Response to Rachel Reed ' The Perineal Bundle Midwifery'

Women’s Healthcare Australasia would like to thank Dr Rachel Reed’s for her blog “What can we do about the Bundle”, outlining current work being undertaken by WHA and participating hospitals to reduce rates of third and fourth degree perineal tears in Australia.   WHA welcomes midwives’ interest in reducing the numbers of women in Australia affected each year whose health and wellbeing is affected by the harms associated with third & fourth degree perineal tears. 

WHA is employing an internationally proven methodology for achieving improvement in healthcare to assist 28 hospitals in 5 states to reduce their rate of perineal tears by 20% by the end of 2018.  Guided by the Institute for Healthcare Improvement, which has facilitated measurable improvements in outcomes for patients globally over the past 2 decades, WHA has taken a methodical and scientific approach to this collaborative, with the primary objective of reducing the numbers of women whose lives and families are affected by severe perineal tears. 

The Bundle as outlined by Dr Reed was formed by a 15 member expert panel with representation from experts around Australia including midwives, obstetricians, urogynaecologists as well as consumer representatives from 4 states. The panel met on two occasions to evaluate evidence from current systematic reviews, source articles and best practice methodology to determine the interventions that could reliably reduce rates of third and fourth degree tears. A consensus process was used to agree on the final interventions selected for inclusion and measurement tools that would be used. In addition to the quality of evidence, other factors were taken into account in the selection process including the acceptability of the interventions for women and the feasibility of their use for clinicians.

The involvement of women in the development of the Bundle and the Collaborative  was very important to ensure that the components of the bundle would be acceptable to  women.  Implicit with all of the interventions, is the consent of the women.  WHA involved consumers in many aspects of planning and development. Their feedback was particularly valuable in the development of the bundle; educational resources; the Information sheet for women; and the development of the evaluation framework.

A key component of the Collaborative is engagement with women. To this end, participating teams have been provided with an information sheet for women which aims to encourage a shared decision making model, informing women about their risk of a tear and what can be done to reduce their chance of experiencing a third or fourth degree tear.   The content within the information sheet was provided entirely by women with experience of perineal tears and/or with links to women with this experience. This antenatal discussion with women aims to introduce preventative strategies and allow women time to make informed decisions about the different elements of the bundle.  We believe this represents the best opportunity for our women to provide informed consent at the time of their labour and birth.

With regard to the evidence around the element of the bundle on offering a PR examination to all women, the WHA is happy to share any of the evidence reviewed by the expert panel in the development of the bundle including material by International Keynote speaker Dr Dharmesh Kapoor, who delivered two world class presentations on the history, current evidence and best practice in the Management of Perineal Trauma . Although the exact risk of missing a tear is not known, as highlighted by Dr Reed, the significant impact that a missed tear can have on a woman reinforces the importance of this recommendation for all women.  We share the unwavering principle that all decisions made, and consent subsequently obtained, should be fully informed. Women have the right to decline any examination if that is their preference. 

One final matter required clarification in relation to the suggestion that hospitals are financially penalised for third and fourth degree tears.  When this issue was under consideration in 2016, WHA strongly advocated on behalf of member hospitals against the inclusion of financial penalties for perineal tears. While third and fourth degree tears remain on a national list of Hospital Acquired Complications (HACs) developed by the Australian Commission on Safety & Quality in Healthcare, they have not been included by the Independent Hospital Pricing Authority in its pricing penalties policy for HACs.  This means that there is no financial disincentive for hospitals to appropriately report third & fourth degree tears. 

WHA’s vision is to enhance the health and wellbeing of women and babies by supporting maternity hospitals and health care services in Australia to achieve excellence in clinical care of women and newborns.   WHA strives for open collaboration and best practice between all professionals involved in the provision of maternity health within the Australian healthcare system.   We understand the unique circumstances and challenges that midwives face within the maternity services environment, and continue to support improvement and evidence based care leading to better outcomes for patients and their carers.

WHA welcomes comments and feedback and can be messaged directly via email: admin2018@wcha.asn.au