Exploring clinicians' perspectives on the 'Obstetric Anal Sphincter Injury Care Bundle' national quality improvement programme: a qualitative study

Optimising recovery after perineal trauma: Implementation of an evidence-based patient-centred care and clinical practice guideline

BACKGROUND

Perineal trauma and pain can affect the quality of life of women who experience vaginal birth.

AIM

To investigate the effect of perineal care and pain management on women's postpartum recovery.

METHODS

This was a Quasi-experimental study. In Phase 1 women were treated using our old postnatal perineal care management guideline. In Phase 2 an updated guideline was introduced (regular administration of icepacks and analgesia during the first 24-48 h postpartum). During Phase 1, pregnant women planning a vaginal birth completed a baseline questionnaire. Those who sustained perineal trauma completed a survey at 24-48 h, seven days and 12 weeks after birth. In Phase 2 we continued recruiting participants, using the same procedure, and investigated the efficacy of pain relief approaches using the new guideline.

RESULTS

In Phase 1, 111 women (Group 1), and Phase 2, 146 women (Group 2) were recruited. No statistically significant differences were found between the two groups in terms of the women's pain catastrophising, their partner's responses to pain behaviours, or birth outcomes. At 24-48 h and seven days postpartum, women in Group 2 were less likely than women in Group 1 to be bothered by back or perineal pain, headache, sleeping difficulties and dizziness (p < 0.05). More women in Group 2 received regular paracetamol and perineal icepacks during their hospital stay, with less use of oxycodone in Group 2 than Group 1.

CONCLUSION

The implementation of the guideline's recommendations was associated with decrease back and perineal pain, headache, sleeping difficulties and dizziness during the first seven days postpartum.

Quality and reporting of large-scale improvement programmes: a review of maternity initiatives in the English NHS, 2010-2023

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.

Neonatal head circumference as a risk factor for obstetric anal sphincter injuries: a systematic review and meta-analysis

OBJECTIVE

Between 53% and 79% of women will sustain some degree of perineal laceration during vaginal delivery. Third- and fourth-degree perineal lacerations are known as obstetric anal sphincter injuries. Timely diagnosis and prompt treatment of obstetric anal sphincter injuries can help to prevent the development of severe consequences like fecal incontinence, urinary incontinence, and rectovaginal fistula. Neonatal head circumference is routinely measured postpartum but is often not mentioned as a risk factor for obstetric anal sphincter injuries in clinical guidelines. Thus far, no review article on the risk factors for obstetric anal sphincter injuries has discussed the role of neonatal head circumference. This study aimed to review and analyze the relationship between head circumference and the occurrence of obstetric anal sphincter injuries among previous studies to conclude whether head circumference should be recognized as an important risk factor.

DATA SOURCES

Through study screening on Google Scholar, PubMed, Scopus, and Science Direct for articles published between 2013 to 2023, followed by assessment of eligibility, this study ended up reviewing 25 studies, 17 of which were included in the meta-analysis.

STUDY ELIGIBILITY CRITERIA

Only studies that reported both the neonatal head circumference and the occurrence of obstetric anal sphincter injuries were included in this review.

METHODS

The included studies were appraised using the Dartmouth Library risk of bias assessment checklist. Qualitative synthesis was based on the study population, findings, adjusted confounding factors, and suggested causative links in each study. Quantitative synthesis was conducted using calculation and pooling of odds ratios and inverse variance using Review Manager 5.4.1.

RESULTS

A statistically significant association between head circumference and obstetric anal sphincter injuries was reported in 21 of 25 studies; 4 studies reported that head circumference was a true independent risk factor. A meta-analysis of the studies that reported neonatal head circumference as a dichotomous categorical variable with a cutoff point of 35±1 cm yielded statistically significant pooled results (odds ratio, 1.92; 95% confidence interval, 1.80-2.04).

CONCLUSION

The risk for obstetric anal sphincter injuries increased as the neonatal head circumference increased-this should be considered in decision-making during labor and postpartum management to attain the best outcome.

A complex and demanding situation - Midwifery preceptors and midwifery students' experiences of teaching and learning prevention of severe perineal trauma

BACKGROUND

Many high-income countries have seen an increase in severe perineal trauma. Teaching strategies and conditions for learning during the active second stage of labour are scarcely described.

AIM

To describe midwifery preceptors and midwifery students' experiences' of teaching and learning how to manage the second stage of labour, with the specific aim of preventing severe perineal trauma.

METHODS

A qualitative study with focus group discussions and individual in depth-interviews with preceptor midwives (n = 23) and student midwives (n = 10). Data were analysed by qualitative content analysis.

RESULTS

"A complex and demanding situation with mutual need for feedback, reflection and safety" was the overall theme describing the conditions. Three sub-themes were identified. "Adapting to a unique situation" refers to the difficulty of teaching and learning the aspects needed to prevent severe perineal trauma, and to provide care during this stage. "Hindering and limiting circumstances" describes teaching strategies that were perceived negatively, and how midwifery students tried to adapt to the preceptors rather than the birthing women. "A trustful and communicative relationship" describes the importance of the relationship between the student and the preceptor, where communication was a central, but not obvious part.

CONCLUSION

An increased awareness among preceptors is needed to optimize teaching strategies, enabling the students to focus on learning the art of the second stage of labour; supporting the woman, preventing severe perineal trauma and ensuring the safety of the unborn baby. Future research should address how existing prevention models can include training to increase preceptors' confidence in teaching.

Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study

Background

To examine which elements of an obstetric anal sphincter injury (OASI) care bundle were protective for OASI. Several interventional trials showed that application of a care bundle involving a hands-on approach to perineal protection may reduce the risk of OASI. Previously, we found that only the element “hand on the fetal head” in itself was protective, although the risk of a type 2 error was calculated to be 50%.

Methods

A prospective follow-up study in an obstetric department in Denmark with 3200 deliveries per year. We included a cohort of 10,383 women giving birth vaginally from gestational week 22 + 0 from 2016 through 2019. We documented on a person-level the five elements of the care bundle together with maternal and obstetrical characteristics. The elements were 1) communication, 2) visible perineum, 3) hand on fetal head, 4) perineal support and 5) certification. Regression analysis was used for analysis of associations. The primary outcome measure was OASI.

Results

The total rate of OASI in vaginally delivering women was 1.9%. The incidence was 3.2% in nulliparous women giving birth vaginally. The rate of cesarean section was 16.5% and for episiotomy 2.4%. The reduction in the incidence of OASI was sustained since 2013. Hand on the fetal head and perineal support both were protective factors for OASI. In case of a nulliparous woman with a neonate weighing 3500 g giving birth spontaneously, the relative risk (RR) for OASI was 0.50 (95% CI 0.49- 0.51) with use of hand on the fetal head together with perineal support against no use. Similarly, with a nulliparous woman giving birth to a neonate of 3500 g by vacuum extraction, the RR for OASI was 0.65 (95% CI 0.62-0.68) against no use.

Conclusions

Both hand on the fetal head and perineal support were associated with a reduced risk of OASI.

Women's experiences of the OASI Care Bundle; a package of care to reduce severe perineal trauma

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is a severe form of perineal trauma that can occur during vaginal birth. Long-term morbidities include anal incontinence and psychosocial disorders. To reduce these injuries within England, Scotland and Wales, the OASI Care Bundle was introduced to 16 maternity units (January 2017-March 2018). The OASI Care Bundle comprises four elements: (1) antenatal information, (2) manual perineal protection, (3) medio-lateral episiotomy (when indicated) and 4) recognition and diagnosis of tears. As part of the project evaluation, a qualitative study was conducted to explore women's experiences of the OASI Care Bundle.

METHODS

Semi-structured interviews were conducted with women (n = 19) who received the OASI Care Bundle as part of their maternity care. This was to explore their experience of each element. A thematic analysis of the interview data was performed.

RESULTS

Three themes were identified: (1) memories of touch, whereby women reported that a 'hands-on' approach to perineal protection was a positive experience; (2) midwife as a supportive guide, where women reported that good communication facilitated a calm birth and post-birth diagnosis; (3) education: women need more information about perineal trauma.

CONCLUSION

This study contributes to the literature through its exploration of women's experiences of perineal protection techniques and diagnosis of perineal trauma. 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.

How can we improve our practices in obstetric anal sphincter injury prevention, diagnosis, and management of symptomatic women?

Obstetric anal sphincter injury (OASI) is strongly associated with a major negative impact on women's health. Due to the consequences of an undiagnosed and therefore unrepaired OASI, it is essential to prevent or at least diagnose OASI at childbirth. We need to promote training of professionals to improve OASI screening at childbirth. High-risk situations such as operative delivery must be identified and preventive strategies such as the choice of a less traumatic instrument (vacuum) and mediolateral episiotomy should be considered. For a woman with OASI and/or symptoms, postnatal consultation with a specialist on pelvic floor disorders is essential to correctly orient her toward an adequate care pathway and to eventually identify occult or underestimated OASI. More data are required on therapeutic approaches for symptomatic women, primarily including physical therapy, sacral neuromodulation, delayed sphincter repair and palliative devices.

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

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.

The OASI care bundle quality improvement project: lessons learned and future direction

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.

How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis

BACKGROUND

A care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one - warm perineal compresses - has highest level evidence. There is scant published research about the impact of implementation of perineal bundles.

QUESTION

How does a perineal care bundle impact midwifery practice in Australian maternity hospitals?

METHODS

Purposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power.

FINDINGS

We interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission.

DISCUSSION

The bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants' responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences.

CONCLUSION

The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy - women's and their own - by using clinical judgement, evidence, and woman-centred care.

Short statured primigravidae: Options for the obstetric management from a survey of UK obstetricians

OBJECTIVE

To assess the current antenatal and intrapartum management options for primigravid women of short stature with a clinically large fetus by a survey of UK Obstetricians.

STUDY DESIGN

An online survey comprised of 15 questions including the options on timing and mode of delivery, counselling about the risk of long-term pelvic floor morbidity following spontaneous vaginal and instrumental deliveries, choice of instruments and the role of episiotomy. The survey was sent to the participants as a part of Royal College of Obstetricians and Gynaecologists (RCOG) Newsletter between September 2017 to October 2018. The scenario described was of a primigravid short stature woman (i.e. height of 160 cm or less) who presents with a clinically large fetus at 38 weeks gestation.

RESULTS

424 Obstetricians participated in the survey. The participation ratio cannot be identified as the survey was emailed as a part of the RCOG Newsletter. Sixty five percent respondents stated that they would scan for estimated fetal weight, 48 % would offer induction of labour at 40 weeks and 14 % would offer an elective/planned caesarean section (CS) at 39-40 weeks. Fifty nine percent would discuss all these risks: obstructed labour, shoulder dystocia, instrumental delivery and obstetric anal sphincter injury (OASI). 73 % would not discuss the long-term risks of urinary and/or faecal incontinence and pelvic organ prolapse. In the presence of failure to progress in the second stage of labour, 69 % would attempt a rotational instrumental delivery and 5% would offer a caesarean section. Manual rotation and 'straight' forceps application were the most frequent type of rotational delivery, followed by Ventouse and Kiellands forceps. Thirty four percent stated that they do not routinely perform an episiotomy in this scenario. Seventy three percent stated that their choice of instrument was not based on the long-term risk of urinary and faecal incontinence.

CONCLUSION

The results suggest that 40 % of the respondents would not discuss all of the complications after vaginal delivery in women of short stature. The most common delivery option would be vaginal delivery.