This post began in 2018 in response to concerns amongst midwives and students about the implementation of a 'bundle' of practices aimed at reducing severe perineal trauma during birth. I kept getting asked "what can we do about the bundle?". Since then, the bundle has become common practice in Australian hospitals and around the globe in various guises. This post now serves as a record of how we ended up intervening in all women's births without evidence to support doing so. It also documents the personal backlash I received from the WHA when I first published the post. Although the content is focused on the Australian perineal bundle, it is also applicable to versions in other countries.

Note: I am using the abbreviation SPT to refer to Severe Perineal Trauma, ie, 3rd and 4th degree tears. The term OASI (obstetric anal sphincter injury) is also used in relation to this topic. 

The WHA CEC Perineal Bundle©

Women's Healthcare Australasia (WHA) has implemented 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 was a WHA National Collaborative Improvement Project aimed at "reducing by 20% the number of women harmed by a third or fourth degree tear [SPT] by the end of 2018". This is much needed with rates of around 3-4% in some hospitals. The WHA stated 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."

The bundle has been rolled out in hospitals across Australia and has changed midwifery practice and women's birth experiences. However, 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 are known to increase the chance of severe perineal tearing (SPT) during birth according to research: hospital birth, particular positions (supine, lithotomy, squatting); directed pushing; syntocinon with multips; hands on for multips; and instrumental birth. See this post for more information, discussion and references about particular interventions. None of those evidence-based factors are included in the WHA bundle. In addition, in the leaflet provided to women about the bundle there is no mention of care provider/intervention factors, only those relating to the woman and her body (age, ethnicity, size of baby, etc.). Essentially, laying the blame for SPT on women and their malfunctioning bodies, rather than what care providers do to women. The leaflet also contains no references to support its statements.

Dahlen et al. (2015) commented on why interventions that cause of SPT have been ignored [1]: "The cascade of intervention in hospital (induction of labour, epidural use, instrumental birth, episiotomy) as a probably cause of higher rates of [SPT] is often not considered in the obstetric discourse around this issue. Perhaps philosophical frameworks and deeply held beliefs around women's bodies and capacity carry a greater weight at the end of the day than does scientific evidence. Perhaps it is ultimately through this lens of 'belief' around women and birth that we select the evidence [or not] that fits most comfortably within our paradigmatic positioning."

I will address each of the five practices in the WHA perineal bundle:

1: Apply warm perineal compresses during the second stage of labour at the commencement of perineal stretching (for all women).

A Cochrane Review [2] found that: "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 the WHA recommendation were worded a little differently, ie 'offer all women...'. Unfortunately, anecdotal reports suggest that women are being told to get into a semi supine position (which increases tearing) so that the midwives can apply the compress and view their 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 reduces the chance of tearing, and supporting physiology assists with this. However, 'hands on' does not reduce tearing according to a Cochrane Review [2]. In addition, a study conducted in Australian hospitals found that 'hands on' made no difference for primips, and increased the chance of tearing for multips [3]. The study concluded that: "A hands poised/undirected approach could be utilised in strategies for the prevention of moderate and severe perineal injury."

Of course, there are always situations in which 'hands-on' is appropriate (e.g., you can see me using hands-on at this birth). However, 'hands-off', i.e., non-intervention, should be the default.

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.

A hands-on approach as dictated above increases the chance of the care provider carrying out an episiotomy [2]; and the implementation of the bundle itself has caused a rise in episiotomy rates [4]. The type of episiotomy recommended is based on limited evidence and markets a particular type of scissor now shown to be ineffective in reducing SPT [4]. However, midwives are being 'up-skilled' in how to cut women using these new (very expensive) scissors. One midwife reported that:

At my hospital the PPH rate went up rapidly when we got the new episcissors as they were like hot knives in butter and women were having buttectomies with them. They are sharp and dreadful with a flexible guide tail to ensure the correct angle is cut. Plus the training guide on them stops practitioners from using clinical judgement, so there’s been some labial episiotomies by medical staff because the practitioners are not looking at the woman's physiology, but following the guide. - Anonymous (midwife)

An episiotomy wound is more painful and heals less well than a spontaneous tear. There is insufficient evidence to support claims that episiotomy reduces the chance of SPT. A mid-line episiotomy actually contributes to the risk of severe perineal trauma [5]. Whereas a medio-lateral episiotomy cuts through more nerves and perineal structures than mid-line [6]. These nerves contribute to sexual sensations. We are also only just beginning to understand the complex structure of the clitoris [7], a structure that is more likely to be damaged during a 60 degree episiotomy. It is not surprising that a medio-lateral episiotomies are associated "with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years" [8].

In relation to episiotomies for 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 carry out a ventouse birth with an intact perineum. However, overall, instrumental birth does increase the risk of SPT. Interestingly, there is no recommendation to avoid adherence to non-evidence based timeframes for 'progress' that result in unnecessary instrumental births and perineal tearing.

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. It is carried out to identify if the tear 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 personally seen this in practice. I have heard rumours that it has happened. However, it must be extremely rare. Considering only around 1% of women having non-instrumental vaginal births have SPT, the proportion of those women who have a 'hidden' SPT must be less than 0. something of a %. 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 [9]: "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.

Yep. I agree with this recommendation. However, I'm not sure why a second practitioner needs to be involved if the initial practitioner is experienced and the tear is easy to diagnose. I'm sure the woman would rather have fewer people examine her than more. This is also not practical in many cases, such as homebirth.

Midwifery Practice

Midwives are supposed to adhere to professional and legal standards. Their professional standards require them to be woman-centred, evidence-based and promote and support physiology. The law also requires them 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, because 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. 'hands on' for all births

• Midwives could refuse to comply with 'hands-on' based on their professional and legal requirements for evidence-based care. Midwifery professional and legal standards trump any workplace directive or employee contract. If all midwives supported each other in this stance, practice would change.

and/or

• 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, may interfere with physiology, and for multips it may increase the chance of them tearing.

Suggestions re. rectal examination for intact perineum

• Demand evidence to support this intervention, ie, what is 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 return to the basics (woman-centred, evidence-based care) and reclaim midwifery as an autonomous profession. 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 are long overdue in maternity care.

Updates – post implementation of the bundle

The following are updates to the post added in the years following the implementation of the perineal bundle into practice.

Backlash to this post by WHA (2018)

In May WHA responded to this blog post with a public media release titled Media Release - Response to Rachel Reed 'The Perineal Bundle Midwifery. The media release later required a log-in (transparency is not on the agenda of WHA) so the public is unable to read it. 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 hospitals 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. Gaining consent for a rectal examination with an intact perineum is problematic without adequate information.

Unfortunately, WHA have still not answered the questions posed above.

WHA Celebration? (August 2020)

The WHA bundle is firmly established as routine care in many hospitals across Australia. The website spins the narrative of damaged women (with heart-wrenching personal stories of SPT) and the hero care providers who can use their special powers (interventions) to save these women. The webpage (no longer available) titled Celebrating Success provided scant information about outcomes and raised more questions than answers:

• No methodology is provided so the reader cannot determine if the findings are valid.
• WHA claims they are working on peer-reviewed journal articles to present the full findings. However, there is no evidence of ethical approval for their 'experiment,' and ethical approval is required before publishing in any decent journal.
• Very limited findings (claims) are presented and there is no public access to the full report.
• The claims of reduced SPT are not placed into context and, therefore, are meaningless. For example, the claim of an 11% reduction of SPT for women having a spontaneous vaginal birth, 11% of what? The rate of SPT for this group of women in Australia was 2.5% before the bundle was implemented [11]. So, if the bundle reduced that rate by 11%, it amounted to a 0.25% reduction, i.e., a rate of 2.25% rather than 2.5%
• Most importantly, no data about the episiotomy rates post bundle implementation has been shared. Why? They most certainly will have collected this data. Episiotomy is perineal damage and needs to be included in any evaluation of a bundle aimed at reducing perineal damage.

I am unsure what exactly WHA are celebrating. Even if we accept their unsubstantiated statistics, the bundle has reduced the SPT by less than half a % while most likely significantly increasing the rates of episiotomy trauma. The bundle has significantly changed midwifery practice, back towards routine intervention during birth and liberal cutting of women. I don't see how that is any cause for celebration.

Research into the effectiveness of the bundle

Quantitative research has being published that reports a small reduction in SPT with the implementation of the bundle. Borrman et al. carried out an observational study comparing outcomes before the implementation of the bundle with afterwards in an Australian hospital [11]. They reported that SPT reduced by 26% during spontaneous birth (stats include induction and epidurals). The article does not provide details about what 26% represents, ie, from what % to what %. However, the article does report a 40% increase in the episiotomy rates during spontaneous birth (7.4% to 10.4%). A large UK-based quantitative study reported that the bundle reduced SPT (3.3% to 3.0%) without increasing the use of episiotomy [12]. This study is currently the 'best available' quantitative research about the impact of the perineal bundle within a medicalised birth setting. However, Scamell et al. wrote to the journal that published the study to voice their disappointment on the quality of the evidence [13]. They raise a number of concerns: 1) The selective nature of the evidence quoted, undermines the credibility of inferences that can be made from the findings. 2. The failure to account for the surprisingly small positive effect of the care bundle compared with the Scandinavian studies they quote. 3. The lack of evidence regarding informed consent for the women subjected to the bundle and no consideration of their experience. They conclude that "we are not only disappointed with the BJOG article but with the professional stake-holder investment in the intervention which seems to have been widely and uncritically supported, with some support even being somewhat evangelical, despite the limited evidence for support."

I agree with Scamell et al., we need some good quality research into the impact of the intervention on women's birth experiences. We also need to acknowledge that the research being carried out can only tell us about medicalised birth in hospital settings. We do not have research into outcomes for women having spontaneous, unmedicated and undisturbed physiological births. Therefore, we cannot apply research findings to this group of women.

Research about the impact of the bundle on women and midwives (April 2023)

Five years after the widespread rollout of the perineal bundle, there is still no good quality evidence that the bundle reduces the rates of SPT. However, we have good quality evidence about the impact of the bundle on women and midwives.

The impact of the bundle on women's experiences of birth

Barnett et al. carried out a qualitative study exploring how the introduction of the perineal bundle impacted women's birth experiences in Queensland (Australia) maternity hospitals [14]. What they found will not surprise to anyone familiar with maternity service culture and practice. Women reported that they received a lack of information about the bundle elements. Interventions were carried out without consent and some women reported disrespectful treatment.

One woman described the midwife putting her 'hands on' despite being asked not to. The midwife refused to stop and said "No, I have to do this". The woman was a sexual assault survivor and experienced a 'freeze' response as she experienced the midwife's treatment as abuse.

Midwives assumed that because women had consented to a post-birth perineal assessment, they had also agreed to a rectal examination. One woman described her experience of having a rectal examination by an obstetrician who walked into the room without introducing herself, "It was a bit shocking, because I wasn’t pre-warned, so I didn’t know. And all of a sudden I was like “Woah, what the hell’s going on?”. ... Then I asked her to stop. She got a bit cranky. And then really didn’t say anything else to me. And when she was finished she got up and walked out."

The researchers concluded: "While the intention of the bundle was for women’s benefit, in practice its implementation appears to have condoned clinicians’ compliance to the detriment of supporting childbearing women’s decision-making autonomy. In some respects, the unintended negative consequences for women were largely foreseeable, given the broader maternity services culture within which the bundle was implemented."

The impact of the bundle on midwifery practice

Another Australian qualitative study explored how the perineal bundle impacted midwifery practice in an Australian maternity hospital [15]. They found that midwives were told to carry out the bundle without being provided with evidence to support the interventions. Midwives were subjected to surveillance to ensure they complied with the bundle and they responded with "obedience, subversion or compliance". The midwives in the study noted that the bundle was much easier to carry out with the woman supine and on the bed. This conflicted with their promotion of upright, active birth positions.

The researchers concluded: "The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy – women’s and their own – by using clinical judgement, evidence, and woman-centred care."

Research on outcomes (August 2023)

Cast your mind back to 2018 when the perineal bundle was implemented without research. At that time elements of the bundle were known to increase the chance of episiotomy for women having their first baby, and perineal tearing for women who had previously given birth.

Five years after the rollout of this intervention package, we have research about the outcomes. This research was not carried out by the WHA, who seem to have moved on from this, job done. The study compared outcomes before and after the implementation of the bundle into Australian hospitals [16]. The findings reflect what was known before the bundle was rolled out. That the bundle:

"...did not result in a significant reduction in the likelihood of women experiencing a SPT, but did increase the probability of receiving an episiotomy in nulliparous women and second degree trauma in multiparous women."

The researchers also state: "Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern."

Whilst this study validates those of us who were shouting about it at the time, I doubt anything will change. Just like all the other interventions implemented without evidence that continue despite evidence.

Research on consent (July 2024)

The bundle is now well-established in hospitals across Australia and Europe. Some newly graduated midwives have never seen non-bundle practice (i.e. observed a physiological, undisturbed birth).

Most women are being subjected to non-evidence-based interventions without their consent. A recent Swedish study concluded [17]: "With less than one in five women reporting informed consent to all practices and interventions performed by midwives, the results emphasize the need for further action to enhance midwives’ knowledge and motivation in obtaining informed consent prior to performing interventions."

Summary

In summary, the perineal bundle has become a cultural norm in many maternity settings. This was inevitable because the bundle aligns with the philosophical underpinnings of the maternity system. Women's bodies are dangerous and need to be managed and controlled to reduce risk. Medical experts and their technology and techniques provide safety. However, carrying out routine interventions during birth prevents care providers from observing and learning about physiological birth. With very low rates of physiological births occurring within institutions, research is carried out on medicalised births. Therefore, the outcomes cannot tell us about the impact of interventions on physiological births. The bundle is here to stay because it meets the needs of the maternity system.

Further Resources

Related blog posts

• Perineal Protectors?
• Supporting Women's Instinctive Pushing Behaviour
• Pushing: leave it to the experts

Related podcast episode

References

1. Dahlen et al. (2015) Severe perineal trauma is rising, but let us not overreact
2. Aasheim et al. (2017) Perineal techniques during the second stage of labour for reducing perineal trauma
3. Lee et al. (2018) Perineal injury associated with hands on/hands poised and directed/undirected pushing
4. Thornton & Dahlen (2020) The UK obstetric anal sphincter injury (OASI) Care Bundle
5. Lappen & Gossett (2014) Changes in episiotomy practice
6. Patel et al. (2018) Midline episiotomy may pose less risk of nerve damage than mediolateral episiotomy
7. O'Connell et al. (2005) Anatomy of the clitoris
8. Dogan et al. (2017) Long-term impacts of vaginal birth with mediolateral episiotomy on sexual and pelvic dysfunction and perineal pain
9. Thornton (2018) Congratulations on your new baby
10. Wilson & Homer (2020) Third- and fourth-degree tears
11. Borrman et al. (2019) The effects of a severe perineal trauma prevention program in an Australian tertiary hospital
12. Gurol-Urganci (2020) Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury
13. Scamell et al. (2021) OASI care bundle
14. Barnett et al. (2023) The impact of a perineal care bundle on women's birth experiences in Queensland, Australia
15. Allen et al. (2022) How a perineal care bundle impacts midwifery practice in Australian maternity hospitals
16. Lee et al. (2024) A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives
17. Häggsgård et al. (2024) Informed consent to midwifery practices and interventions during the second stage of labor