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The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study
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The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study Mary J. Borrmana , Deborah Davisb,* , Alison Porteousc , Boon Limd a
Centenary Hospital for Women and Children, Canberra, Australia University of Canberra, and ACT Government Health Directorate, Canberra, Australia Department of Obstetrics and Gynaecology, Canberra Hospital and Health Services, Canberra, Australia d Department of Obstetrics and Gynaecology, Canberra Hospital and Health Services, and Australian National University, Canberra, Australia b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 March 2019 Received in revised form 30 July 2019 Accepted 30 July 2019 Available online xxx
Background: Severe perineal trauma during childbirth is associated with significant morbidity and rates internationally, are on the rise. Aims: To determine the impact of a prevention program on severe perineal trauma in a nulliparous population at a tertiary hospital in Australia. Methods: Routinely collected maternity data were used comparing outcomes in two time periods; two years before and two years after the introduction of the program. Categorical data were compared using the Chi Squared statistic and continuous data Student’s t-test. Logistic regression examined the association between independent and dependent variables using unadjusted and adjusted odds ratios, with 95% confidence intervals and p -values with significance set at 0.05. The main outcome of interest is severe perineal trauma. Results: The proportion of women in this nulliparous population experiencing severe perineal trauma during vaginal birth decreased from 8.8% in the first time period to 5.6% in the second. Reductions were achieved in all modes of vaginal birth but were most pronounced in vacuum births. Rates of episiotomy increased between time periods and further analysis found that this was protective of severe perineal trauma in all modes of birth for women of Asian country of birth and only in forceps birth for non-Asian women. Factors found to contribute to severe perineal trauma in this population were Asian country of birth, neonatal weight 4000 gm, forceps birth and maternal age. Conclusions: The prevention program is associated with reduced rates of severe perineal trauma. The challenge for the service is to maintain this positive change. Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Keywords: Perineum Parturition Tertiary healthcare Patient care bundles Episiotomy
Statement of significance
introduced at service level have shown to be effective in the short term. What this paper adds
Problem or issue Increasingly women are suffering severe perineal trauma during childbirth which causes significant morbidity.
A prevention program introduced to a tertiary maternity service can be successful in reducing rates of severe perineal trauma in a nulliparous population.
What is already known Several individual interventions have proven successful in preventing severe perineal trauma and prevention programs
* Corresponding author at: Centenary Hospital for Women and Children, Building 11, Cnr Gilmore Cres & Hospital Road, Garran, ACT 2605, Australia. E-mail address: [email protected] (D. Davis).
1. Introduction Severe perineal trauma (SPT), defined here as any tear involving the anal sphincter or rectal mucosa (3rd, 4th and rectal button hole tears),1 is associated with significant morbidity. This can include perineal pain, dyspareunia, anal incontinence and fistula, which impact not only a woman’s physical health but her emotional,
http://dx.doi.org/10.1016/j.wombi.2019.07.301 1871-5192/Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Please cite this article in press as: M.J. Borrman, et al., The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.301
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mental and social.2–5 Risk factors for SPT include; nulliparity, Asian ethnicity, large baby, occipito-posterior fetal position, shoulder dystocia, and instrumental birth.6,7 In Australia, reported rates vary significantly between states with Western Australia reporting the lowest at 2.6% in 2016 and South Australia the highest at 3.6%.8 The rate of SPT appears to be increasing in Australia and other comparable countries and this may be associated with increasing risk factors (maternal age, assisted modes of birth) and/ or reporting practices and improved detection.7,9 While some factors contributing to SPT are outside of the control of the maternity caregiver (such as parity and ethnicity), various techniques and factors have been found to be effective in preventing SPT. Antenatal perineal massage has been found to reduce perineal tearing requiring suturing though not specifically severe perineal trauma.11 The application of warm compress to the perineum in the second stage of labour has been shown to be effective12 while hands on support of the perineum and fetal head continues to engender debate.13 High level evidence demonstrates no effect12 though large-scale observational studies of the “Finnish Intervention” (which includes hands on support of the perineum) demonstrate a protective effect.14 Routine episiotomy has not been shown to be protective in spontaneous vaginal birth though the angle of the mediolateral episiotomy is emerging as an important concern.15,16 Researchers have also examined birth position finding the lateral position protective while lithotomy, birth seat (multiparous women only) and squatting (multiparous women only) increased the risk of SPT.17 Several large maternity services have attempted to reduce rates of SPT with a suite of strategies. Mohiudin, et al.18 successfully reduced rates of SPT in nulliparous women at two London Hospitals after implementing a strategy that included the introduction of antenatal perineal massage, manual perineal protection and use of EPISCISSORS-60 to facilitate correct angle of episiotomy. Also in the UK, Basu et al.19 more than halved the rate of SPT with a strategy that included; avoidance of semirecumbent position, coaching the woman to achieve controlled less expulsive pushing along with a hands-on approach to slowing down the birth of the fetal head and spontaneous birth of shoulders with minimal downward traction. Still in the UK, Frost et al.20 reduced their rate of SPT with a multidisciplinary education program that included strategies for the prevention of SPT (though they do not specify the strategies) and a focus on building midwifery confidence to perform episiotomy. These studies compare outcomes for a relatively short period of time following the intervention (up to one year) while the challenge with changing practice comes in its sustainability.21 This paper compares outcomes two years before and two years after the implementation of a multidisciplinary SPT prevention program in a tertiary maternity setting. 2. Materials and methods The primary aim of the study is to compare the proportion of nulliparous women experiencing severe perineal trauma in our service before and after the introduction of a prevention strategy. The secondary aim is to report on the factors associated with severe perineal trauma in this sample of women. Ethical approval for the study was received from the relevant ethics committee. 2.1. Design and sample This is a retrospective observational study using data drawn from the service’s electronic maternity database (Birth Outcomes System) from 1st June 2014 to 31st May 2018. Data are entered into the database by clinicians contemporaneously or as soon as
practicable after an episode of care. Data are validated regularly by the system administrator. Mandatory reporting fields are validated by the Epidemiology Section of the Department of Population Health at the jurisdiction level. The prevention strategy was implemented in June 2016 thus outcomes for time period 1 (1st June 2014–31st May 2016) are compared with those of time period 2 (1st June 2016–31st May 2018). The sample consists of all nulliparous women experiencing vaginal birth of a singleton baby with a cephalic presentation (any gestation) with data on perineal outcomes. 2.2. Variables and analysis Variables drawn from the database include date of birth of the mother which was converted to age at date of baby’s birth. Prepregnancy obesity (BMI 30) is calculated following self-reported pre-pregnancy weight and height reported at the first antenatal visit with the service. Maternal country of birth was used in preference to ethnicity as the latter was not well reported in the database. This was dichotomised to “Asian country of birth” and includes those countries in South Asia, South East Asia and North Asia and excludes the Middle East and Russia. Severe perineal trauma includes any tear that involves the anal sphincter or rectal mucosa and intact perineum was defined as any intact perineum (with any other tear or graze to labia, vaginal wall, clitoris or urethra not sutured). To detect a statistically significant difference between two proportions (from 9% to 6%) with 95% confidence and 80% power using a two tailed test a sample size of 1209 in each group is required. The total sample size of this study is 4128; 2037 in time period 1 and 2091 in time period 2. Data were transferred to Statistical Programme for Social Sciences (IMB SPSS version 23) for analysis. Categorical data were analysed using the chi-squared statistic. Continuous data were analysed using Student’s t -test after checking for normality. All tests were two-tailed, and significance was set at p < 0.05. Results of logistic regression are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05. In the main model examining predictors for SPT, known confounders were included in the regression model as covariates and included; maternal pre-pregnancy obesity (binary variable; BMI 30), maternal age (continuous measure), neonatal macrosomia (binary variable; birth weight 4000 g), and Asian country of birth (binary variable). Further analysis of the role of episiotomy in the prevention of SPT was undertaken by developing separate logistic regression models for each mode of birth for women using born in Asia and those born elsewhere. In these models the OR between episiotomy and SPT was adjusted for maternal age, prepregnancy obesity and macrosomia. In all regression models we examined potential collinearity between the independent variables using variance inflation factors (VIF) and in all analyses, results indicated very low levels of multicollinearity with maximum VIF for any variable at <1.5. Additionally, interaction effects were examined in each model (pre-pregnancy obesity*neonatal macrosomia*Asian country of birth) showing no significant interaction. 2.3. Setting and prevention strategy The maternity service is an Australian tertiary level service which is a referral centre for the surrounding region. It facilitates approximately 3500 births per annum. The service offers several models of care including private obstetric and private midwifery, continuity of midwifery care, shared care with GPs and standard public care. A team approach is taken to the care of women in labour with midwives providing most labour care, facilitating birth where obstetric intervention is not required. The service had a
Please cite this article in press as: M.J. Borrman, et al., The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.301
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stable caesarean section rate in the study population over the study period of approximately 30% (29.1% time period 1 vs 30.4% time period 2, p = 0.29). In 2016 a multidisciplinary working party was convened to develop and implement strategies for the prevention of severe perineal trauma. Local data were examined to understand the factors contributing to the rates in our service and an extensive literature review was undertaken to identify evidence-based prevention strategies.11–17 After reviewing our data and the evidence the following strategies were agreed;
promotion of antenatal perineal massage, avoidance of instrumental birth where possible, use of vacuum in preference to forceps wherever possible, warm compress in the second stage of labour, controlled birth of the fetal head (with communication OR hands on technique), restricted episiotomy (i.e. with clinical indications rather than routine), medio-lateral episiotomy if episiotomy required, avoidance of lithotomy position wherever possible. Prior to the introduction of these strategies, there were no policies in place with respect to these particular interventions and practice varied amongst individual practitioners. These strategies were communicated to maternity staff with a series of mandatory multidisciplinary workshops that were facilitated by members of the multidisciplinary working party. These workshops were free and staff members were given leave to attend. Each workshop was of four hours duration and included a presentation focussing on; definitions, classification, diagnosis, risk factors, associated morbidity and an overview of the evidence for prevention strategies. The presentation was followed by simulation exercises (at 4–5 stations) focusing on; 1 Assisted modes of birth [including primary level strategies for prevention (e.g. hydration, active labour, birth positions)], vacuum and forceps techniques focussing on preservation of the perineum. The strategy allowed for practitioner discretion in relation to the use of episiotomy in assisted modes of birth. 2 Warm compress application in the second stage of labour and control of the fetal head. Techniques for warm compress application and control of the fetal head were explored in the simulation (varying with positioning of the woman). The strategy allowed for practitioner discretion in the technique used. 3 Antenatal perineal massage (including discussion of evidence for commercial products aimed at prevention). 4 Use of the obstetric bed to support a variety of birth positions. 5 Correct episiotomy technique.1 Workshops commenced in June 2016 (with most clinicians attending in June) and have been repeated every six months to date, to capture new staff members and those who hadn’t yet attended. Staff members not attending the training sessions were exposed to the intervention through word of mouth, staff meetings and program updates (e.g. progress reports provided on ward notice boards). The working group monitored the following outcomes regularly to gauge the impact of the program; proportion of women having vaginal birth experiencing SPT, rate of forceps and vacuum modes of birth and episiotomy. While it can be easy to bring about an initial change in practice, the working party also understood the need to sustain any changes to practice
1
This station was included more latterly after feedback from participants. The content however was previously included in the presentation.
3
and maintain a focus on the issue within the service. To this end, SPT was added to the agenda of relevant staff meetings, all cases of SPT were discussed at multidisciplinary meetings, monthly reports were generated and displayed in relevant areas and a “reflection on practice” tool was developed and implemented. This tool aims at assisting practitioners to reflect with their manager on any case of SPT in which they were involved, to identify any learning needs they may have and to relate any relevant contextual information. The working party continues to meet though with a focus now on sustaining the positive change. Completed “reflection on practice” forms are reviewed by the working party to inform future educational strategies. 3. Results The sample consisted of 4128 nulliparous women giving birth to cephalic presenting babies vaginally; 2037 in time period 1 and 2091 in time period 2. Table 1 shows the characteristics of mothers and babies in this group demonstrating a significant difference in induction of labour, mean maternal age, maternal obesity, mean gestation and type of vaginal birth in the two time periods. While the proportion of women experiencing assisted modes of birth did not change significantly, fewer women were exposed to forceps in the second time period. Table 2 presents perineal outcomes. Fewer women had an intact perineum in the second time period and overall, more women had an episiotomy. Rates of episiotomy increased almost 10% in combined instrumental births (56.5%–62.1%), and 40% in spontaneous vaginal births (7.4%–10.4%). Importantly, the proportion of women experiencing SPT reduced significantly from the first to the second time period and this was true for all modes of vaginal birth. Rates of SPT for all types of vaginal birth reduced by 37%, spontaneous vaginal birth by 26% and for combined instrumental births it was reduced by 49%. Table 3 presents the results of logistic regression analysis. Analyses demonstrate that time period was statistically significant with women in the second time period having reduced odds of SPT than women in the first. Other factors increasing the odds of SPT in this group include Asian country of birth, forceps birth, neonatal weight 4000 gm, and maternal age. Episiotomy was protective of SPT. As Table 4 demonstrates, episiotomy was protective in all modes of birth for women born in Asian countries but only in forceps births for women not born in an Asian country.
Table 1 Characteristics of women and babies and mode of vaginal birth. Samplea
Time 1 (n = 2037)
Mothers
Mean (SD) n (%) 28.95 (4.94) 29.44 (4.90) 267 (13.2%) 333 (16%) 420 (20.7%) 442 (21.3%)
Mean Age Obese Asian Country of Birth Labour onset Induction of labour Type of vaginal birth Spontaneous vaginal Vacuum Forceps Babies Mean gestation (SD) Macrosomia Mean head circumference (SD)
Time 2 (n = 2091)
643 (31.6%)
826 (39.5%)
1348 (66.2%) 327 (16.0%) 362 (17.8%)
1370 (65.5%) 401 (19.2%) 329 (15.2%)
39.23 (2.33) 126 (6.2%) 33.92 (3.23)
38.99 (2.83) 127 (6.1%) 33.81 (3.41)
p value
0.001 0.012 0.649 <0.001 0.008
0.002 0.935 0.303
Bold values indicate results are statistically significant. a Primiparous women, singleton fetus, cephalic presentation, vaginal birth with data on perineal outcome.
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Table 2 Perineal outcomes. Perineal outcome
Time 1 (n = 2037)
Time 2 (n = 2091)
p Value
Intact perineum Episiotomy Episiotomy by mode of birth Spontaneous vaginal Combined instrumental Vacuum Forceps Severe perineal trauma (SPT) SPT by mode of birth Spontaneous vaginal Combined instrumental Vacuum Forceps
252 (12.4%) 489 (24.0%)
216 (10.3%) 591 (28.3%)
0.044 0.002
100 (7.4%) 389 (56.5%) 157 (48.0%) 232 (64.1%) 8.9%
143 (10.4%) 448 (62.1%) 207 (51.9%) 241 (75.3%) 5.6%
0.007
97 (7.2%) 85 (12.3%) 34 (10.4%) 51 (14.1%)
73 (5.3%) 45 (6.2%) 17 (4.2%) 28 (8.8%)
0.045
birth reduced by 36% within the context of a relatively stable caesarean section rate. The STOMP program reported by Basu et al.19 saw a 53% SPToverall reduction in their population of primi and multi parous women (4.7%–2.2%). Regression analysis of our data demonstrates a 40% reduction in the odds of severe perineal trauma in the second time period compared to the first (Adj OR 0.60). This is similar to the findings of Frost et al.20 who identified a 34% reduction after the introduction of an education package in a population of primi and multi parous women (OR 0.66). For women experiencing spontaneous vaginal birth in our study the reduction in severe perineal trauma was in the magnitude of 27% (from 7.2% to 5.3%) and for combined instrumental births it was reduced by 47% (12.3%– 6.2%). These reductions are smaller than those achieved by Mohiudin et al.18 who examined outcomes for a similar group of women at two sites pre and post an education program. Baseline rates of severe perineal trauma were significantly lower than ours in both spontaneous and instrumental births and they report a 51% and 58% reduction in rates for women experiencing spontaneous vaginal birth and 25% and 80% reduction for women experiencing instrumental birth. The reason for the disparate results across the two sites for instrumental birth is unclear. The program reported on by Mohiudin et al.18 emphasised the role of episiotomy (using EPISCISSORS-60) and whilst their
0.371 0.002 <0.001
0.001 0.030
Bold values indicate results are statistically significant.
4. Discussion The main finding of this study was that rates of SPT were lower in nulliparous women at our institution following implementation of this bundle of care. Crude rates of SPT for all modes of vaginal Table 3 Regression analysis presenting OR for severe perineal trauma for select variables. Variable Time period Time period 2 Time period 1 Country of birth Asian Non-Asian Mode of birth Vacuum Forceps Spontaneous Episiotomy Episiotomy No episiotomy Pre-pregnancy obesity Obesity No obesity Neonatal macrosomia 4000 g <4000 g Maternal age
Crude OR
95% CI
p value
Adjusted ORa
95% CI
p Value
0.61 (reference)
0.48–0.77
0.001
0.60
0.47–0.76
<0.001
2.18 (reference)
1.70–2.80
<0.001
2.14
1.65–2.76
<0.001
1.13 1.97 (reference)
0.82–1.57 1.49–2.08
0.445 0.001
1.03 1.75
0.74–1.42 1.31–2.23
0.878 <0.001
0.83 (reference)
0.63–1.10
0.199
0.68
0.51–0.90
0.008
0.61 (reference)
0.41–0.90
0.012
0.73
0.49–1.09
0.126
1.87 (reference) 1.04
1.26–2.78
0.002
2.20
1.47–3.30
<0.001
1.01–1.06
0.001
1.04
1.01–1.07
0.002
Nb. Tests for multicollinearity indicated that a very low level of multicollinearity was present (VIF = 1.009 time period, 1.048 country of birth, 1.460 mode of birth, 1.470 episiotomy, 1.029, pre-pregnancy obesity, 1.011 neonatal macrosomia and 1.020 maternal age). Bold values indicate results are statistically significant. a Results adjusted for maternal age, pre-pregnancy obesity, neonate 4000 g, Asian country of birth.
Table 4 Effect of episiotomy on severe perineal trauma by mode of birth for women of Asian and non-Asian country of birth. Variable Asian country of birthb Spontaneous Vacuum Forceps Non-Asian country of birthb Spontaneous Vacuum Forceps
Crude OR
95% CI
p value
Adjusted ORa
95% CI
p Value
0.36 0.37 0.19
0.13–1.01 0.18–1.01 0.09–0.44
0.053 0.053 <0.001
0.33 0.31 0.20
0.11–0.95 0.11–0.86 0.09–0.45
0.040 0.024 <0.001
0.98 0.48 0.54
0.47–2.05 0.27–1.04 0.29–0.99
0.960 0.062 0.047
0.78 0.49 0.53
0.35–1.71 0.22–1.06 0.29–0.97
0.528 0.069 0.040
Nb. Tests for multicollinearity indicated that a very low level of multicollinearity was present (VIF = 1.048 country of birth, 1.456 mode of birth, 1.464 episiotomy, 1.027 prepregnancy obesity, 1.011 neonatal macrosomia and 1.018 maternal age). Bold values indicate results are statistically significant. a Results adjusted for maternal age, pre-pregnancy obesity and neonate 4000 g. b Reference group in all comparisons is type of vaginal birth with no episiotomy.
Please cite this article in press as: M.J. Borrman, et al., The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.301
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baseline rate for episiotomy in instrumental births was high at 85.96%, they saw a 6.6% increase following the education program. In spontaneous vaginal births the rate of episiotomy increased by 43% (16.2%–23.2%). Our study also saw an increase in episiotomy rates; by 14% in instrumental births (56.5%–62.1%) and 40% in spontaneous vaginal births (7.4%–10.4%) though our baseline rates were much lower than those reported by Mohiudin et al.18 Routine episiotomy has not been found to reduce the risk of SPT in a systematic review22 though several observational studies have demonstrated a protective effect in instrumental births.23,24 In our study of nulliparous women, factors increasing the chance of severe perineal trauma included Asian country of birth, forceps birth, neonate 4000 g and maternal age. These are known risk factors that have been well documented.25 In our study, women of an Asian country of birth had more than twice the odds of SPT than their non-Asian counterparts. A recent Australian observational study26 found that compared to women born in Australia or New Zealand, South Asian women (Afghanistan, Bangladesh, India, Nepal, Pakistan and Sri Lanka) were most at risk of SPT (adj OR 3.62) compared to South East Asian women (Brunei, Myanmar, Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand and Vietnam) (adj OR 1.84). Asia is a large geographical region encompassing many ethnicities. Future studies into SPT would benefit from examining the role of ethnicity in a more nuanced way. Where prevention strategies include a “bundle” of interventions it is difficult to identify the element or combination of elements that may have made a difference. Despite the apparent success of the program, fidelity to the strategies by practitioners cannot be assured. Future studies would benefit from rigorous documentation of the strategies used by practitioners in each case. Retrospective observational studies are affected by the quality of the data on which they draw. Poor documentation of ethnicity for example in this study meant that a proxy was used, and we acknowledge that “county of birth’ does not necessarily indicate ethnicity. Women of an Asian ethnicity born in Australia for example would be categorised as non-Asian in our study. There may be additional variables not included in our analysis that impacted perineal outcomes including woman’s position for birth. In addition, the use of historical controls means that changes in practice (other than the intervention) could have occurred over time, impacting the results found. This study found an association between time period and rates of SPT and this should not be interpreted as a cause and effect relationship. It should also be noted that the proportion of women experiencing SPT in our service at baseline was high compared to comparable maternity services in Australia.27 While several authors have demonstrated success with the implementation of a prevention program for SPT those published to date have had relatively short follow up periods. The challenge for us and indeed all services is to maintain the improvement over the longer term. Author contributions MJB, DD, BL and AP all contributed to the project on which this manuscript is based. MJB competed a first draft of the manuscript and analysed data and prepared results presented in the manuscript with support of DD. DD revised the manuscript and results while BL and AP critically reviewed the manuscript. Ethical statement Ethical approval for the study was obtained in April 2018 from the ACT Health Human Research Ethics Committee; approval number ETHLR:18.066.
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Conflict of interest None declared. Funding None declared. Acknowledgements Thank you to the key staff members who played an important role in developing and implementing the prevention strategy that is the focus of this article and thank you to Professor Michael Peek for reviewing a draft of this article and providing helpful feedback. References 1. Royal College of Obstetricians and Gynaecologists. The management of third and forth degree perineal tears. Vol green top guideline no. 29. United Kingdom: Royal College of Obstetricians and Gynaecologists; 2015. 2. Priddis H, Schmied V, Dahlen H. Women’s experiences following severe perineal trauma: a qualitative study. BMC Womens Health 2014;14(February (1)):32. 3. Crookall R, Fowler G, Wood C, Slade P. A systematic mixed studies review of women’s experiences of perineal trauma sustained during childbirth. J Adv Nurs 2018. doi:http://dx.doi.org/10.1111/jan.13724 [Epub ahead of print]. 4. Andrews V, Thakar R, Sultan AH, Jones PW. Evaluation of postpartum perineal pain and dyspareunia—a prospective study. Eur J Obstet Gynecol Reprod Biol 2008;137(2):152–6. 5. Sultan AH. Editorial: obstetrical perineal injury and anal incontinence. AVMA Med Legal J 1999;5(6):193–6. 6. Eskandar O, Shet D. Risk factors for 3rd and 4th degree perineal tear. J Obstet Gynaecol 2009;29(2):119–22. 7. Gurol-Urganci I, Cromwell D, Edozien L, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120(12):1516–25. 8. Australian Institute of Health and Welfare. Labour and birth: perineal status. Australian Institute of Health and Welfare; 2018 Available at: https://www. aihw.gov.au/reports/mothers-babies/perinatal-data-visualisations/contents/ data-visualisations. [Accessed 2 July 2018]. 9. Australian Commission on Safety and Quality in Health Care. The second Australian atlas of healthcare variation. Australian Commission on Safety and Quality in Health Care; 2017 Available at: https://www.safetyandquality.gov. au/atlas/atlas-2017/. [Accessed July 2018]. 11. Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 2013(4). 12. Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011(12). 13. Priddis H, Dahlen H, Thornton C. Severe perineal trauma is rising, but let’s not overreact. Women Birth 2015;28:S26. 14. Poulsen MØ, Madsen ML, Skriver-Møller A-C, Overgaard C. Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature. BMJ Open 2015;5(9). 15. Ginath S, Elyashiv O, Weiner E, et al. The optimal angle of the mediolateral episiotomy at crowning of the head during labor. Int Urogynecol J 2017;28 (December (12)):1795–9. 16. Gonzalez-Díaz E, Moreno Cea L, Fernández Corona A. Trigonometric characteristics of episiotomy and risks for obstetric anal sphincter injuries in operative vaginal delivery. Int Urogynecol J 2015;26(February (2)):235–42. 17. Elvander C, Ahlberg M, Thies-Lagergren L, Cnattingius S, Stephansson O. Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births. BMC Pregnancy Childbirth 2015;15 (October (1)):252. 18. Mohiudin H, Ali S, Pisal PN, Villar R. Implementation of the RCOG guidelines for prevention of obstetric anal sphincter injuries (OASIS) at two London Hospitals: a time series analysis. Eur J Obstet Gynecol 2018;224:89–92. 19. Basu M, Smith D, Edwards R. Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience. Eur J Obstet Gynecol Reprod Biol 2016;202:55–9. 20. Frost J, Gundry R, Young H, Naguib A. Multidisciplinary training in perineal care during labor and delivery for the reduction of anal sphincter injuries. Int J Gynecol Obstet 2016;134(2):177–80. 21. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci 2013;8(October (1)):117. 22. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017(2).
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23. de Vogel J, van der Leeuw-van Beek A, Gietelink D, et al. The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J Obstet Gynecol 2012;206 (5):404.e401–5. 24. Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population–based cohort study. Am J Obstet Gynecol 2014;210(1):59.e51–6.
25. Keriakos R, Gopinath D. Obstetric anal sphincter injuries. J Acute Dis 2015;4 (4):259–65. 26. Brown J, et al. The Great Divide: country of birth as a risk factor for obstetric anal sphincter injuries. Aust N Z J Obstet Gynaecol 2018;58(1):79–85. 27. Women’s Healthcare Australasia (WHA). Benchmarking maternity care data 2015-16 [unpublished]. Canberra: Women’s Healthcare Australasia; 2016.
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Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study Mary J. Borrmana , Deborah Davisb,* , Alison Porteousc , Boon Limd a
Centenary Hospital for Women and Children, Canberra, Australia University of Canberra, and ACT Government Health Directorate, Canberra, Australia Department of Obstetrics and Gynaecology, Canberra Hospital and Health Services, Canberra, Australia d Department of Obstetrics and Gynaecology, Canberra Hospital and Health Services, and Australian National University, Canberra, Australia b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 5 March 2019 Received in revised form 30 July 2019 Accepted 30 July 2019 Available online xxx
Background: Severe perineal trauma during childbirth is associated with significant morbidity and rates internationally, are on the rise. Aims: To determine the impact of a prevention program on severe perineal trauma in a nulliparous population at a tertiary hospital in Australia. Methods: Routinely collected maternity data were used comparing outcomes in two time periods; two years before and two years after the introduction of the program. Categorical data were compared using the Chi Squared statistic and continuous data Student’s t-test. Logistic regression examined the association between independent and dependent variables using unadjusted and adjusted odds ratios, with 95% confidence intervals and p -values with significance set at 0.05. The main outcome of interest is severe perineal trauma. Results: The proportion of women in this nulliparous population experiencing severe perineal trauma during vaginal birth decreased from 8.8% in the first time period to 5.6% in the second. Reductions were achieved in all modes of vaginal birth but were most pronounced in vacuum births. Rates of episiotomy increased between time periods and further analysis found that this was protective of severe perineal trauma in all modes of birth for women of Asian country of birth and only in forceps birth for non-Asian women. Factors found to contribute to severe perineal trauma in this population were Asian country of birth, neonatal weight 4000 gm, forceps birth and maternal age. Conclusions: The prevention program is associated with reduced rates of severe perineal trauma. The challenge for the service is to maintain this positive change. Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
Keywords: Perineum Parturition Tertiary healthcare Patient care bundles Episiotomy
Statement of significance
introduced at service level have shown to be effective in the short term. What this paper adds
Problem or issue Increasingly women are suffering severe perineal trauma during childbirth which causes significant morbidity.
A prevention program introduced to a tertiary maternity service can be successful in reducing rates of severe perineal trauma in a nulliparous population.
What is already known Several individual interventions have proven successful in preventing severe perineal trauma and prevention programs
* Corresponding author at: Centenary Hospital for Women and Children, Building 11, Cnr Gilmore Cres & Hospital Road, Garran, ACT 2605, Australia. E-mail address: [email protected] (D. Davis).
1. Introduction Severe perineal trauma (SPT), defined here as any tear involving the anal sphincter or rectal mucosa (3rd, 4th and rectal button hole tears),1 is associated with significant morbidity. This can include perineal pain, dyspareunia, anal incontinence and fistula, which impact not only a woman’s physical health but her emotional,
http://dx.doi.org/10.1016/j.wombi.2019.07.301 1871-5192/Crown Copyright © 2019 Published by Elsevier Ltd on behalf of Australian College of Midwives. All rights reserved.
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mental and social.2–5 Risk factors for SPT include; nulliparity, Asian ethnicity, large baby, occipito-posterior fetal position, shoulder dystocia, and instrumental birth.6,7 In Australia, reported rates vary significantly between states with Western Australia reporting the lowest at 2.6% in 2016 and South Australia the highest at 3.6%.8 The rate of SPT appears to be increasing in Australia and other comparable countries and this may be associated with increasing risk factors (maternal age, assisted modes of birth) and/ or reporting practices and improved detection.7,9 While some factors contributing to SPT are outside of the control of the maternity caregiver (such as parity and ethnicity), various techniques and factors have been found to be effective in preventing SPT. Antenatal perineal massage has been found to reduce perineal tearing requiring suturing though not specifically severe perineal trauma.11 The application of warm compress to the perineum in the second stage of labour has been shown to be effective12 while hands on support of the perineum and fetal head continues to engender debate.13 High level evidence demonstrates no effect12 though large-scale observational studies of the “Finnish Intervention” (which includes hands on support of the perineum) demonstrate a protective effect.14 Routine episiotomy has not been shown to be protective in spontaneous vaginal birth though the angle of the mediolateral episiotomy is emerging as an important concern.15,16 Researchers have also examined birth position finding the lateral position protective while lithotomy, birth seat (multiparous women only) and squatting (multiparous women only) increased the risk of SPT.17 Several large maternity services have attempted to reduce rates of SPT with a suite of strategies. Mohiudin, et al.18 successfully reduced rates of SPT in nulliparous women at two London Hospitals after implementing a strategy that included the introduction of antenatal perineal massage, manual perineal protection and use of EPISCISSORS-60 to facilitate correct angle of episiotomy. Also in the UK, Basu et al.19 more than halved the rate of SPT with a strategy that included; avoidance of semirecumbent position, coaching the woman to achieve controlled less expulsive pushing along with a hands-on approach to slowing down the birth of the fetal head and spontaneous birth of shoulders with minimal downward traction. Still in the UK, Frost et al.20 reduced their rate of SPT with a multidisciplinary education program that included strategies for the prevention of SPT (though they do not specify the strategies) and a focus on building midwifery confidence to perform episiotomy. These studies compare outcomes for a relatively short period of time following the intervention (up to one year) while the challenge with changing practice comes in its sustainability.21 This paper compares outcomes two years before and two years after the implementation of a multidisciplinary SPT prevention program in a tertiary maternity setting. 2. Materials and methods The primary aim of the study is to compare the proportion of nulliparous women experiencing severe perineal trauma in our service before and after the introduction of a prevention strategy. The secondary aim is to report on the factors associated with severe perineal trauma in this sample of women. Ethical approval for the study was received from the relevant ethics committee. 2.1. Design and sample This is a retrospective observational study using data drawn from the service’s electronic maternity database (Birth Outcomes System) from 1st June 2014 to 31st May 2018. Data are entered into the database by clinicians contemporaneously or as soon as
practicable after an episode of care. Data are validated regularly by the system administrator. Mandatory reporting fields are validated by the Epidemiology Section of the Department of Population Health at the jurisdiction level. The prevention strategy was implemented in June 2016 thus outcomes for time period 1 (1st June 2014–31st May 2016) are compared with those of time period 2 (1st June 2016–31st May 2018). The sample consists of all nulliparous women experiencing vaginal birth of a singleton baby with a cephalic presentation (any gestation) with data on perineal outcomes. 2.2. Variables and analysis Variables drawn from the database include date of birth of the mother which was converted to age at date of baby’s birth. Prepregnancy obesity (BMI 30) is calculated following self-reported pre-pregnancy weight and height reported at the first antenatal visit with the service. Maternal country of birth was used in preference to ethnicity as the latter was not well reported in the database. This was dichotomised to “Asian country of birth” and includes those countries in South Asia, South East Asia and North Asia and excludes the Middle East and Russia. Severe perineal trauma includes any tear that involves the anal sphincter or rectal mucosa and intact perineum was defined as any intact perineum (with any other tear or graze to labia, vaginal wall, clitoris or urethra not sutured). To detect a statistically significant difference between two proportions (from 9% to 6%) with 95% confidence and 80% power using a two tailed test a sample size of 1209 in each group is required. The total sample size of this study is 4128; 2037 in time period 1 and 2091 in time period 2. Data were transferred to Statistical Programme for Social Sciences (IMB SPSS version 23) for analysis. Categorical data were analysed using the chi-squared statistic. Continuous data were analysed using Student’s t -test after checking for normality. All tests were two-tailed, and significance was set at p < 0.05. Results of logistic regression are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05. In the main model examining predictors for SPT, known confounders were included in the regression model as covariates and included; maternal pre-pregnancy obesity (binary variable; BMI 30), maternal age (continuous measure), neonatal macrosomia (binary variable; birth weight 4000 g), and Asian country of birth (binary variable). Further analysis of the role of episiotomy in the prevention of SPT was undertaken by developing separate logistic regression models for each mode of birth for women using born in Asia and those born elsewhere. In these models the OR between episiotomy and SPT was adjusted for maternal age, prepregnancy obesity and macrosomia. In all regression models we examined potential collinearity between the independent variables using variance inflation factors (VIF) and in all analyses, results indicated very low levels of multicollinearity with maximum VIF for any variable at <1.5. Additionally, interaction effects were examined in each model (pre-pregnancy obesity*neonatal macrosomia*Asian country of birth) showing no significant interaction. 2.3. Setting and prevention strategy The maternity service is an Australian tertiary level service which is a referral centre for the surrounding region. It facilitates approximately 3500 births per annum. The service offers several models of care including private obstetric and private midwifery, continuity of midwifery care, shared care with GPs and standard public care. A team approach is taken to the care of women in labour with midwives providing most labour care, facilitating birth where obstetric intervention is not required. The service had a
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stable caesarean section rate in the study population over the study period of approximately 30% (29.1% time period 1 vs 30.4% time period 2, p = 0.29). In 2016 a multidisciplinary working party was convened to develop and implement strategies for the prevention of severe perineal trauma. Local data were examined to understand the factors contributing to the rates in our service and an extensive literature review was undertaken to identify evidence-based prevention strategies.11–17 After reviewing our data and the evidence the following strategies were agreed;
promotion of antenatal perineal massage, avoidance of instrumental birth where possible, use of vacuum in preference to forceps wherever possible, warm compress in the second stage of labour, controlled birth of the fetal head (with communication OR hands on technique), restricted episiotomy (i.e. with clinical indications rather than routine), medio-lateral episiotomy if episiotomy required, avoidance of lithotomy position wherever possible. Prior to the introduction of these strategies, there were no policies in place with respect to these particular interventions and practice varied amongst individual practitioners. These strategies were communicated to maternity staff with a series of mandatory multidisciplinary workshops that were facilitated by members of the multidisciplinary working party. These workshops were free and staff members were given leave to attend. Each workshop was of four hours duration and included a presentation focussing on; definitions, classification, diagnosis, risk factors, associated morbidity and an overview of the evidence for prevention strategies. The presentation was followed by simulation exercises (at 4–5 stations) focusing on; 1 Assisted modes of birth [including primary level strategies for prevention (e.g. hydration, active labour, birth positions)], vacuum and forceps techniques focussing on preservation of the perineum. The strategy allowed for practitioner discretion in relation to the use of episiotomy in assisted modes of birth. 2 Warm compress application in the second stage of labour and control of the fetal head. Techniques for warm compress application and control of the fetal head were explored in the simulation (varying with positioning of the woman). The strategy allowed for practitioner discretion in the technique used. 3 Antenatal perineal massage (including discussion of evidence for commercial products aimed at prevention). 4 Use of the obstetric bed to support a variety of birth positions. 5 Correct episiotomy technique.1 Workshops commenced in June 2016 (with most clinicians attending in June) and have been repeated every six months to date, to capture new staff members and those who hadn’t yet attended. Staff members not attending the training sessions were exposed to the intervention through word of mouth, staff meetings and program updates (e.g. progress reports provided on ward notice boards). The working group monitored the following outcomes regularly to gauge the impact of the program; proportion of women having vaginal birth experiencing SPT, rate of forceps and vacuum modes of birth and episiotomy. While it can be easy to bring about an initial change in practice, the working party also understood the need to sustain any changes to practice
1
This station was included more latterly after feedback from participants. The content however was previously included in the presentation.
3
and maintain a focus on the issue within the service. To this end, SPT was added to the agenda of relevant staff meetings, all cases of SPT were discussed at multidisciplinary meetings, monthly reports were generated and displayed in relevant areas and a “reflection on practice” tool was developed and implemented. This tool aims at assisting practitioners to reflect with their manager on any case of SPT in which they were involved, to identify any learning needs they may have and to relate any relevant contextual information. The working party continues to meet though with a focus now on sustaining the positive change. Completed “reflection on practice” forms are reviewed by the working party to inform future educational strategies. 3. Results The sample consisted of 4128 nulliparous women giving birth to cephalic presenting babies vaginally; 2037 in time period 1 and 2091 in time period 2. Table 1 shows the characteristics of mothers and babies in this group demonstrating a significant difference in induction of labour, mean maternal age, maternal obesity, mean gestation and type of vaginal birth in the two time periods. While the proportion of women experiencing assisted modes of birth did not change significantly, fewer women were exposed to forceps in the second time period. Table 2 presents perineal outcomes. Fewer women had an intact perineum in the second time period and overall, more women had an episiotomy. Rates of episiotomy increased almost 10% in combined instrumental births (56.5%–62.1%), and 40% in spontaneous vaginal births (7.4%–10.4%). Importantly, the proportion of women experiencing SPT reduced significantly from the first to the second time period and this was true for all modes of vaginal birth. Rates of SPT for all types of vaginal birth reduced by 37%, spontaneous vaginal birth by 26% and for combined instrumental births it was reduced by 49%. Table 3 presents the results of logistic regression analysis. Analyses demonstrate that time period was statistically significant with women in the second time period having reduced odds of SPT than women in the first. Other factors increasing the odds of SPT in this group include Asian country of birth, forceps birth, neonatal weight 4000 gm, and maternal age. Episiotomy was protective of SPT. As Table 4 demonstrates, episiotomy was protective in all modes of birth for women born in Asian countries but only in forceps births for women not born in an Asian country.
Table 1 Characteristics of women and babies and mode of vaginal birth. Samplea
Time 1 (n = 2037)
Mothers
Mean (SD) n (%) 28.95 (4.94) 29.44 (4.90) 267 (13.2%) 333 (16%) 420 (20.7%) 442 (21.3%)
Mean Age Obese Asian Country of Birth Labour onset Induction of labour Type of vaginal birth Spontaneous vaginal Vacuum Forceps Babies Mean gestation (SD) Macrosomia Mean head circumference (SD)
Time 2 (n = 2091)
643 (31.6%)
826 (39.5%)
1348 (66.2%) 327 (16.0%) 362 (17.8%)
1370 (65.5%) 401 (19.2%) 329 (15.2%)
39.23 (2.33) 126 (6.2%) 33.92 (3.23)
38.99 (2.83) 127 (6.1%) 33.81 (3.41)
p value
0.001 0.012 0.649 <0.001 0.008
0.002 0.935 0.303
Bold values indicate results are statistically significant. a Primiparous women, singleton fetus, cephalic presentation, vaginal birth with data on perineal outcome.
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Table 2 Perineal outcomes. Perineal outcome
Time 1 (n = 2037)
Time 2 (n = 2091)
p Value
Intact perineum Episiotomy Episiotomy by mode of birth Spontaneous vaginal Combined instrumental Vacuum Forceps Severe perineal trauma (SPT) SPT by mode of birth Spontaneous vaginal Combined instrumental Vacuum Forceps
252 (12.4%) 489 (24.0%)
216 (10.3%) 591 (28.3%)
0.044 0.002
100 (7.4%) 389 (56.5%) 157 (48.0%) 232 (64.1%) 8.9%
143 (10.4%) 448 (62.1%) 207 (51.9%) 241 (75.3%) 5.6%
0.007
97 (7.2%) 85 (12.3%) 34 (10.4%) 51 (14.1%)
73 (5.3%) 45 (6.2%) 17 (4.2%) 28 (8.8%)
0.045
birth reduced by 36% within the context of a relatively stable caesarean section rate. The STOMP program reported by Basu et al.19 saw a 53% SPToverall reduction in their population of primi and multi parous women (4.7%–2.2%). Regression analysis of our data demonstrates a 40% reduction in the odds of severe perineal trauma in the second time period compared to the first (Adj OR 0.60). This is similar to the findings of Frost et al.20 who identified a 34% reduction after the introduction of an education package in a population of primi and multi parous women (OR 0.66). For women experiencing spontaneous vaginal birth in our study the reduction in severe perineal trauma was in the magnitude of 27% (from 7.2% to 5.3%) and for combined instrumental births it was reduced by 47% (12.3%– 6.2%). These reductions are smaller than those achieved by Mohiudin et al.18 who examined outcomes for a similar group of women at two sites pre and post an education program. Baseline rates of severe perineal trauma were significantly lower than ours in both spontaneous and instrumental births and they report a 51% and 58% reduction in rates for women experiencing spontaneous vaginal birth and 25% and 80% reduction for women experiencing instrumental birth. The reason for the disparate results across the two sites for instrumental birth is unclear. The program reported on by Mohiudin et al.18 emphasised the role of episiotomy (using EPISCISSORS-60) and whilst their
0.371 0.002 <0.001
0.001 0.030
Bold values indicate results are statistically significant.
4. Discussion The main finding of this study was that rates of SPT were lower in nulliparous women at our institution following implementation of this bundle of care. Crude rates of SPT for all modes of vaginal Table 3 Regression analysis presenting OR for severe perineal trauma for select variables. Variable Time period Time period 2 Time period 1 Country of birth Asian Non-Asian Mode of birth Vacuum Forceps Spontaneous Episiotomy Episiotomy No episiotomy Pre-pregnancy obesity Obesity No obesity Neonatal macrosomia 4000 g <4000 g Maternal age
Crude OR
95% CI
p value
Adjusted ORa
95% CI
p Value
0.61 (reference)
0.48–0.77
0.001
0.60
0.47–0.76
<0.001
2.18 (reference)
1.70–2.80
<0.001
2.14
1.65–2.76
<0.001
1.13 1.97 (reference)
0.82–1.57 1.49–2.08
0.445 0.001
1.03 1.75
0.74–1.42 1.31–2.23
0.878 <0.001
0.83 (reference)
0.63–1.10
0.199
0.68
0.51–0.90
0.008
0.61 (reference)
0.41–0.90
0.012
0.73
0.49–1.09
0.126
1.87 (reference) 1.04
1.26–2.78
0.002
2.20
1.47–3.30
<0.001
1.01–1.06
0.001
1.04
1.01–1.07
0.002
Nb. Tests for multicollinearity indicated that a very low level of multicollinearity was present (VIF = 1.009 time period, 1.048 country of birth, 1.460 mode of birth, 1.470 episiotomy, 1.029, pre-pregnancy obesity, 1.011 neonatal macrosomia and 1.020 maternal age). Bold values indicate results are statistically significant. a Results adjusted for maternal age, pre-pregnancy obesity, neonate 4000 g, Asian country of birth.
Table 4 Effect of episiotomy on severe perineal trauma by mode of birth for women of Asian and non-Asian country of birth. Variable Asian country of birthb Spontaneous Vacuum Forceps Non-Asian country of birthb Spontaneous Vacuum Forceps
Crude OR
95% CI
p value
Adjusted ORa
95% CI
p Value
0.36 0.37 0.19
0.13–1.01 0.18–1.01 0.09–0.44
0.053 0.053 <0.001
0.33 0.31 0.20
0.11–0.95 0.11–0.86 0.09–0.45
0.040 0.024 <0.001
0.98 0.48 0.54
0.47–2.05 0.27–1.04 0.29–0.99
0.960 0.062 0.047
0.78 0.49 0.53
0.35–1.71 0.22–1.06 0.29–0.97
0.528 0.069 0.040
Nb. Tests for multicollinearity indicated that a very low level of multicollinearity was present (VIF = 1.048 country of birth, 1.456 mode of birth, 1.464 episiotomy, 1.027 prepregnancy obesity, 1.011 neonatal macrosomia and 1.018 maternal age). Bold values indicate results are statistically significant. a Results adjusted for maternal age, pre-pregnancy obesity and neonate 4000 g. b Reference group in all comparisons is type of vaginal birth with no episiotomy.
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baseline rate for episiotomy in instrumental births was high at 85.96%, they saw a 6.6% increase following the education program. In spontaneous vaginal births the rate of episiotomy increased by 43% (16.2%–23.2%). Our study also saw an increase in episiotomy rates; by 14% in instrumental births (56.5%–62.1%) and 40% in spontaneous vaginal births (7.4%–10.4%) though our baseline rates were much lower than those reported by Mohiudin et al.18 Routine episiotomy has not been found to reduce the risk of SPT in a systematic review22 though several observational studies have demonstrated a protective effect in instrumental births.23,24 In our study of nulliparous women, factors increasing the chance of severe perineal trauma included Asian country of birth, forceps birth, neonate 4000 g and maternal age. These are known risk factors that have been well documented.25 In our study, women of an Asian country of birth had more than twice the odds of SPT than their non-Asian counterparts. A recent Australian observational study26 found that compared to women born in Australia or New Zealand, South Asian women (Afghanistan, Bangladesh, India, Nepal, Pakistan and Sri Lanka) were most at risk of SPT (adj OR 3.62) compared to South East Asian women (Brunei, Myanmar, Cambodia, East Timor, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand and Vietnam) (adj OR 1.84). Asia is a large geographical region encompassing many ethnicities. Future studies into SPT would benefit from examining the role of ethnicity in a more nuanced way. Where prevention strategies include a “bundle” of interventions it is difficult to identify the element or combination of elements that may have made a difference. Despite the apparent success of the program, fidelity to the strategies by practitioners cannot be assured. Future studies would benefit from rigorous documentation of the strategies used by practitioners in each case. Retrospective observational studies are affected by the quality of the data on which they draw. Poor documentation of ethnicity for example in this study meant that a proxy was used, and we acknowledge that “county of birth’ does not necessarily indicate ethnicity. Women of an Asian ethnicity born in Australia for example would be categorised as non-Asian in our study. There may be additional variables not included in our analysis that impacted perineal outcomes including woman’s position for birth. In addition, the use of historical controls means that changes in practice (other than the intervention) could have occurred over time, impacting the results found. This study found an association between time period and rates of SPT and this should not be interpreted as a cause and effect relationship. It should also be noted that the proportion of women experiencing SPT in our service at baseline was high compared to comparable maternity services in Australia.27 While several authors have demonstrated success with the implementation of a prevention program for SPT those published to date have had relatively short follow up periods. The challenge for us and indeed all services is to maintain the improvement over the longer term. Author contributions MJB, DD, BL and AP all contributed to the project on which this manuscript is based. MJB competed a first draft of the manuscript and analysed data and prepared results presented in the manuscript with support of DD. DD revised the manuscript and results while BL and AP critically reviewed the manuscript. Ethical statement Ethical approval for the study was obtained in April 2018 from the ACT Health Human Research Ethics Committee; approval number ETHLR:18.066.
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Conflict of interest None declared. Funding None declared. Acknowledgements Thank you to the key staff members who played an important role in developing and implementing the prevention strategy that is the focus of this article and thank you to Professor Michael Peek for reviewing a draft of this article and providing helpful feedback. References 1. Royal College of Obstetricians and Gynaecologists. The management of third and forth degree perineal tears. Vol green top guideline no. 29. United Kingdom: Royal College of Obstetricians and Gynaecologists; 2015. 2. Priddis H, Schmied V, Dahlen H. Women’s experiences following severe perineal trauma: a qualitative study. BMC Womens Health 2014;14(February (1)):32. 3. Crookall R, Fowler G, Wood C, Slade P. A systematic mixed studies review of women’s experiences of perineal trauma sustained during childbirth. J Adv Nurs 2018. doi:http://dx.doi.org/10.1111/jan.13724 [Epub ahead of print]. 4. Andrews V, Thakar R, Sultan AH, Jones PW. Evaluation of postpartum perineal pain and dyspareunia—a prospective study. Eur J Obstet Gynecol Reprod Biol 2008;137(2):152–6. 5. Sultan AH. Editorial: obstetrical perineal injury and anal incontinence. AVMA Med Legal J 1999;5(6):193–6. 6. Eskandar O, Shet D. Risk factors for 3rd and 4th degree perineal tear. J Obstet Gynaecol 2009;29(2):119–22. 7. Gurol-Urganci I, Cromwell D, Edozien L, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013;120(12):1516–25. 8. Australian Institute of Health and Welfare. Labour and birth: perineal status. Australian Institute of Health and Welfare; 2018 Available at: https://www. aihw.gov.au/reports/mothers-babies/perinatal-data-visualisations/contents/ data-visualisations. [Accessed 2 July 2018]. 9. Australian Commission on Safety and Quality in Health Care. The second Australian atlas of healthcare variation. Australian Commission on Safety and Quality in Health Care; 2017 Available at: https://www.safetyandquality.gov. au/atlas/atlas-2017/. [Accessed July 2018]. 11. Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev 2013(4). 12. Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011(12). 13. Priddis H, Dahlen H, Thornton C. Severe perineal trauma is rising, but let’s not overreact. Women Birth 2015;28:S26. 14. Poulsen MØ, Madsen ML, Skriver-Møller A-C, Overgaard C. Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature. BMJ Open 2015;5(9). 15. Ginath S, Elyashiv O, Weiner E, et al. The optimal angle of the mediolateral episiotomy at crowning of the head during labor. Int Urogynecol J 2017;28 (December (12)):1795–9. 16. Gonzalez-Díaz E, Moreno Cea L, Fernández Corona A. Trigonometric characteristics of episiotomy and risks for obstetric anal sphincter injuries in operative vaginal delivery. Int Urogynecol J 2015;26(February (2)):235–42. 17. Elvander C, Ahlberg M, Thies-Lagergren L, Cnattingius S, Stephansson O. Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births. BMC Pregnancy Childbirth 2015;15 (October (1)):252. 18. Mohiudin H, Ali S, Pisal PN, Villar R. Implementation of the RCOG guidelines for prevention of obstetric anal sphincter injuries (OASIS) at two London Hospitals: a time series analysis. Eur J Obstet Gynecol 2018;224:89–92. 19. Basu M, Smith D, Edwards R. Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience. Eur J Obstet Gynecol Reprod Biol 2016;202:55–9. 20. Frost J, Gundry R, Young H, Naguib A. Multidisciplinary training in perineal care during labor and delivery for the reduction of anal sphincter injuries. Int J Gynecol Obstet 2016;134(2):177–80. 21. Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci 2013;8(October (1)):117. 22. Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017(2).
Please cite this article in press as: M.J. Borrman, et al., The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.301
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Please cite this article in press as: M.J. Borrman, et al., The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study, Women Birth (2019), https://doi.org/10.1016/j.wombi.2019.07.301