Reducing severe perineal trauma in childbirth

Third and fourth degree (severe) perineal tears during childbirth impact significantly on a woman’s physical and mental health. Rising rates in Australia and internationally prompted the Quality and Safety Committee of the Centenary Hospital for Women and Children, Canberra, to begin monitoring the incidence of severe perineal tears in the hospital from 2011.

The hospital chose to submit data to Women’s Healthcare Australasia (WHA) and the Health Roundtable as they allow comparison with data from similar hospitals. WHA provides a benchmarking service that measures a range of indicators of labour and birth care and outcomes, including severe perineal tears.

Birth data was captured in the electronic maternity database (Birth Outcome System). Every morning the multidisciplinary team discussed all births in the database from the previous 24 hours. Any cases of severe tears were verified by team members present at the birth to ensure that they were accurately recorded.

In 2014/15, the hospital’s rate of severe perineal tears among women giving birth vaginally was 6.1%, compared with the national rate of 3.6% in the WHA dataset. Data from the Second Australian Atlas of Healthcare Variation and the Health Roundtable showed that the rates of severe tears in the ACT were the highest in the country. 

The high rates prompted the formation of a multidisciplinary working group to investigate and address the issue. The group was jointly chaired by the Professor of Midwifery and the Clinical Director of Obstetrics and Gynaecology; it also included midwives, physiotherapists and obstetricians.

The working group examined the hospital’s birth data to identify risk factors associated with severe tears. The group also conducted a literature review, which supported the findings from the hospital data analysis. They concluded that primiparity, operative deliveries, malposition and inappropriately performed episiotomies were significant risk factors for severe tears. 

The working group agreed on the following risk-reduction strategies identified from the literature:

• Promoting antenatal perineal massage from the third trimester
• Avoiding instrumental birth when possible
• Using vacuum instead of forceps when possible
• Applying warm compresses in the second stage of labour
• Controlling delivery of the head and shoulders 
• Performing episiotomies only when clinically indicated, and at a medio-lateral angle
• Avoiding the lithotomy position (lying on back, legs bent) when possible.

The working group held staff workshops every six months on preventing perineal tears. They also introduced a Reflection on Practice tool and a colleague debriefing process for practitioners involved in the care of women who sustained severe perineal tears

During the intervention period, the team posted progress reports on ward quality boards to show performance in rates of severe perineal trauma, as well as use of forceps, vacuum, and episiotomy.

The rate of women sustaining severe perineal tears during their first vaginal birth fell from 6.1% over the two years before the intervention to 3.9% in the two years after the intervention was introduced. Since then, there has been a further steady decline in the rates of the tears.

Rates of severe perineal tears continue to be reported routinely to:

• the Department’s Quality and Safety Committee
• the Divisional Quality and Safety Committee 
• monthly morbidity and mortality meetings
• the Hospital’s Executive – which also monitors the rates against the Health Roundtable data. 

Any deviation from the expected rate is examined and if rates increase, an audit is carried out and further review of practice is conducted. All cases of severe tears are also recorded in the hospital’s incident management system (Riskman).

To sustain the improvements, severe perineal trauma was added to the agenda of staff meetings and all cases were discussed at multidisciplinary meetings. The Quality and Safety Committee continues to review rates and discuss strategies to sustain the improvements.