Have you discovered the 3rd/4th degree tear rate in your maternity unit yet?

You may have read my previous blog! ‘Do you know the 3rd degree tear rate in your maternity unit?

And you may have found out your local OASIS (Obstetric Anal Sphincter Injury) rate??

The project at Frimley Health has been now been running for 15 months and there have been successes, exciting developments and challenges, like most projects I’m sure.

I continue to work on the project 30 hours a week, and since June we have extended the project from the Frimley Park site to the Wexham Park site. The initial process was repeated with a deep dive into the case histories of those women who experienced OASIS for the last whole year to ensure teaching was relevant to those women, and those staff. This demonstrated very similar themes to the first site and again similar to those found in the literature. Talking to staff and repeating the survey monkey told me that there were issues round de-skilling if episiotomy was required, suturing and some lack of confidence about diagnosis.

So opportunities to meet and teach as many midwives and obstetricians as possible were sought out including the midwives annual mandatory update days and the departmental academic/audit days. Not being so well known in the unit I did not undertake personal debriefs with individual midwives as I felt this could be seen as punitive and the numbers of tears  at this unit already sat close to our target level of 2.5% (of total births).

I find a greater diversity of techniques and opinions when it comes to the “hands on”   versus “hands poised” debate, and this leads to some lively teaching sessions, but less experienced midwives in particular are keen to learn and reflect upon the current and emerging evidence base and those staff who have been practising for many years roll their eyes and say “just like we were taught many years ago!!”

The Episcissors-60 were introduced at Frimley site in May 2016 and have been well received. I feel they have contributed to the reduction in the tear rate, but that it is equally as important that all staff are confident in how to work with the mum to achieve a slow controlled birth and which techniques help. The Episcissors 60 will be introduced at the Wexham site in early 2017 and will hopefully be a useful adjunct.

Other exciting developments in the world of 3rd/4th degree tears include the establishment of the MASIC Foundation (Mothers with Anal Sphincter Injuries in Childbirth) a charity whose aims are supporting mothers, making the public aware and educating professionals. Their first multidisciplinary study day takes place in 2017 titled “Tearing in Childbirth: raising awareness and restoring dignity for mothers”. I’ve been asked to contribute and it promises to be an excellent event to raise awareness and give publicity and information to this extremely personal subject which can be so difficult to talk about.

2017 also brings the scaling up to 16 sites of the Royal College of Obstetricians and Gynaecologist and Royal College of Midwives joint care bundle for the reduction of OASI

This national project will run in participating units over the course of 2017. The evaluation of the programme will include an evaluation of the impact of the OASI care bundle on clinical practice and clinical outcomes and results will be shared through a report and launch event. The care bundle consists of:

  • Inform the woman about OASI and what steps can be taken to minimize her risk
  • Performing an episiotomy when required at 60 degrees from the midline at crowning
  • Using manual perineal protection (MPP) at the time of birth unless the woman objects or her chosen position for birth doesn’t allow MPP
  • Thorough examination after birth, including a per rectum examination, to detect tears not all of which will be immediately   obvious.

The introduction of the care bundle follows training using a specially developed manual, videos and simulations. Professionals from the participating units will receive training from the project team. They in turn will provide training for all midwives and obstetricians in their participating units.

I have been seconded to help with the training and it’s very exciting to see how a national project of this scale works, and ensures that I align my local project with the bigger picture developing nationally and internationally.

The 3rd/4th degree tear rate at our initial site is 1% down on this time last year, and generally hovers around our target rate of 2.5% which is satisfying and means that fewer women are experiencing this potentially life changing injury. I suspect that over the next 5 years that practice really will be influenced by both the national work to reduce 3rd/4th degree tears and local projects like our own.

Opportunities to concentrate on safety issues within maternity with a targeted approach, ring fenced funding  and support from a national organisations like Sign up to Safety do not occur very often so must be grabbed with both hands. Avoidable harm can be reduced by sustainable evidence based change, in a way that is acceptable to staff and users.

So what have I learnt in the last 15 months? That sustaining change is hard, that different people need different approaches, that report* writing is a necessary hardship and that small acorns can lead to big oak trees!

*The team at Sign up to Safety doesn’t ask members to report the progress of their overarching safety improvement plans. However, the NHS Litigation Authority does ask those who received funding from their one-off bid process in early 2015 to report on the impact of that extra investment.

About the Author

Vivienne Novis qualified as a Registered General Nurse in 1984 at St Thomas’ Hospital and as a midwife in 1987 at Frimley Park Hospital. She has worked at Frimley Health Foundation Trust as a midwife for the last 29 years with last 10 being as a Labour Ward Co-ordinator at the Frimley Park Hospital site. Since September 2015 she has been seconded to lead the local perineal management project, and since September 2016 also seconded to the RCOG/RCM OASI project as Lead Midwife.

Useful references

  • Manual protection of the perineum reduces the risk of obstetric anal sphincter ruptures Stine Leenskjold, Lars Hoj,& Jouko Pirhonen – Danish medical Journal 62/5 May 2015
  • Birth position and obstetric anal sphincter injury: a population-based study of 113,000 spontaneous births Charlotte Elvander et al, BMC Pregnancy and Childbirth (2015) 15:252
  • Anal sphincter tears: prospective study of obstetric risk factors E Samuelsson et al, BJOG: An International Journal of Obstetrics & Gynaecology, 107: 926-93 July 2000
  • Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study Katariina Laine et al BMJ Open 2012;2
  • Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors I Gurol-Urganci et al BJOG July 2013
  • The Management of Third- and Fourth- Degree Perineal Tears – Green Top Guideline 29 June 2015 – RCOG
  • Cutting an episiotomy at 60 degrees: how good are we? Naidu M, Kapoor DS et al Int Urogynecol J. 2015 Jun;26(6):813-6.