Updated: August 2023
I’ve tried to avoid tackling this issue for months now but it won’t go away. It seems that the ‘bundle’ is one of the main topics of concern amongst midwives and students at the moment. So here goes – my answer to “what can we do about the bundle?”
Note: I am using the abbreviation SPT to refer to Severe Perineal Trauma ie. 3rd and 4th degree tears.
The WHA CEC Perineal Bundle©
Women’s Healthcare Australasia (WHA) is implementing a “range of initiatives to support members to achieve the highest possible standards of maternity & newborn care, including benchmarking, networking, and collaborative improvement projects.” One of the initiatives is a WHA National Collaborative Improvement Project aimed at “reducing by 20% the number of women harmed by a third or fourth degree tear [SPT] by the end of 2018”. This is much needed with rates of around 3-4% in some hospitals. The WHA state that: “Teams from twenty six maternity services… are participating. Teams are receiving regular coaching and support to reliably implement a bundle of evidence based practices known to reduce risk harm from tears.” A similar project is underway in the UK. However this post focuses on the Australian bundle.
The bundle has been rolled out in hospitals across Australia and has changed midwifery practice and the experience of birth for women. The bundle is not adequately supported by evidence and the WHA did not obtain ethical clearance for this experiment.
Before we go any further it is important to note what ‘controllable’ factors are known to increase the chance of severe perineal tearing (SPT) during birth according to research: hospital birth, particular positions (supine, lithotomy, squatting); directed pushing; syntocinon with multips; hands on for multips; and instrumental birth. See this post for more information, discussion and references about particular interventions. None of those evidence-based factors are included in the WHA bundle. In addition, in the leaflet provided to women about the bundle there is no mention of care provider / intervention factors, only those relating to the woman and her body (age, ethnicity, size of baby, etc.). Essentially, laying the blame for SPT on women and their malfunctioning bodies, rather than what care providers do to women. The leaflet also contains no references to support its statements.
Dahlen et al. (2015) comment on why interventions that cause of SPT have been ignored: “The cascade of intervention in hospital (induction of labour, epidural use, instrumental birth, episiotomy) as a probably cause of higher rates of [SPT] is often not considered in the obstetric discourse around this issue. Perhaps philosophical frameworks and deeply held beliefs around women’s bodies and capacity carry a greater weight at the end of the day than does scientific evidence. Perhaps it is ultimately through this lens of ‘belief’ around women and birth that we select the evidence [or not] that fits most comfortably within our paradigmatic positioning.”
I will address each of the 5 practices in the WHA perineal bundle:
1: Apply warm perineal compresses during the second stage of labour at the commencement of perineal stretching (for all women).
A Cochrane Review = “Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent”. It would be nice if it was worded a little differently ie. ‘offer all women…’ You can find more information about how to apply warm perineal compresses here. Unfortunately, anecdotal reports suggest that women are being told to get into a semi supine position (which increases tearing) so that the midwives can apply the compress and view the perineum.
2: With a spontaneous vaginal delivery [birth!], using gentle verbal guidance, to encourage a slow controlled birth of the fetal head and shoulders: a) support the perineum with the dominant hand; b) apply counter pressure on the fetal head with the non-dominant hand; c) if the shoulders do not delivery spontaneously, apply gentle traction to release the anterior shoulder; d) allow the posterior shoulder to be released following the curve of Carus.
Slow birth does reduce the chance of tearing and supporting physiology assists with this. However, ‘hands on’ does not reduce tearing according to a Cochrane Review. (best evidence). In addition, a recent study conducted in Australian hospitals found that ‘hands on’ made no difference for primips, and increased the chance of tearing for multips. The study concluded that: “A hands poised/undirected approach could be utilised in strategies for the prevention of moderate and severe perineal injury.” The ‘hands on’ recommendation also contradicts Queensland Health Normal Birth Guidelines which state that ‘hands on’ makes no difference to tearing and increases the chance of an episiotomy.
Of course there are always situation in which ‘hands on’ is appropriate. You can see me using hands on at this birth. However, ‘hands off’ ie. non-intervention should be default as per evidence and midwifery professional standards.
3: When episiotomy is indicated it should be performed: a) at crowning of the fetal head; b) using a medio-lateral incision; c) at a minimum 60 degree angle from the fourchette. NB. An episiotomy is indicated for all women requiring a forceps or vacuum assisted delivery having their first vaginal birth.
A hands on approach as dictated above increases the chance of the care provider carrying out an episiotomy (Aasheim et al. 2017); and the implementation of the bundle itself has caused a rise in rates (Thornton & Dahlen 2020). The type of episiotomy recommend is based on limited evidence and markets a particular type of scissor now shown to be ineffective in reducing SPT (Thornton & Dahlen 2020). However, midwives are being ‘up-skilled’ in how to cut women using these new (very expensive) scissors. One midwife reported that:
At my hospital the PPH rate went up rapidly when we got the new episcissors as they were like hot knives in butter and women were having buttectomies with them. They are sharp and dreadful with a flexible guide tail to ensure the correct angle is cut. Plus the training guide on them stops practitioners from using clinical judgement so there’s been some labial episiotomies by medical staff because the practitioners are not looking at the woman physiology but following the guide. – Anonymous (midwife)
An episiotomy wound is more painful and heals less well than a spontaneous tear. There is insufficient evidence to support claims that episiotomy reduces the chance of SPT. A mid-line episiotomy actually contributes to the risk of severe perineal trauma (Lappen & Gossett 2014). Whereas a medio-lateral episiotomy cuts through more nerves and perineal structures than mid-line (Patel et al. 2018). We are only just beginning to understand the complex anatomy of the clitoris , a structure that is cut during 60 degree episiotomy. It is not surprising that a medio-lateral episiotomy is associated “with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years” (Dogan et al. 2017).
In relation to episiotomies for instrumental birth, this is an obstetrician directed recommendation. I’m sure there are some OBs a bit miffed at being told to cut every woman during instrumental births rather than use their clinical judgement for individual women. I’ve worked with many OBs who are able to carry out a ventouse birth with an intact perineum. However, overall, instrumental birth does increase the risk of SPT. It is interesting that there is no recommendation to avoid adherence to non-evidence based timeframes for ‘progress’ that result in unnecessary instrumental births and perineal tearing (WHO).
4: Genito-anal examination following birth needs to: a) be performed by an experienced clinician; b) include a PR [rectal] examination on all women, including those with an intact perineum.
Rectal examination has always been part of assessing a perineal tear, particularly a 2nd degree tear. It is carried out to identify if the tear is a 3rd or 4th degree. If clinicians are missing 3rd / 4th degree tears then they need to be supported to improve their assessment of tears. The main issue with this recommendation is doing a rectal examination on a woman with an intact perineum. I have been unable to get any stats on the incidence of 3rd/4th degree tears with an intact vaginal wall. I have never seen this. I have heard rumours that it has happened. However, it must be extremely rare. Considering only around 1% of women having non-instrumental vaginal births have SPT, the proportion of those women who have a ‘hidden’ SPT must be less than 0. of a %. The incidence of this rare situation needs to be shared with women who have an intact perineum so that they can make an informed decision to consent to a rectal examination. Anyone with the stats – please share them! A blog post by Jim Thornton (an OB) about this invasive intervention concludes: “Routine rectal examination in the presence of an intact perineum fails all the criteria of a useful screening test. Most midwives wisely don’t do it. Those that do, should stop.”
5: All perineal trauma should be: a) graded according to the RCOG grading guideline; b) reviewed by a second experienced clinician to confirm the diagnosis and grading.
As midwives we are supposed to adhere to professional and legal standards. Our professional standards require us to be woman-centred, evidence-based and promote and support physiology (ICM; NMBA – Australia). The ICM position statement on the ‘appropriate use of intervention childbirth’ provides guidance about the use of intervention by midwives and states that: “Women have the right to make informed decisions about the use or non-use of intervention” and “urges midwives to only use or promote the use of intervention during childbirth when indicated.” The law requires us to gain consent for any proposed intervention, consent involves providing adequate information. The mother-midwife relationship requires that midwives share information with women and support their decisions. This is where midwives and students are struggling. Aspects of the bundle conflict with their professional responsibilities.
So back to the initial question “what can we do about the bundle”. The recommendations that are causing the most upset are the ‘hands on’ approach for all births, and the rectal examination with an intact perineum.
Suggestions re. ‘hands on’ for all births
- We could just refuse to comply with ‘hands on’ based on our professional and legal requirements for evidence-based care. Our professional and legal standards trump any workplace directive or employee contract. If all midwives supported each other in this stance practice would change.
- Ensure that women are given adequate information to consent to this intervention, preferably in the antenatal period so that their wishes can be clearly documented before labour. This information needs to include the fact that the intervention is not supported by evidence, may interfere with physiology, and for multips it may increase the chance of them tearing.
Suggestions re. rectal examination for intact perineum
- Demand the evidence to support this intervention ie. the incidence of 3rd / 4th degree tearing with an intact perineum. Without this we cannot…
- Ensure that women are given adequate information to consent. Including a statement along the lines of (after initial assessment of the perineum post birth): “Your perineum is intact and I can’t see any evidence of a tear. In rare circumstances (quantify here eg. 1: 1000) there is a tear in the rectum despite the perineum being intact. I can check your rectum for you if you’d like, or I can leave you to get on with x [feeding baby, etc.]. What would you like me to do?”
We could also use the bundle as an opportunity to get back to basics (woman-centred, evidence-based care) and reclaim midwifery as an autonomous profession (ICM). It is about time that midwives said ‘enough’ to the bombardment of non-evidence based medicalisation of birth. Solidarity (with each other and women) and activism is long overdue in maternity care.
Update – Backlash to this post by WHA (2018)
Since the publication of this post WHA have publicly challenged my critic of the bundle. Below is a record of this ‘debate’:
Media Release from WHA (May 2018)
In May WHA responded to this blog post with a public media release . The media release later required a log-in (transparency is not on the agenda of WHA). Essentially, the media release re-iterated the intention of WHA to improve outcomes. It did not provide any evidence for the bundle or address any of the issues I raised. It did state that financial penalties for hospital have been removed for 3rd and 4th degree tears. However, these penalties are being implemented, reinforcing the rise in episiotomies as there is no fine for cutting rates. I responded to WHA with the questions below, which remain unanswered:
- Which members of the expert panel had the final say regarding which interventions were included in the bundle? Were all of the experts in agreement about the final bundle?
- Could WHA provide a statement from the consumers involved that they approved the final bundle; and provide information about whether consumers withdrew from the working party (and what proportion withdrew)?
- WHA state that they are “happy to share any of the evidence reviewed by the expert panel in the development of the bundle”. Could you please share the evidence relating to a ‘hands on’ approach for all women during birth, and explain why this recommendation contradicts the QH Normal Birth guidelines.
- Why were other evidence-based approaches that align with clinical guidelines not included in the bundle eg. spontaneous pushing, encouraging/discouraging particular birthing positions?
- Will WHA monitor episiotomy rates during this intervention. Anecdotally midwives and students are reporting increased use of episiotomy during normal birth, particularly for primips.
- Could WHA provide an estimated risk of a 3rd/4th degree tears WITH AN INTACT PERINEUM. Gaining consent for a rectal examination with an intact perineum is problematic without adequate information.
Readers please email WHA (firstname.lastname@example.org) with your concerns and experiences relating to the bundle. It is important that WHA are made aware of how the bundle is impacting on the care of women in the clinical setting.
In December 2018 WHA made the media release about this post public again due to ‘ongoing interest’ (see comment below by ‘Adele’ ? WHA). The comment also provides a link to a promotional video of various professionals marketing the bundle. A very different perspective to the one I am hearing from practitioners on the ‘shop floor’! The media release has since been removed from the website again. Unfortunately WHA have still not answered the questions posed above.
Update – Celebration? (August 2020)
The WHA bundle is firmly established as routine care in many hospitals across Australia. The website spins the narrative of damaged women (with heart-wrenching personal stories of SPT) and the hero care providers who can use their special powers (interventions) to save these women. The webpage (no longer available) titled ‘Celebrating Success’ provides scant information about outcomes and raises more questions that answers:
- No methodology is provided so the reader cannot determine if the findings are valid.
- WHA claim they are working on peer reviewed journal articles to present the full findings. However, there is no evidence of ethical approval for their ‘experiment’ and you cannot publish in any decent journal without ethics.
- Very limited findings (claims) are presented and there is no public access to the full report.
- The claims of reduced SPT are not placed into context, therefore are meaningless. For example, the claim of an 11% reduction of SPT for women having a spontaneous vaginal birth… 11% of what? The rate of SPT for this group of women in Australia was 2.5% in 2015 (Wilson & Homer 2020). So, if the bundle reduced that rate by 11% it amounted to a 0.25% reduction ie. to a rate of 2.25%.
- Most importantly, there is no data shared about the episiotomy rates post bundle implementation. Why? They most certainly will have collected this data. Episiotomy is perineal damage and needs to be included in any evaluation of a bundle aimed at reducing perineal damage.
I am unsure what exactly WHA are celebrating. Even if we accept their unsubstantiated statistics, the bundle has reduced the SPT by less than half a % while most likely significantly increasing the rates of episiotomy trauma. The bundle has significantly changed midwifery practice, back towards routine intervention during birth and liberal cutting of women. I don’t see how that is any cause for celebration.
Research into the effectiveness of the bundle
Quantitative research is being published that reports a small reduction in SPT with the implementation of the bundle. Borrman et al. 2019 carried out an observational study comparing outcomes before the implmentation of the bundle with afterwards in an Australian hospital. They reported that SPT reduced by 26% during spontaneous birth (stats include induction and epidurals). The article does not provide details about what 26% represents ie. from what % to what %. However, the article does reported a 40% increase in the episiotomy rates during spontaneous birth (7.4% to 10.4%). A large UK-based quantitative study reported that the bundle reduced SPT (3.3% to 3.0%) without increasing the use of episiotomy (Gurol-Urganci 2020). This study is currently the ‘best available’ quantitative research about the impact of the perineal bundle within a medicalised birth setting. However, Scamell et al. 2021 wrote the journal that published the study to voice their disappointment on the quality of the evidence. They raise a number of concerns: 1) The selective nature of the evidence quoted, undermines the credibility of inferences that can be made from the findings. 2. The failure to account for the surprisingly small positive effect of the care bundle compared with the Scandinavian studies they quote. 3. The lack of evidence regarding informed consent for the women subjected to the bundle and no consideration of their experience. They conclude that “we are not only disappointed with the BJOG article but with the professional stake- holder investment in the intervention which seems to have been widely and uncritically supported, with some support even being somewhat evangelical, despite the limited evidence for support.”
I agree with Scamell et at., we need some good quality research into the impact of the intervention on women’s birth experiences. We also need to acknowledge that the research being carried out can only tell us about medicalised birth in hospital settings. We do not have research into outcomes for women having spontaneous, unmedicated and undisturbed physiological births. Therefore, we cannot apply research findings to this group of women.
Update – Research about the impact of the bundle on women and midwives (April 2023)
Here we are five years after the widespread roll out of the perineal bundle, and still do not have good quality evidence that the bundle reduces the rates of SPT. However, we have good quality evidence about the impact of the bundle on women and midwives.
The impact of the bundle on women’s experiences of birth
Barnett et al. 2023 carried out a qualitative study exploring how the introduction of the perineal bundle impacted women’s birth experiences in Queensland (Australia) maternity hospitals. What they found will not surprise to anyone familiar with maternity service culture and practice. Women reported that they received a lack of information about the bundle elements. Interventions were carried out without consent and some women reported disrespectful treatment.
One woman described the midwife putting her ‘hands on’ despite being asked not to. The midwife refused to stop and said “No, I have to do this”. The woman was a sexual assault survivor and experiences a ‘freeze’ response as she experience the midwife’s treatment as abuse.
Midwives assumed that because women had consented to a post-birth perineal assessment, they had also agreed to a rectal examination. One woman described her experience of having a rectal examination by an obstetrician who walked into the room without introducing herself “It was a bit shocking, because I wasn’t pre-warned, so I didn’t know. And all of a sudden I was like “Woah, what the hell’s going on?”. … Then I asked her to stop. She got a bit cranky. And then really didn’t say any- thing else to me. And when she was finished she got up and walked out.”
The researchers concluded: “While the intention of the bundle was for women’s benefit, in practice its implementation appears to have condoned clinicians’ compliance to the detriment of supporting childbearing women’s decision-making autonomy. In some respects, the unintended negative consequences for women were largely foreseeable, given the broader maternity services culture within which the bundle was implemented.”
The impact of the bundle on midwifery practice
Another Australian qualitative study explored how the perineal bundle impacted midwifery practice in an Australian maternity hospital (Allen et al. 2021). They found that midwives were told to carry out the bundle without being provided with evidence to support the interventions. Midwives were subjected to surveillance to ensure they complied with the bundle and they responded with “obedience, subversion or compliance“. The midwives in the study noted that the bundle was much easier to carry out with the woman supine and on the bed. This conflicted with their promotion of upright, active birth positions.
The researchers concluded: “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.”
Update – Research on outcomes (August 2023)
Cast your mind back to 2018 when the perineal bundle was implemented without research. At that time elements of the bundle were known to increase the chance of episiotomy for women having their first baby, and perineal tearing for women who had previously given birth.
Five years after the roll out of this intervention package, we have research into the outcomes. This research was not carried out by the WHA, who seem to have moved on from this, job done. The study compared outcomes before and after the implementation of the bundle into Australian hospitals (Lee et al. 2023). The findings reflect what was known before the bundle was rolled out. That the bundle:
“…did not result in a significant reduction in the likelihood of women experiencing a SPT, but did increase the probability of receiving an episiotomy in nulliparous women and second degree trauma in multiparous women.”
The researchers also state: “Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern.”
Whilst this study validates those of us who were shouting about it at the time, I doubt anything will change. Just like all the other interventions implemented without evidence that continue despite evidence.
In summary, the perineal bundle has become a cultural norm in many maternity settings. This was inevitable because the bundle aligns with the philosophical underpinnings of the maternity system. Women’s bodies are dangerous and need to be managed and controlled to reduce risk. Medical experts and their technology and techniques provide safety. However, carrying out routine interventions during birth prevents care providers from observing and learning about physiological birth. With very low rates of physiological births occurring within institutions, research is carried out on medicalised births. Therefore, any outcomes cannot tell us about the impact of interventions on physiological births. The bundle is here to stay because it meets the needs of the maternity system.
- Perineal Bungles (The Midwives’ Cauldron Podcast)
- Protecting Your Perineum – Birthful Podcast
- Severe perineal trauma is rising, but let us not overreact – Dahlen et al. 2015
- The UK obstetric anal sphincter injury (OASI) care bundle: a critical review – Thornton & Dahlen 2020
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