Leading change

The midwifery Matron at Bedford Hospital NHS Trust led on the implementation of an education and training programme and care bundle to reduce third and fourth degree tears post-partum. The programme has led to improvements in outcomes, experiences and use of resources locally.

Where to look

In 2017, there were 679,106 live births within England and Wales. A NICE (2006) report on postnatal care suggests that health concerns during this phase may include physical morbidity such as backache, breast feeding problems, perineal pain, stress incontinence, and mental health problems, such as postnatal depression. During child birth itself, vaginal delivery puts pressure on the perineum (the skin and muscle between your vagina and anus) which must stretch to accommodate your baby’s head. During delivery, women can be left with swelling, tenderness or, in worse case scenarios, tearing or laceration (episiotomy) of the perineum which may need stitches. Healing times vary, but in general, the deeper the cut or tear, the longer the recovery time. A third- or fourth-degree laceration, which is a more serious tear that extends to the rectum, may result in pain and discomfort for a month or even longer. This trauma can have a significant impact on the lives of women who sustain them, both in the short term and in the long term. This includes perineal pain, social issues affecting everyday life, emotional and psychological trauma, faecal urgency, faecal and flatus incontinence even after repair, and retro-vaginal fistula with an associated cost to the woman as well as the NHS.

The national third and fourth degree tear rate has increased three-fold in the last 10 years with the average rate between 6 and 8%. Variation across the country is evident. Within Bedford NHS Foundation Trust, the third and fourth degree tear rate at the hospital mirrored the national average at 4%, however available published literature highlighted this rate could still be reduced significantly, highlighting unwarranted variation in practice.

What to change

Facilities within the Maternity Department at Bedford Hospital NHS Trust include an antenatal clinic, delivery suite, midwife led unit, post-natal / transitional care ward and a neonatal unit.

The Matron undertook a review of the evidence, which indicated that there were methods the team could implement that could improve practice in the unit and reduce the third and fourth degree tear rates by up to half. Stedenfold et al (2014) highlighted that manual assistance during the final part of second stage of labour can decrease the risk of sustaining a third or fourth degree tear by 59%. An audit of current practice identified that 60% of midwives performed a hands off / poised approach to delivering the baby and that midwives with under 5 years post qualification weren’t always confident at performing an episiotomy, and when performed did not appear to be cut at an angle of 60 degrees.

How to change

Alongside support from the Trust’s Obstetric Consultant, the Matron for inpatients developed an education and development programme as mandatory training for all staff to complete to support them to provide high quality care.

A Royal College of Obstetrics and Gynaecology (RCOG) and Royal College of Midwifery (RCM) competency package of training was rolled out for relevant clinical staff which included the care bundle, education regarding best practice, including manual assistance during delivery, signposting to relevant literature, and inviting colleagues to reflect on their own practice.

Staff were asked to consider how they could change their own practice to improve the rates of third and fourth degree tears. Staff were trained in a multidisciplinary environment, as well as individual professions, by the Obstetric Consultant and the Matron for inpatients.

An application was made by the Trust to work with the RCOG and RCM to test a care bundle. It was anticipated that a reduction in third and fourth degree tears could be achieved. The care bundle includes:

1. Good communication with the person;
2. Adequate perineal support;
3. A delivery position that allows visualisation of the perineum during the end of the second stage of labour; and,
4. Training on performing an episiotomy, only on indication, at an angle of at least 60 degrees from the midline.

Adding value

Better outcomes – The new education and development programme has been completed as mandatory training by all midwives within the unit and subsequent changes in practice have demonstrated a third and fourth degree tear reduction from 4% to 1.2%. In reducing the third and fourth degree tear rate, there is an associated improvement in the other factors associated with third and fourth degree tears e.g. emotional trauma or faecal urgency.

Better experience – Staff have responded well to the new way of working and anecdotally women are pleased with the care they are receiving. The reduced rate of tears is of course positive regarding experience.

Better use of resources – Due to reduced complications such as tears, there is an associated cost saving to the NHS. This is namely due to a reduced need for treatment of third and fourth degree tears as well as associated ‘side effects’. This will positively impact on well-being as well as the availability of staff resource for ongoing patient care.

Challenges and lessons learnt for implementation

Ensuring that staff understood the need for change and were empowered and confident to reduce the rates of third and fourth degree tears was crucial to the success of the programme.

Small adaptions in practice can have had a significant impact; don’t under-estimate these and ensure that data is collected to measure the impact a change has across a range of indicators.

Debate and discussion regarding the evidence base is positive and supports the right decisions being made as we move towards leading change.

Multidisciplinary delivery of (and attendance at) training is extremely beneficial.

Find out more

For more information contact:

• Amanda Pachulski, Matron, Maternity Care, Bedford NHS Hospitals Trust, Amanda.pachulski@bedfordhospital.nhs.uk