How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice

Abstract

BackgroundThe accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.MethodsA descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.Results405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.ConclusionsThere are considerable gaps with implementation of evidence to support management of perineal trauma.

Care in a birth center according to the recommendations of the World Health Organization

“…The difficulty surrounding the incorporation of evidence-based guidelines into clinical practice is not only evident with the persistent use of episiotomy, but is also seen in the management of perineal trauma. This phenomenon was highlighted in a cross-sectional study of British midwives who reported difficulties identifying and repairing perineal trauma (26) .…”

Implementação de práticas assistenciais para prevenção e reparo do trauma perineal no parto

“…A study (6) published in 2012 focused on the inadequate classification of perineal trauma among professionals because the anatomical variables of the vulvoperineal region may interfere with this classification, especially in the case of third and fourth-degree lacerations, which are generally underestimated. The classification of perineal trauma has been proposed and accepted internationally, as follows: first-degree trauma (involves skin and mucosa), second-degree trauma (includes perineal muscles), third-degree trauma (involves the anal sphincter and is subclassified into 3a: damage to less than 50% of the external anal sphincter; 3b: damage to more than 50% of the external anal sphincter; 3c: damage to the entire internal and external anal sphincter and fourth-degree trauma (affects the anal epithelium) (9) .…”

“…Thus, after the generation, synthesis and transfer of evidence, evidence-based practices are implemented through the assessment of their impact on the healthcare process (2) . Over the past decades, research in maternal health has sought solutions to various problems, such as perineal trauma, defined as any damage to the genitalia during childbirth that occurs by spontaneous laceration or intentionally by surgical incision (episiotomy) (6) . It is estimated that approximately 70% of women having vaginal birth sustain some sort of perineal trauma, and three quarters of them will require suturing (7) .…”

Association between perineal trauma and pain in primiparous women

“…Only midwives with 20 years or more of experience and those with higher levels of qualification were more likely to implement evidencebased recommendations and felt more confident about perineal care (30) .…”