The OASI care bundle quality improvement project: lessons learned and future direction

Rising rates of obstetric anal sphincter injury (OASI) led to a collaborative effort by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) to develop and evaluate the OASI Care Bundle (OASI-CB). The OASI-CB comprises four practices (antenatal discussion about OASI, manual perineal protection, mediolateral episiotomy at 60° from the midline, and systematic examination of the perineum, vagina and ano-rectum after vaginal birth) and was initially implemented as part of a quality improvement (QI) project—“OASI1”—in 16 maternity units across Great Britain. Evaluation of the OASI1 project found that the care bundle reduced OASI rates and identified several barriers and enablers to implementation. This paper summarises the key findings, including strengths, limitations and lessons learned from the OASI1 QI project, and provides rationale for further evaluation of the OASI-CB.

Women’s experiences of the OASI Care Bundle; a package of care to reduce severe perineal trauma

Introduction and hypothesis Obstetric anal sphincter injury (OASI) is a severe form of perineal trauma that can occur during vaginal birth. Long-term morbidities include anal incontinence and psychosocial disorders. To reduce these injuries within England, Scotland and Wales, the OASI Care Bundle was introduced to 16 maternity units (January 2017–March 2018). The OASI Care Bundle comprises four elements: (1) antenatal information, (2) manual perineal protection, (3) medio-lateral episiotomy (when indicated) and 4) recognition and diagnosis of tears. As part of the project evaluation, a qualitative study was conducted to explore women’s experiences of the OASI Care Bundle. Methods Semi-structured interviews were conducted with women (n = 19) who received the OASI Care Bundle as part of their maternity care. This was to explore their experience of each element. A thematic analysis of the interview data was performed. Results Three themes were identified: (1) memories of touch, whereby women reported that a ‘hands-on’ approach to perineal protection was a positive experience; (2) midwife as a supportive guide, where women reported that good communication facilitated a calm birth and post-birth diagnosis; (3) education: women need more information about perineal trauma. Conclusion This study contributes to the literature through its exploration of women’s experiences of perineal protection techniques and diagnosis of perineal trauma. Interviewed women indicated that they did not experience any of the care bundle elements as an intrusion of their physical integrity. Additionally, an urgent need was identified for more information about perineal trauma in terms of risk, prevention and recovery.

Metrics of perineal support (MOPS) study

Background: Manual perineal protection (MPP) is an intrapartum intervention suggested to protect perineal integrity during childbirth. Proper execution of MPP is complex and evaluation of its true contribution is difficult in the clinical setting because of the large number of obstetric variables, some of which are hardly quantifiable. In this study we aimed to gather initial data on the forces executed by the accoucheur's thumb, index and middle fingers during MPP at the time of fetal head expulsion, quantify the duration of the intervention and investigate the timely interaction of the different components of MPP.Methods: Two bespoke right-handed measurement gloves (MG), with built in sensors, were designed and produced. The MG allowed the electronic real-time measurement of applied forces during MPP and transferred this data wirelessly to an integrated computer system. Sterile gloves were worn over the MG when used at the time of birth. The study was undertaken between January and December 2019. Singleton, term pregnant women having their first vaginal birth who provided a valid written consent were enrolled into this prospective pilot study. All deliveries were undertaken by one of two obstetricians experienced in MPP Results: Twenty women were enrolled. The mean duration of execution of MPP during the last contraction was 13.6s. In 20% it lasted <5s. The overall mean values of the average and maximum forces of the thumb, index and middle fingers were 26.7 N; 25.5 N; 20.2 N and 34.3 N; 32.6 N; and 27.6 N respectively. The onset of fingers and thumb activity was simultaneous in 13 cases (65%), while in seven (35%) deliveries the middle finger's force activity was initiated later. Conclusions: MPP during fetal head expulsion happens over a short period of time. In the majority of cases the thumb and fingers actions started simultaneously. There were differences in the duration of application and the forces executed by the fingers and thumb between the two practitioners, however this was only significant for thumb measurements. The results obtained will aid in improving further MPP modeling studies to optimize the technique.

Metrics of Perineal Support (MOPS) Study

Background: Manual perineal protection (MPP) is an intrapartum intervention suggested to protect perineal integrity during childbirth. Proper execution of MPP is complex and evaluation of its true contribution is difficult in the clinical setting because of the large number of obstetric variables, some of which are hardly quantifiable. In this study we aimed to gather initial data on the forces executed by the accoucheur's thumb, index and middle fingers during MPP at the time of fetal head expulsion, quantify the duration of the intervention and investigate the timely interaction of the different components of MPP.Methods: Two bespoke right-handed measurement gloves (MG), with built in sensors, were designed and produced. The MG allowed the electronic real-time measurement of applied forces during MPP and transferred this data wirelessly to an integrated computer system. Sterile gloves were worn over the MG when used at the time of birth. The study was undertaken between January and December 2019. Singleton, term pregnant women having their first vaginal birth who provided a valid written consent were enrolled into this prospective pilot study. All deliveries were undertaken by one of two obstetricians experienced in MPPResults: Twenty women were enrolled. The mean duration of execution of MPP during the last contraction was 13.6 s. In 20% it lasted < 5 s. The overall means of the mean and maximum forces of the thumb, index and middle fingers were 26.7 N; 25.5 N; 20.2 N and 34.3 N; 32.6 N; and 27.6 N respectively. The onset of fingers and thumb activity was simultaneous in 13 cases (65%), while in seven (35%) deliveries the middle finger's force activity was initiated later.Conclusions: MPP during fetal head expulsion happens over a short period of time. In the majority of cases the thumb and fingers actions started simultaneously. There were differences in the duration of application and the forces executed by the fingers and thumb between the two practitioners, however this was only significant for thumb measurements. The results obtained will aid in improving further MPP modeling studies to optimize the technique.