Episiotomy, 3rd and 4th degree tears and the Perineal Tear Bundle
Transcript of my podcast about episiotomy, 3rd and 4th degree tears and the perinal teart bundle with Dr Nigel Lee:
Welcome to Episode 29 of Birth: the forgotten feminist issue. Today with me I have midwife and researcher Nigel Lee. He's based at the University of Queensland and has some pretty good research about a range of different things. But today I got him on to talk about the perineal tear bundle. I've seen it now renamed in the midwifery circles as the prettier tear bundle. But I guess I wanted to maybe dissect the elements of the bundle the issues around consent and perhaps the harm that this bundle has caused. So welcome, Nigel, do you want to first so maybe give us a bit of your intro and background, it's fairly unusual to see a male midwife. But maybe we could just do a little bit on how you got into Midwifery, but also your areas of research.
So I've been a midwife for for quite some time since 1987. And in those days, it was a registered nurse to begin with, and you're really sort of only had a couple of options to to expand beyond that. And that was either mental health nursing or Midwifery, I didn't have a really huge amount of interest in mental health nursing. So like many others, I went off and did mid and really enjoyed it. So I kind of stuck with midwifery all the all the way through. And I've worked mainly in, in that birthing setting in both suites and in metropolitan and regional areas as well. And also overseas in the UK. And then about I finished a PhD in about 2013 Looking at through water injections, the back pain in labor. And then badger just transitioned into academia and full time research. since then.
And most recently, some of you researchers around this brilliant Hereby know, it was introduced a few years ago from the Australian. Now what is it? What are women's health? What are they called?
Women's? Women's hospitals, Australia who collaborative? Yep,
there you go. So I try to avoid using acronyms. And that's why sometimes I don't even know what that acronym stands for. But it was introduced a few years ago to reduce the third and fourth degree tear rates. Because I know that I'd seen some data from the health care Atlas, which was highlighting the variations or unwarranted variances and there was maybe like an 11 fold variance at the time, between third and fourth degree tear rates. You might be able to correct me on that though. Can you tell me? Do you think that the perineal tear bundle has worked in reducing third and fourth degree tips?
Yeah, it's a really good question. And it seems that, you know, if we the the bundle they've they're using which is basically consists mostly of the components that have been taken from the cog Royal College proposition gynecologist in the UK, their bundle, which again was was taken from the sort of finished bundle for used in Scandinavia. And when you look at the the research around these bundles, where they've reported on on, you know, sort of the impact they've had, it varies quite considerably. So the, when they introduced these into into Norway and Finland, some of the studies reported that over a 50% reduction in in, in perineal tears, when you drill down into that, you find that that about half of that reduction occurred prior to actually introducing that particular bundle. So there was already a reduction in in third and fourth degree tears in those areas prior to the introduction, the bundle,
is there a term for that? I just I'm a teacher, and I know when we become aware of something, sometimes that's enough to actually change practice before we actually get rolled out with these very strict set of I think, is there a term for that?
It's sometimes it's a bit like a Hawthorne effect. It's you know, when people know things are changing, they will alter their their their behavior is accordingly and you're quite right. That's kind of one of the explanations given for the reasons why pay rates have reduced. So that even just kind of talking about the topic and making people more aware of it appears to to have similar reductions in perineal tear rates. And there's been a study in in Denmark that kind of looked at this, they looked at a couple of sites, one which had the formal perineal bundle, and one which didn't have a formal perineal bundle, but kind of, you know, talked about ways and means of reducing it. And they saw a similar reduction in both sides. And their various iterations of perineal bundles, as well as a couple in the UK that are nowhere near as sort of prescriptive as the the W. H, a one, which has also had similar reductions. So it's, you know, whether it works or not, again, the, the impacting can vary quite considerably. If the, the ASIO G recently published from their bundle in the UK, and they stated that they saw a 20% reduction across afterwards, sort of 40,000 women had been had, had had the bundle during their births. And, you know, that sounds fairly dramatic. 20% When you actually look at the figures, it was dropped from 3.3 down to 3%. Tiny, and when you Yes, yeah, and when you're in that kind of, you know, when you're talking about very small baselines to begin with. So, you know, basically that equates to for every 1000 women who had the bundle, there were three less certain perineal tears or one less tear for every 330 Odd women who are the bundle was applied to
one thing that I often see skimmed over by this because like, when you break it down to percentages actually comes down to quite small, but then they talk about 20% We see this in other areas with the stillbirth and, you know, double the stillbirth rate and per 1000. It's actually very tiny. But one thing that is always admitted from this data when they're selling it back to consumers to midwives, and probably obstetricians as well, in that cohort are women. How much did the episiotomy rate increase?
Yes, and that varies considerably as well. So in the Dr. cog one they did they didn't report a particular increase in episiotomy. But the EPIS rate is pretty high. It's about 24 25%. Anyway, which in the latest stats from Australian perinatal database, have the video often the rate has risen quite considerably in the last couple of years, and now sits at around about 24%.
Yeah, and that's up from like, around 20%, two years before. So from 2017 to 2019. We've gone from one in five to now one in four. And I think that was just first time mothers data that I was looking at. But that's still like, we're back to the 80s with women just being routinely car.
Yeah. And that's Yeah, and again, in you know, in other studies is one from Denmark, where they saw a significant increase in your video, I mean, right to print from something like eight to about sort of 18%. But they also, you know, sort of decrease in tech paradigms, but no change in third and fourth degree is, and some of the research that we published a few years ago, we looked at data from a large Richmond Metropolitan Hospital, and we looked at 27,000 births, and half of which had for about two thirds of which were the midwife to use the hands on approach. And about a third where the midwives would use their hands poised approach, which is kind of one of the big debates within the bundle.
Can you sorry, Nigel, I just because we're going to have like lay women consumers, that they're not going to know the difference between hands on and poised. Can you just explain that before you go through the database yet?
Yes, absolutely. Yeah. So hands on, it's kind of an old approach, we've been discussing the hands on hands pointer back for about 150 years. The hands on approach basically means that the midwife will put a hand on the baby's head as it's emerging from the vagina and the press inwards and downwards to try and sort of slow the, the progression of the head and also what they call, maintain that kind of nice flex chin down position. And then also put a hand on the perineum itself, thumb and a couple of fingers, and try and literally try and pinch that the tissue together to to stop it from tearing.
Doesn't sound like as a woman.
No, it isn't, particularly at that moment where they're trying to give birth, and someone's trying to hold back and pinch it together. And so there's two things about this, that this has been examined and compared to the hands, poise and the hands point is doesn't exclude someone putting a bit of a little bit of pressure on their head to if it's starting to be birthed a bit quickly. But it uses a bit of clinical judgment on when and when that's not not required. And also when waterbirds we use a completely hands off approach. Yeah. Which which babies actually out
which the no coincidence that often it's delivered, delivers the best outcomes like if you leave women alone, funnily enough, they'll burn Babies
Well, and that's the kind of the the theoretical idea behind that the hands boys, if you leave the baby alone, that they will basically find their own and best way out. Because they're they're not completely passive, they do wriggle around a little bit, and they can watch the head kind of moving around a bit on the perineum has worked its way out. And the interesting thing, of course, is that we use a hands off in water births, but the rates of third and fourth degree tears do not differ between water birds and land birds were a hands on approach is used some kind of, you know, we start looking at well, is that actually having any impact. And there's been lots of trials, very high quality randomized control trials that compared hands with two hands on and none of them have demonstrated any any benefit from a hands on approach to a hands poised. And the trouble with the hands on is that you've realistically going to have a woman giving birth on her back or on a bit least, to apply the hands on. And we know that the saving our research 97% of the midwives who use the hands on or 97% of the women who had the hands on approach, they gave birth on the bed on reclining, as opposed to about 70%. Who had their hands for it. So we know it has an impact upon the choices women have and the birth position they actually give birth in in because the midwives feel a bit a bit pressured to actually apply this technique and read it as I say the only realistic way of doing it is to have the woman reclining on the bed.
Now, I mean, obviously bits and pieces. But is it true though, when you're on your back, I mean, it makes sense because of the shape of the pelvis that like obviously the baby's then got to kind of head up defying gravity, but a woman issue more likely to tear when she's birthing on a back.
That seems to be what the research is telling us. And there's been a couple of studies about that, that, you know, that they are more likely for various reasons to, to tear, if they're in a reclined position, some of it's the shape of the pelvis, and the way the legs are positioned. In that particular position that tends to reduce the amount of stretch available to the perineum. And it seems to be that when women give birth on on more upright positions, or for their standing or even even on their side, sort of reclined on the left lateral position line on the left side, that seems to reduce the incidence of tearing. And, you know, when I started out at the midwife way, you know, 30 odd years ago, I remember working with some some, you know, very experienced elder midwives who would when women were giving birth, or these young and young women were giving birth to babies that they were attending to adopt up dropped out at that period of time, they would also always get these women to birth line on this side, as opposed to the line on the back, which is kind of traditional approach in the 1980s. And their rationale was that they you know, they knew from years of experience that when women gave birth on this side, they were less likely to get a personal injury. So these young girls would would leave the hospital without a scar on their perineum.
Yeah, well, and yet we have these, it just seems like the cycles that come round and got all this evidence to the contrary yet, because I do want to talk about next, like the elements of the bundle. And one of the elements is not like a sideline position. And there's plenty of things that could have been included that weren't. Can you go through what the five elements of the bundle are? So for those who are not familiar with it, this is this is the bundle with five different things, you know, that pretty much been rolled out. I mean, it was only a certain amount of hospitals, but just from anecdote seems to have bled into pretty much all hospitals, whether it's the full bundle or particular elements, particularly a PC automate of the bundle. Can you describe the five parts of that bundle and perhaps some time if you know where parts of it came from, like the whole 60 degree thing? Of angle of a PC autonomy. I know it's been controversial or it's controversial, but perhaps you might be able to describe where some of the parts of the bundle have come from and the rationale behind why they are included.
Okay, so yeah, there are five parts to the bundle itself. The first one is actually applying one compresses or one packs to the to the woman's perineum as the baby's head starting to starting to emerge, or during that birthing stage, and this is something that midwives have been using for years and years. And was demonstrated in some great work by Hannah Dahlen for her PhD to reduce the incidence of perineal tearing, and including third and fourth degree days. And I'd say you know, midwives have been using this for years and that's actually a quite a good component of this of this bundle.
And I guess, like a few physical point of view, it doesn't need the woman on her back flat on her back.
Oh no, no, you can apply this pretty well, any any position, it's really just a matter of getting a pack. So getting a nice hot water and holding it against the perineum, and it helps take the sting away. And also, we think helps increase the blood supply to the, to the perineal area at the time and just makes it easier and better for it to stretch. So that's one part. The other part is this hands on the hidden parent and the hands on approach, which is, again, is fairly controversial. And something again, we've been debating for many, many years. And as you mentioned, you know, that's kind of putting a pressure on the baby's head to not only sort of maintain that kind of flexion, or that chin down position, but also try and slow the head down and pinch the perineum together. And that's not to say that we just don't have any evidence kind of supporting that that has any benefit over a hands pause or even a hands off approach. Third part was the physio Atomy. And, you know, again, this kind of essay gets quite controversial because they say a physio, I think, when indicated, but it's pretty clear from the discussions we've had with with midwives and the research we've done with them. And just we've heard ourselves that within this there was a subtext of using a busy Ottoman more liberally. Whenever the woman was look like she was going to tear then the midwives were encouraged to consider cutting and PC autonomy. And certainly, you know, it's mentioned in a number of the studies we've seen that introduction of the bundle has increased rates of episiotomy.
Why do you think Nigel that they think a PC automate is better than a woman tearing because, you know, in this instance, they don't know if that woman's going to care. But you're guaranteed when you're going to Peasy automate that you've got to cut it like there's, you know, like, where is the logic but because often say to women, like there's no guarantee you're going to tear, but if you accept that a piece yummy, you guarantee you've got that trauma.
I think there are two different cases here. I mean, one of them's in as you're saying, you know, an otherwise normal, spontaneous vaginal birth. There is, you know, up until the introduction, the bundles we had moved away from from cutting episiotomy is routinely and pretty well, the only reason we would would do one, that if the baby was in trouble, you know, the heart rate was down and not recovering. And we clearly need to expedite that birth. And, you know, interestingly the, you think about sort of the, the anatomy that the tears go through the episiotomy goes through exactly the same signed layers of skin and perineum and muscle. And there are certainly probably benefits to having a tear over in a busy automate. Jerry they considered to be to be less painful, and they also heal a little bit better, then then episiotomy scenarios. Again, some evidence for this, I was looking at, at some studies that have looked actually looked at, they've cut episiotomy is on cadavers, it sounds really dramatic, but But they'd be looking at the actual structures that are involved. And there's certainly a lot more nerve and and muscle damage involved in cutting episiotomy compared to a tear that invariably occurs down the midline, or down the center, because of the direction of the ankle that it goes off. And what's happened with the bundle was that they changed the the minimum angle for an episiotomy from around about sort of 30 to 45 degrees up to 60 degrees, the idea being that that would would prevent the episiotomy from extending themselves into third degree tears into severe perineal injury and involving the angels fainter, which did actually happen. And was a known risk factor, if you cut an episiotomy, then that self became a risk factor for severe perineal injury. So the the idea was that they would, if we increase the angle cutting off at 60 degrees, which is really quite wide, it's almost sort of cutting into the body, as opposed to the just that the the perineal area.
Where did that? Because this is, I guess, some of my issue that where did the 60 degrees come from? Or is this just consensus or the usual like, I just pulled it out of my ass and decided that you know, like, gonna kind of put it in this bundle?
It's probably a bit of both. I mean, I think it came out of someone's opinion that okay, with the boiler we cut it, the less likely it is to extend there hasn't been an enormous amount of of, of research on it. So there's probably sort of done a good RCT to see whether this actually works in terms of, of reducing third and fourth. The other thing is that they haven't actually done any research into the to the minimum long term outcomes either so, you know, there may be some some indication that okay, we're probably getting fewer episiotomy is extended into third and fourth degree tears. Because we're cutting out a wider angle, whether it actually reduces overall third and fourth degree tears, there's still a bit contentious but it's the the ongoing harm and ongoing problems. We know that there's an increased incidence of urinary incontinence and sexual dysfunction from women who've had a PC automates and this appears to increase with the rate with the angle at which the video automates card. But, you know, nobody's going back out there and had a look of his wouldn't have had the 60 degree angle episiotomy ease and done any research in terms of what are the the ongoing issues resulting from that that wider angle of episiotomy?
I mean, anecdotally, from women, they're not happy. Because at the time they thought it was needed, but then afterwards, and I guess they probably have a look at the bundle and go What the hell. But but anecdotally, from women, I'm hearing that, yeah, like sexual dysfunction is a huge issue, the pain, and sometimes it is just painful just to sit. And this isn't just like a six week, this is 12 months later as well. So it would be great if there was some, you know, high quality research around these long term issues, because these things are often implemented. And there is no, I guess, strategy for how do we properly evaluate this outside of the data that the hospitals getting us, you know, like giving us that women, which should be the center of care, often the afterthought, or the long term impacts of implementing such like a bundle that's having such a huge impact on women, and it's so prolific, like it's so widespread now that it's not just in those main hospitals that first signed up for it.
Yes, and you're quite right, that that is kind of the problem. You know, we've and maternity care is notorious for this sort of thing as in other areas of medicine, but in in maternity care, we kind of made this a, you know, almost a refined art, introducing procedures or changing procedures without actually giving a great deal of thought to what are really going to be the ongoing squilliam ramifications of what we're actually doing.
Now, I think we got up to number four, what was the fifth part of the bundle? So we've got the compress the whatever else was it?
was number three, yeah, so four and five, were all about the PR examination afterwards. Yeah.
How could I forget that? So yeah, fine. PR is, you know, is there any evidence behind it? And, you know, what could the alternative be? I mean, I just tell women say no, but it's all well and good when there's a power imbalance, and, you know, various other things just to tell women to say, No, it just doesn't happen like that.
No, it doesn't. And there is, you know, again, as you mentioned, in this quarter, the kind of power and balance around consent for this is one of the big problems, but a PR, which stands for PR rectum, which is basically a rectal examination after birth, which we would, we used to do quite routinely after a run after, before and after suturing, to see if there was any, any damage to the anal sphincter, because there is you can't always see it. But you can sometimes feel it there if you're reasonably experienced practitioner, and then you can, if the perineum is torn, then you can actually repair the the anal sphincter and hopefully to reduce the chances of having things like fecal incontinence and, and that sort of thing afterwards. So but what the the, the difference that came along with the perineal bundle was, instead of applying this to women who had just had a perineal injury, they applied it to all women. On because it had been a little bit of research, and very, very small numbers of women who had injuries to the angels might have an injury to the sphincter that weren't that, but still had in tech Paranaense. But they were very, very small numbers. But now they're applying that the the PR exam to women with intact parent names, which is the contentious part because gender will be considered if the if the the parent major intact, then the likelihood of having a sphincter injury is really, really small.
Yeah, and I guess my issue comes back to the consent because the informed consent part is often missing. It's kind of our I'll just do this, you know, it doesn't consider women's previous trauma. And we know, you know, whether it's birth trauma or other like sexual trauma, that I just, you know, it's really poor form, but, again, the way it's been rolled out and implemented routinely, and a lot of women, particularly, you know, vulnerable women and those who are uneducated, they actually don't know that the He's not part of birth, like, they just think that all this stuff that's done to them is just routine. And a lot of women will say to me, I didn't even know I could say no.
Yeah, and I think, you know, that's it's a broader debate about consent. And I think we certainly need to be, you know, supporting women and telling them that it's perfectly okay to say no, that, you know, the consent is, is in means that they can actually decline this sort of care if they don't want it. And I think there are two issues with with the bundle, and it's in terms of the PR exam. It's interesting that, you know, I was looking at the, the, the information that the brochure that they send out to women, there is no mention of the Bihar exam on their, their information for women, not one, it's just just not there.
Can you also explain how the bundle like as in we're all just included, unless you opt out? So if you're not even told about it, or or don't know, the comparison is that none of this happens that it like we all just get herded into it. And it would take it would be a very small number of usually quite well educated or resourced and very health literate consumers that would know that they could actually get out of this.
Yes, and that you're quite right, that the problem one of the other problem is that this has been presented to the midwives and other practitioners as as an opt out scenario. So the default is that happens to every woman every time, unless the woman actually pipes up and says, No, actually, I don't want that. And it also relies upon all of these sorts of things being discussed, you know, prior to the woman actually going into labor, labor is a terrible time to try and sort of get consent from people because it's, you know, there's there's pain, and there's analgesia, and it's going sometimes goes fairly quickly. So it's not the ideal time to be trying introducing concepts or ideas and trying to get them to think about them and discussing alternatives.
And also, from a physiological perspective, like, like that logical part of our brain is not really it's not there for birth, like, it's just, you know, I mean, that's not that's not to mean that consent shouldn't be obtained at all. But those kind of lengthy discussions and you know, a woman trying to weigh up the pros and cons. It's a lot harder if she doesn't have that any education on it beforehand. Can you tell me because I actually haven't looked into this? Were these information brochures? Were they ever converted? Or translated into other languages as well, for our more vulnerable groups? Or, you know, were there more infographics for consumers with low health literacy?
I'm not sure what they did in terms, you know, once I could find on the WHO website were in English. And I think they were probably because they sent this out to their, to them their member hospitals as well. And I think the idea was that they're the member hospitals would then be responsible for translating into various language, including in their their antenatal packages. And that's really an issue as well, because you know, that sometimes they'll they'll print up these brochures, and I'll put them in your head, and that these big antenatal packs for the whole lot of other information they send out to women when they book into hospital. And we know that women generally do not read these things, they put them aside and they've got better things to do. And there is a whole suite of information that goes out. And generally, these sorts of information brochures are pretty ineffective unless you actually sit down with a woman and make a specific time and take time to go through and, and talk about each one. And then actually record them whether she feels that she wants to consent to this sort of thing or not.
Yeah, yeah, I agree. Um, I know, we earlier just compare the data between 2017 and 2019. So the mothers in the national mothers and babies report, and it has shown that a PC order being right, at least for first time mothers has increased. Why do you think this is? So why do you think this has happened?
I think there are theories. I think the within the bundle There they met basically mandated the use of episiotomy is for women who had an instrumental birth of force, its birth or a vacuum birth for their first birth. So they that was opposed to having an episiotomy. And so I think that's probably had an impact as well. But I also think going back to the they also mandated the the hands on approach. And you know, the research that we published a few years ago, again, looking at those 27,000 births. What we saw was that midwives use the hands on approach words, about two and a half times more likely to cut an episiotomy than those that use the hands poised approach. But there was no difference in third and fourth degree tears between those groups. They just women who had their hands on too came out with more personal injuries.