Updated: December 2018
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?”
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 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.” Unfortunately, the WHA webpage does not describe what the ‘evidence based practices’ are. and the page specific to the bundle also requires a log-in (not very transparent). 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 is significantly changing midwifery practice and the experience of birth. 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 increase the chance of perineal trauma during birth according to research (see this post for more info and refs): particular positions (supine, lithotomy, squatting); directed pushing; syntocinon particularly with multips; hands on for multips; and instrumental birth. None of these factors are included in the bundle.
I will address each of the 5 ‘evidence based practices’ in the 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 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 – supporting physiology assists with this. However, ‘hands on’ does not reduce tearing according to the 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. 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 midwifery 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.
An episiotomy wound is more painful and heals less well than a spontaneous tear. A midline episiotomy contributes to the risk of severe perineal trauma (Lappen & Gossett 2014). A medio-lateral episiotomy cuts through more nerves and perineal structures than mid line (Patel et al. 2018). tissues. 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). The rising rate of episiotomy – in part fuelled by this bundle – needs to be carefully reviewed in relation to long term outcomes for women. Unfortunately, in some hospital settings midwives are being told that the episiotomy rate is too low and education sessions have been implemented to ‘up-skill’ midwives in cutting women along with expensive new equipment to do the job.
In relation to 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 do a ventouse with an intact perineum. However, instrumental birth does increase the risk of 3rd/4th degree tearing. It is interesting that there is no recommendation to avoid adherence to non-evidence based timeframes for ‘progress’ that result in unnecessary instrument 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 – to identify if it 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. 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. ‘hand’s 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, 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 – Media Release from WHA (May 2018)
In May WHA responded to this blog post with a public media release. The media release now requires 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. It is the rectal examination with an intact perineum that is problematic re. informed consent.
Readers – please email WHA (email@example.com) 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.
Update (December 2018)
WHA have 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’! Unfortunately WHA have still not answered the questions posed above.
WHA also provide an update on progress. The update is rather brief and in places misleading, for example:
- The compliance rate ie. practitioners carrying out the bundle = 17%: There is no critical analysis about why the compliance rate is so low. Is it because midwives and doctors are unhappy with the bundle and/or women are not consenting?
- Since the time the bundle was introduced 3rd/4th degree tear rates fell by 25%:
- This cannot be considered a causal relationship ie. that the bundle caused the reduced rate. It can barely be called an association considering the low compliance rate (see this post for more about research reporting bias).
- The initial rates of 3/4 degree tearing were 6.4% across instrumental and no-instrumental vaginal births. Therefore, a 25% reduction in this rate = 1.6% ie. a reduction from 6.4% to 4.8%.
- The update declares a 30% reduction in 3/4 degree tearing for spontaneous vaginal births. Sounds great… but what were the initial rates for this group? The update only provides the combined rates of 6.4%. As instrumental birth significantly increases the chance of 3/4 degree tearing the rates for spontaneous birth would likely be much lower. Therefore 30% in real terms may be less than 1%.
- Most importantly, there is no data shared about the episiotomy rates post bundle implementation. Why? They most certainly will have collected this data. Anecdotally the rates are rising. Episiotomy is perineal damage and needs to be included in any evaluation of a bundle aimed at reducing perineal damage.
- How will this data be published in a peer reviewed publication? In order to publish research in a journal you need to demonstrate you have obtained research ethical approval from a board. I can find no evidence that this project has ethical clearance.
Severe perineal trauma is rising, but let us not overreact – Dahlen et al. 2015
Protecting Your Perineum – Birthful Podcast (Rachel Reed)