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Okeahialam NA, Sultan AH, Thakar R. The prevention of perineal trauma during vaginal birth. Am J Obstet Gynecol 2024; 230:S991-S1004. [PMID: 37635056 DOI: 10.1016/j.ajog.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 08/29/2023]
Abstract
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
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Affiliation(s)
| | - Abdul H Sultan
- Croydon University Hospital, London, United Kingdom; St George's University of London
| | - Ranee Thakar
- Croydon University Hospital, London, United Kingdom; St George's University of London.
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McGowan J, Attal B, Kuhn I, Hinton L, Draycott T, Martin GP, Dixon-Woods M. Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023. BMJ Qual Saf 2024:bmjqs-2023-016606. [PMID: 38050180 DOI: 10.1136/bmjqs-2023-016606] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/13/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Large-scale improvement programmes are a frequent response to quality and safety problems in health systems globally, but have mixed impact. The extent to which they meet criteria for programme quality, particularly in relation to transparency of reporting and evaluation, is unclear. AIM To identify large-scale improvement programmes focused on intrapartum care implemented in English National Health Service maternity services in the period 2010-2023, and to conduct a structured quality assessment. METHODS We drew on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidance to inform the design and reporting of our study. We identified relevant programmes using multiple search strategies of grey literature, research databases and other sources. Programmes that met a prespecified definition of improvement programme, that focused on intrapartum care and that had a retrievable evaluation report were subject to structured assessment using selected features of programme quality. RESULTS We identified 1434 records via databases and other sources. 14 major initiatives in English maternity services could not be quality assessed due to lack of a retrievable evaluation report. Quality assessment of the 15 improvement programmes meeting our criteria for assessment found highly variable quality and reporting. Programme specification was variable and mostly low quality. Only eight reported the evidence base for their interventions. Description of implementation support was poor and none reported customisation for challenged services. None reported reduction of inequalities as an explicit goal. Only seven made use of explicit patient and public involvement practices, and only six explicitly used published theories/models/frameworks to guide implementation. Programmes varied in their reporting of the planning, scope and design of evaluation, with weak designs evident. CONCLUSIONS Poor transparency of reporting and weak or absent evaluation undermine large-scale improvement programmes by limiting learning and accountability. This review indicates important targets for improving quality in large-scale programmes.
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Affiliation(s)
- James McGowan
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Bothaina Attal
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Isla Kuhn
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Tim Draycott
- Department of Women's Health, North Bristol NHS Trust, Westbury on Trym, Bristol, UK
| | - Graham P Martin
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Mary Dixon-Woods
- The Healthcare Improvement Studies Institute (THIS Institute), Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Roman MP, Aggarwal S, Doumouchtsis SK. A systematic review and meta-synthesis of qualitative studies on childbirth perineal trauma for the development of a Core Outcome Set. Eur J Obstet Gynecol Reprod Biol 2023; 290:51-59. [PMID: 37734138 DOI: 10.1016/j.ejogrb.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/02/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023]
Abstract
OBJECTIVES Perineal injury occurs in 85% of cases during vaginal childbirth. This study aimed to synthesize qualitative data on women's perceptions of perineal trauma during vaginal childbirth. STUDY DESIGN Thematic synthesis was applied utilizing a structured three-step framework. First, line-by-line coding strategy was applied to the included studies. Secondly, related codes were grouped together to develop descriptive themes to emphasize what matters most for women suffering from childbirth perineal trauma. Thirdly, analytical themes were developed. The quality of the included studies was high based on the assessment using the Critical Appraisal Skills Programme tool. RESULTS Ten eligible studies were included in the meta-synthesis. Twenty-three codes encompassing multiple aspects of childbirth trauma from women's perspective were organised into a set of eight descriptive themes: psychosocial effects, communication, recovery, pain, support, knowledge of childbirth perineal trauma, sexuality, and prioritization. CONCLUSIONS Among the descriptive themes, psychosocial effects, communication, and recovery exhibited the highest prevalence. The findings of this meta-synthesis may serve as a reporting guideline for future studies investigating the consequences of childbirth perineal trauma, ensuring that women's priorities are accurately reflected in reported outcomes.
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Affiliation(s)
- Maria Patricia Roman
- 2nd Department of Obstetrics and Gynaecology, "Iuliu Hațieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania; 2nd Department of Obstetrics and Gynaecology, County Emergency Hospital Cluj-Napoca, Romania.
| | - Shaurya Aggarwal
- Broomfield Hospital, Mid and South Essex NHS Foundation Trust, UK
| | - Stergios K Doumouchtsis
- Department of Obstetrics and Gynaecology, Epsom and St. Helier University Hospitals NHS Trust, Epsom, UK; St. George's University of London, London, UK; Laboratory of Experimental Surgery and Surgical Research "N.S. Christeas", National and Kapodistrian University of Athens, Medical School, Athens, Greece; School of Medicine, American University of the Caribbean, Cupecoy, Sint Maarten (Dutch Part); School of Medicine, Ross University, Miramar, FL, USA
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Sananès J, Pire S, Feki A, Boulvain M, Faltin DL. Antenatal, Intrapartum and Postpartum Interventions for Preventing Postpartum Urinary and Faecal Incontinence: An Umbrella Overview of Cochrane Systematic Reviews. J Clin Med 2023; 12:6037. [PMID: 37762976 PMCID: PMC10531825 DOI: 10.3390/jcm12186037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/03/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Post-partum, women can suffer from urinary and faecal incontinence. It is important to assess interventions to prevent this problem. Cochrane systematic reviews summarize the data available from systematic reviews of randomized trials assessing interventions. We conducted an umbrella overview of Cochrane systematic reviews encompassing antenatal, intrapartum and postpartum interventions for preventing postpartum urinary and faecal incontinence. We searched the Cochrane Database of Systematic Reviews on the 9 May 2023. Results: Our search identified nine Cochrane reviews providing results. Data for urinary and faecal incontinence were available from 77 (72%) trials and included 51,113 women. The reviews assessed antenatal digital perineal massage, pelvic floor muscle training, techniques for repairing anal sphincter tears, routine use of episiotomy, use of endoanal ultrasound prior to repairing perineal tears, caesarean versus vaginal delivery (overall, for breech and for twins), and vaginal delivery with forceps or vacuum. Only the use of a vacuum instead of forceps if an assisted vaginal delivery is needed, the use of an endo-anal ultrasound prior to repairing perineal tears and postpartum pelvic floor muscle training suggest a reduction in postpartum incontinence. Due to the small number of relevant reviews, a consequence of the relatively small number of primary studies, the effect of almost all the tested interventions was found to be imprecise.
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Affiliation(s)
- Juliette Sananès
- Department of Obstetrics and Gynecology, HFR—Cantonal Hospital of Fribourg, 1752 Villars-sur-Glânes, Switzerland
| | - Sophie Pire
- Department of Obstetrics and Gynecology, HFR—Cantonal Hospital of Fribourg, 1752 Villars-sur-Glânes, Switzerland
| | - Anis Feki
- Department of Obstetrics and Gynecology, HFR—Cantonal Hospital of Fribourg, 1752 Villars-sur-Glânes, Switzerland
| | - Michel Boulvain
- Department of Obstetrics and Gynecology, HFR—Cantonal Hospital of Fribourg, 1752 Villars-sur-Glânes, Switzerland
| | - Daniel L. Faltin
- Department of Obstetrics and Gynecology, HFR—Cantonal Hospital of Fribourg, 1752 Villars-sur-Glânes, Switzerland
- Centre de Périnéologie Dianuro Geneva, 1227 Carouge, Switzerland
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Barnett B, Jenkinson B, Lee N. The impact of a perineal care bundle on women's birth experiences in Queensland, Australia: A qualitative thematic analysis. Women Birth 2022; 36:271-280. [PMID: 36109291 DOI: 10.1016/j.wombi.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/12/2022] [Accepted: 09/05/2022] [Indexed: 10/14/2022]
Abstract
A care bundle was introduced into 28 Australian hospitals in 2018 with the aim of reducing severe perineal tears. There has been limited research regarding the impact of this bundle on women's birth experiences. QUESTION How does the introduction of a perineal care bundle impact on women's birth experiences in Queensland maternity hospitals? METHODS We recruited 18 women who had birthed in five Queensland hospitals where the bundle had been implemented. Semi-structured, individual interviews were analysed using reflexive thematic analysis. FINDINGS Three descriptive themes were generated: 1) Lack of information and consent to bundle elements, 2) Other non-consented and disrespectful treatment and 3) Recommendations for hospitals and clinicians. Two analytic themes were generated: 1) Default-position: Prioritising policies over women's autonomy and 2) Counter-position: Women asserting their rights to autonomy and respect. DISCUSSION None of the women interviewed could recall having received information about the perineal care bundle from clinicians during pregnancy. While many women accepted that its elements were in their or their baby's best interests, this was not the case for all women. Some women reported coercive and non-consented application of bundle elements, which they found distressing. CONCLUSION Given the broader institutional context in which the perineal bundle was implemented, the impact on information provision, informed consent and the detrimental emotional consequences for some women arising from the bundle's implementation were largely foreseeable. The potential for bundled care initiatives to impinge on women's human rights to autonomy and respectful care should be given greater preventative attention prior to implementation.
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Affiliation(s)
- Belinda Barnett
- School of Nursing, Midwifery and Social Work, University of Queensland, Australia.
| | - Bec Jenkinson
- Faculty of Health and Behavioural Sciences, University of Queensland, Australia.
| | - Nigel Lee
- School of Nursing, Midwifery and Social Work, University of Queensland, Australia.
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Ryan T, Smith V. Care bundles for women during pregnancy, labor/birth, and postpartum: a scoping review protocol. JBI Evid Synth 2022; 20:2319-2328. [DOI: 10.11124/jbies-22-00030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Thakar R, Bidwell P, Freeman R, Gurol-Urganci I, Jurczuk M, Martinez D, Percy E, Sevdalis N, Silverton L, van der Meulen J. Authors' reply re: OASI Care Bundle. BJOG 2021; 129:175-176. [PMID: 34590412 DOI: 10.1111/1471-0528.16901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/12/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Ranee Thakar
- Croydon University Hospital, Croydon Health Services NHS Trust, London, UK.,Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Posy Bidwell
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Robert Freeman
- Department of Women's Health, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ipek Gurol-Urganci
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
| | - Magdalena Jurczuk
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Dorian Martinez
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK
| | - Elizabeth Percy
- Royal College of Obstetricians and Gynaecologists, Centre for Quality Improvement and Clinical Audit, London, UK.,Department of Women's Health, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, London, UK
| | | | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK
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OASI2: a cluster randomised hybrid evaluation of strategies for sustainable implementation of the Obstetric Anal Sphincter Injury Care Bundle in maternity units in Great Britain. Implement Sci 2021; 16:55. [PMID: 34022926 PMCID: PMC8140475 DOI: 10.1186/s13012-021-01125-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Obstetric Anal Sphincter Injury (OASI) Care Bundle comprises four primary and secondary prevention practices that target the rising rates of severe perineal tearing during childbirth, which can have severe debilitating consequences for women. The OASI Care Bundle was implemented in 16 maternity units in Britain in the OASI1 project (2017-2018), which demonstrated the care bundle's effectiveness in reducing OASI rates. In OASI2, the care bundle will be scaled up to 20 additional National Health Service (NHS) maternity units in a hybrid effectiveness-implementation study that will examine the effectiveness of strategies used to introduce, implement and sustain the care bundle. METHODS OASI2 is a two-arm cluster-randomised control trial (C-RCT) of maternity units in England, Scotland and Wales, with an additional non-randomised study arm. C-RCT arm 1 (peer support, n = 10 units) will be supported by 'buddy' units to implement the OASI Care Bundle. C-RCT arm 2 (lean implementation, n = 10 units) will implement without external support. The additional study arm (sustainability, n = 10 units) will include some original OASI1 units to evaluate the care bundle's sustainability and OASI rates over time, from before OASI1 and through the end of OASI2. Units in all three study arms will receive an Implementation Toolkit with training resources and implementation support. The C-RCT arms will be compared in terms of OASI rate reduction (primary effectiveness outcome) and clinicians' adoption of the care bundle (primary implementation outcome). Clinical data will be collated from maternity information systems; implementation data will be collected through validated surveys with women and clinicians, supplemented by qualitative methods. Descriptive statistics and regression modelling will be used for analysis. Emergent themes from the qualitative data will be assessed using framework analysis. DISCUSSION OASI2 will study the impact of various implementation strategies used to introduce and sustain the OASI Care Bundle, and how these strategies affect the bundle's clinical effectiveness. The study will generate insights into how to effectively scale-up and sustain uptake and coverage of similar interventions in maternity units. A locally adaptable 'implementation blueprint' will be produced to inform development of future guidelines to prevent perineal trauma. TRIAL REGISTRATION ISRCTN26523605.
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Jurczuk M, Bidwell P, Gurol-Urganci I, van der Meulen J, Sevdalis N, Silverton L, Thakar R. The OASI care bundle quality improvement project: lessons learned and future direction. Int Urogynecol J 2021; 32:1989-1995. [PMID: 33988784 PMCID: PMC8295109 DOI: 10.1007/s00192-021-04786-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/24/2021] [Indexed: 12/11/2022]
Abstract
Rising rates of obstetric anal sphincter injury (OASI) led to a collaborative effort by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) to develop and evaluate the OASI Care Bundle (OASI-CB). The OASI-CB comprises four practices (antenatal discussion about OASI, manual perineal protection, mediolateral episiotomy at 60° from the midline, and systematic examination of the perineum, vagina and ano-rectum after vaginal birth) and was initially implemented as part of a quality improvement (QI) project—“OASI1”—in 16 maternity units across Great Britain. Evaluation of the OASI1 project found that the care bundle reduced OASI rates and identified several barriers and enablers to implementation. This paper summarises the key findings, including strengths, limitations and lessons learned from the OASI1 QI project, and provides rationale for further evaluation of the OASI-CB.
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Affiliation(s)
- Magdalena Jurczuk
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK.
| | - Posy Bidwell
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - Ipek Gurol-Urganci
- Centre for Quality Improvement and Clinical Audit, Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK.,Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Jan van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, King's College London, De Crespigny Park, London, SE5 8AF, UK.
| | - Louise Silverton
- Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK
| | - Ranee Thakar
- Croydon University Hospitals NHS Trust, 530 London Road, Croydon, CR7 7YE, UK
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