwives are told to do all the things in the bundle to every woman, which doesn’t align with the notion of individualised care, or take personal factors and preferences into account.
There are a number of questions that people are asking about the wider context. For instance, why we are focusing on adding more interventions to address problems which are partly caused by the way we have medicalised birth. Another approach would be to take a more physiological and holistic approach where this is appropriate.
And then there are huge questions around informed consent and decision making. This is an especially pertinent issue with perineal care bundles. Women aren’t always told about these bundles ahead of time. And evidence shows that they are not receiving the kind of information which allows them to decide whether or not they want these interventions.
In fact, when you read the guidelines about perineal care bundles, they aren’t presented as a choice.
And the guideline writers aren’t focused on what individual women want.
Like many public health interventions, there is an assumption that we will go along with these interventions, some of which are quite invasive, simply because policymakers have decided that this is what’s best for us.
What’s in the bundles?
The bundles are slightly different in different countries, but the interventions that form a part of perineal care bundles can include things like:
- vaginal examinations
- rectal examinations (after the baby is born, to feel if you have a tear that cannot be seen)
- a midwife or doctor holding a warm compress on your perineum as you push your baby out
- a midwife or doctor putting pressure on your bottom or another part of your body
- a midwife or doctor putting their hands on your perineum to protect it as you push your baby out
- having a catheter put in so that your bladder is empty
- having an episiotomy (a surgical cut into the opening of your vagina).
In this blog post, I’m going to discuss a few recent studies on this topic.
I want to be clear that this is not a systematic literature review, or an exhaustive list of relevant research. I’m discussing a few studies that I have previously shared with colleagues, students, and those on my email list, because I have found them interesting.
I’m also sharing my own thoughts and concerns, which have grown as I have talked to many midwives and doctors about what they are seeing in practice in relation to perineal care bundles.
Please look at the information from the RCOG and Women’s Healthcare Australia if you want to find out more from those who are very pro perineal care bundles.
Are the bundles effective?
One important question is whether perineal care bundles are effective.
This is hard to research, because they are an entire group of interventions, rather than just one, and there are so many factors involved.
And not all bundles are the same. The UK, Australian and Scandinavian bundles contain different components. Modified approaches are used even within the same country. For instance, Julie Frohlich, a consultant midwife in the UK, has developed an approach which she has termed PEACHES.
The Cochrane review of perineal techniques during the second stage of labour for reducing perineal trauma, which was published before the bundles were implemented, had showed that:
“Moderate‐quality evidence suggests that warm compresses, and massage, may reduce third‐ and fourth‐degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor‐quality evidence suggests hands‐off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.
Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and babies. It is important for any future research to collect information on women’s views.” (Aasheim et al 2017).
Evaluating the bundles in the UK
One important study in the UK (Gurol‐Urganci et al 2020) was an evaluation of the perineal care bundle as a whole.
The results showed that “the OASI rate decreased from 3.3% before to 3.0% after care bundle implementation.” (Gurol‐Urganci et al 2020).
So they do seem to make a difference, and I want to say at the outset that some clinicians and groups are VERY keen on them, and I respect that.
But the reduction is, as the authors themselves acknowledge, a relatively small reduction. You will see some people saying that the bundle resulted in up to a 20% risk reduction, which sounds a lot. But this is why it’s key to look at the absolute numbers and some of the deeper aspects of the conversation rather than taking one number at face value.
Jim Thornton, Professor of Obstetrics and Gynaecology, has written a comprehensive blog post breaking down the elements of this study. I’m going to link to his work rather than repeating it here. Suffice to say that he and I are in agreement that the underlying evidence base for the individual components of the bundle is weak, and that the results of this study are unclear.
A systematic review
A 2025 systematic review and meta-analysis looked at the effectiveness of care bundles for preventing or reducing perineal trauma during childbirth, and its authors conclude that:
“The use of perineal protection care bundles may reduce OASI during childbirth. The evidence, however, is of low certainty and fraught with clinical and methodological heterogeneity. Insufficient, high certainty evidence exists for use of perineal protection care bundles. A more standardised approach to care bundle development and evaluation is recommended.” (Smith et al 2025).
It’s always important to remember that, even if there is good reason to consider whether we can change things, the potential benefits of an intervention always need to be weighed against the potential disadvantages and costs.
And there are always other approaches, and multiple ways in which we could potentially solve the problem.
Which is where it can also be valuable to look at the wider issues and consider other perspectives.
Who is more or less at risk?
For example, many people believe that severe perineal tears are more common because of interventions used in birth.
There is some evidence to support this. The authors of one study suggest that, “modifiable factors such as use of forceps and oxytocin should be taken into consideration in clinical practice” (Joris et al 2019).
It’s also the case that not all women are equally at risk.
Joris et al (2019) looked at the maternity records of 11,483 women in order to identify those who had experienced OASI (a total of 88 women) and compared them with the wider population of the women who birthed in that area.
The authors found that, “The only statistically significant differences between symptomatic and asymptomatic women were age (p = 0.02), body mass index (p = 0.04) and the use of forceps (p = 0.04). Women with more severe symptoms were more likely to have received oxytocin during the second stage of labor (p = 0.03) and had shorter delivery to follow-up interval (p = 0.008).” (Joris et al 2019).
We don’t know why older women have a higher chance of more severe symptoms or why larger women are less affected, although the authors speculate about this.
I wrote about how higher BMI is protective against severe perineal tears in Plus Size Pregnancy. There are several studies and audits which have confirmed this, including a recent study by Shalabna et al (2024).
We do know that both of these groups of women are often treated more poorly by care providers and exposed to more intervention than other women, so the issues are complex.
Interventions and care providers
The finding that the use of oxytocin (which is a key component of induction of labour) was more common in women who had more severe symptoms following anal sphincter injury is an important piece of information which women should be able to take into account in their decision-making.
More and more women are being offered induction of labour, often with little or no evidence to support this recommendation. This issue is even more pertinent for older women, who already have a higher chance of having an OASI and who are among the groups of women who are now routinely offered induction of labour in some areas of the world.
We also know from a recent US study that women who have midwifery care are less likely to experience OASI than women cared for by doctors. This finding is consistent even when we account for differences in the populations that seek different types of care, and for other factors such as doctors having higher induction rates.
“The overall rate of OASIs amongst our study population was 4.24%, which is similar to the approximate rate found in the full CSL cohort at 5.8% [1]. We discovered that in this cohort, physicians were serving a slightly older, Whiter, and more affluent population than the midwives. Physician patients were also more likely to have medical co-morbidities documented and undergo labor induction and/or augmentation compared to certified nurse-midwife patients. Even when controlling for these population differences and known risk factors for OASIs, we found that OASIs at the time of vaginal delivery were more likely to occur with an obstetrician physician as the delivering provider when compared to certified nurse-midwives.” (Walker et al 2024).
Researching clinicians’ perspectives
Bidwell et al (2020) published a paper exploring clinicians’ perspectives on the UK care bundle. This study was part of the wider official evaluation of the care bundle. The participants in this study were self-selected, so the findings aren’t necessarily representative of all midwives and doctors. While midwives and doctors did report a number of concerns, we have to bear in mind that other people may not have felt able to be honest, for instance if they were worried about their job or registration, or about whether their colleagues might judge them.
Despite this, a number of issues came through loud and clear.
Participants felt that there had been no consultation before the bundle was implemented.
They said that aspects of the bundle were too fixed, and didn’t allow for individual clinical judgement, where midwives and doctors adapt their practice to what is happening for the individual woman.
Midwives were particularly concerned, and more likely than obstetricians to report themes alluding to ‘what women want’ and variations in intrapartum perineal protection techniques.
But both midwives and doctors were concerned about whether there was good evidence to support the bundle, and about whether the potential benefits justified the very invasive procedures that were being rolled out.
For instance, an obstetrician in one of the focus groups in Bidwell et al (2020) summarised the concerns of many people 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).
It’s always your decision
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.
What do women think?
Another paper from the same team, on women’s experiences of the OASI care bundle concluded that:
“Interviewed women indicated that they did not experience any of the care bundle elements as an intrusion of their physical integrity. Additionally, an urgent need was identified for more information about perineal trauma in terms of risk, prevention and recovery.” (Bidwell et al 2021).
I found this paper fascinating, because it did not reflect my experience, that of my colleagues, or the comments that we were seeing from women who were posting on my social media accounts.
I had also created a teaching unit on perineal care bundles in an online course that I was running, and was really struck by the many concerns that were being raised by the participants. This group included midwives, obstetricians, doulas, and others involved in birth in the UK, Australia, and several other countries where perineal care bundles have been introduced.
The other side of the story
These midwives, doctors and birth workers reported many concerns.
A lot of their concerns stemmed not only from their experiences, but from those of the women they were caring for. In a nutshell, they did not feel that the Bidwell et al (2020) paper on women’s experiences was reflecting the totality of what they were seeing in practice about what women thought and felt.
They acknowledged that a good number of women were okay with the perineal care bundle, although midwives often felt that this was because they were assuming that ‘what is, must be best.’ This is a phenomenon that was identified by Porter and Macintyre in 1984, wherein, “Pregnant women appeared to assume that whatever arrangements they had experienced were the best arrangements possible.” Later research by van Teijlingen et al (2003) confirmed that ‘customer satisfaction’ surveys, like the Bidwell et al (2021) study, should be used with caution, because of this phenomenon.
But clinicians knew that a proportion of women felt traumatised by what had been done to them in the name of perineal ‘care’. Some were concerned that women were not being given adequate information, and were thus not making a truly informed decision. But they often felt powerless to do anything about it.
This is because the perineal care bundle approach had become hospital policy. And, while women can of course decline any intervention, it is very hard in many areas to find time to discuss options with labouring women in ways that mean they are truly able to weigh up the evidence and decide what is right for them. This is even more difficult if you have pro-bundle colleagues in the room with you, which is what was happening for some midwives.
More on clinicians’ concerns
Before I discuss more recent data on what women think, I want to share a few papers and blog posts in which midwives and doctors have written about their concerns about the evidence base for perineal care bundles.
First, here’s a paper in which Professors of obstetrics, gynaecology and midwifery raised their concerns.
Obstetrician Jim Thornton wrote about how rectal examination after a normal birth makes no sense as a screening test, and is invasive.
“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).
And here’s another paper which highlights some of the problems with the use of the bundles in practice.
Let’s go back to women and consent
A more recent study has confirmed some of the concerns that we have long had about women’s experiences of perineal care bundles.
In a 2024 study, Häggsgård et al (2024) set out, “…to study informed consent to midwifery practices and interventions during the second stage of labor and to investigate the association between informed consent and experiences of these practices and interventions and women’s experiences of the second stage of labor.”.
Their research, “…uses an observational design with data from a follow-up questionnaire sent to women one month after giving birth spontaneously in the Oneplus trial, a study aimed at evaluating collegial midwifery assistance to reduce severe perineal trauma.” (Häggsgård et al 2024).
Sadly, their findings confirm the concerns of the colleagues who I have discussed in this blog post.
“Of the 3049 women participating in the trial, 2849 consented to receive the questionnaire.” (Häggsgård et al 2024).
This is a far larger number than in previous research.
“Informed consent was reported by less than one in five women and was associated with feelings of being safe, strong, and in control.” (Häggsgård et al 2024).
“Informed consent was further associated with more positive experiences of clinical practices and interventions, and with less discomfort and pain from interventions involving physical penetration of the genital area.” (Häggsgård et al 2024).
Informed consent is vital
Häggsgård et al (2024) concluded that:
“The findings indicate that informed consent during the second stage is associated with feelings of safety and of being in control. With less than one in five women reporting informed consent to all practices and interventions performed by midwives, the results emphasize the need for further action to enhance midwives’ knowledge and motivation in obtaining informed consent prior to performance of interventions.” (Häggsgård et al 2024).
Before we blame midwives for this situation, however, we also need to be looking more widely. I’ve already explained some of the issues that midwives face.
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.
Again, it’s important to account for the guidelines and recommendations that are increasingly dictating midwives’ practice, and the staffing levels and practice constraints which mean that midwives are often not able to spend enough time with women to be able to discuss their feelings and options ahead of their giving birth.
There are many midwives who wish things were different.
What next?
This debate is ongoing, and I will add to this page as new research emerges.
I will say that, as someone who spends 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. These might include a number of individualised, midwifery-focused approaches, set within a context that prioritises women’s experiences, individualised care, and informed decision making.
But it’s important to not forget that perineal care bundles weren’t brought in for the sake of it.
Severe perineal injuries can, as I explained at the outset, cause lifelong health problems, and the bundles are an attempt to reduce these, and improve women’s lives.
I think the real problem lies in the ‘one size fits all’ approach that is taken within the western medical public health framework that dominates our culture today. This leaves little room for nuance, individual variations, personalised assessment of risk, respecting of needs and wishes, and clinical judgement.
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.
But this isn’t the focus of those who are making the rules, or championing the bundles.
For now, it’s clear than we need to keep talking about this, at every level. And making sure that as many women as possible know about these interventions ahead of time, and know that they have the right to decide whether or not they want a perineal care bundle to be part of their birth experience.
If you’re looking for help in making the decisions that are right for you:
Thanks to Margaret Jowitt who pointed me to additional research on this topic.
About the Author: Dr Sara Wickham is an author, speaker, and researcher specialising in pregnancy, birth and maternity care. Her work focuses on evidence-based, woman-centred information and informed decision-making, drawing on more than 30 years of midwifery knowledge and experience.
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