WHA CEC Perineal Protection Bundle & How To Guide

The Perineal Protection Bundle

The US Institute for Healthcare Improvement (IHI) developed the concept of a Bundle to describe a collection of care elements needed to reliably deliver the best possible care and safety for patients [1],[2]. Bundles are effective in ensuring evidence based practices are consistently performed by all staff within a clinical service [1],[2]. Monitoring compliance with each component of the Bundle enables individual units to assess the impact of the Bundle within their unit and ensure changes are having the desired effect in improving care. 

To support services wanting to reduce their rates of harm from perineal tears using the Perineal Protection Bundle, A How to Guide has been developed. The guide describes the five components that form the WHA CEC Perineal Protection Bundle© that when implemented together, have been shown to reduce third and fourth degree perineal tears. 

Development of the WHA CEC Perineal Protection Bundle©

The Perineal Protection Bundle© was developed by an Expert Panel formed with representation from around Australia including midwives, obstetricians, urogynaecologists and consumer representatives.  The varied perspectives allowed for a diverse cross section of stakeholder issues to be taken into account.   

The expert panel met on two occasions to evaluate evidence to determine the care elements that could reliably reduce rates of harm from third and fourth degree tears. In addition to the quality of evidence, other factors were taken into account in the selection process including: 

- Acceptability of proposed elements of care to women

- Research evidence from current systematic reviews, source articles, best practice guidelines 

- The feasibility of implementation within Australian maternity services.  This was determined by on-site testing of the draft Bundle consecutively at 6 maternity hospitals in 3 different states, including a range of service types from tertiary to rural services.  

The final design of the Perineal Protection Bundle was based on pragmatic decisions about the best fit for the majority of stakeholders involved in informing the design. It is acknowledged that the skills and expertise of clinicians, both obstetricians and midwives, varies within and between hospitals and at different times of the day and night, depending on the seniority and experience of the practitioner. 

The Care Bundle was designed to support clinicians at 2 o’clock in the morning to reliably provide care to protect the woman from a severe perineal tear to the greatest extent possible.  We acknowledge that additional research may help to further reduce rates of perineal tears in the future.    

[1] Institute for Healthcare Improvement. Bundle up for safety (accessed 26 June 2017). Available via: http://www.ihi.org/resources/Pages/ImprovementStories/BundleUpforSafety.aspx

[2] Resar, R., Griffin, F. A., Haraden, C., & Nolan, T. W. (2012). Using care bundles to improve health care quality. IHI innovation series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.