Obstetrics
Metropolitan hospital

Read how a hospital Quality and Safety committee investigated clinical variation in rates of severe perineal tears in childbirth. Benchmarking data with similar hospitals showed they had the highest rates in Australia. Introducing a range of risk-reduction strategies reduced rates of severe perineal tears substantially. The hospital continues to monitor rates and discuss how to sustain the improvements.

To view the summarised case study, you can skip to At a glance.

Last updated on 19 October 2022

Step 1. Select priority areas
Step 1. Select priority areas

Highlighting the issue – a high rate of severe perineal tears in childbirth

Third and fourth degree (severe) perineal tears during childbirth impact significantly on a woman’s physical and mental health. Rising rates in Australia and internationally prompted the Quality and Safety Committee of the Centenary Hospital for Women and Children, Canberra, to begin monitoring the incidence of severe perineal tears in the hospital from 2011.

Step 2. Plan the project
Step 2. Plan the project

Finding the right data source – one that allows comparisons

The hospital chose to submit data to Women’s Healthcare Australasia (WHA) and the Health Roundtable as they allow comparison with data from similar hospitals. WHA provides a benchmarking service that measures a range of indicators of labour and birth care and outcomes, including severe perineal tears.

Birth data was captured in the electronic maternity database (Birth Outcome System). Every morning the multidisciplinary team discussed all births in the database from the previous 24 hours. Any cases of severe tears were verified by team members present at the birth to ensure that they were accurately recorded.

Step 3. Measure and review
Step 3. Measure and review

Assessing the findings – do they measure up to the standard of care?

In 2014/15, the hospital’s rate of severe perineal tears among women giving birth vaginally was 6.1%, compared with the national rate of 3.6% in the WHA dataset. Data from the Second Australian Atlas of Healthcare Variation and the Health Roundtable showed that the rates of severe tears in the ACT were the highest in the country. 

The high rates prompted the formation of a multidisciplinary working group to investigate and address the issue. The group was jointly chaired by the Professor of Midwifery and the Clinical Director of Obstetrics and Gynaecology; it also included midwives, physiotherapists and obstetricians.

Step 4. Explore reasons
Step 4. Explore reasons

Getting to the root of the problem – look for all the angles

The working group examined the hospital’s birth data to identify risk factors associated with severe tears. The group also conducted a literature review, which supported the findings from the hospital data analysis. They concluded that primiparity, operative deliveries, malposition and inappropriately performed episiotomies were significant risk factors for severe tears. 

Step 5. Act to improve
Step 5. Act to improve

Putting the changes in place – a multi-faceted approach

The working group agreed on the following risk-reduction strategies identified from the literature:

  • Promoting antenatal perineal massage from the third trimester
  • Avoiding instrumental birth when possible
  • Using vacuum instead of forceps when possible
  • Applying warm compresses in the second stage of labour
  • Controlling delivery of the head and shoulders 
  • Performing episiotomies only when clinically indicated, and at a medio-lateral angle
  • Avoiding the lithotomy position (lying on back, legs bent) when possible.

The working group held staff workshops every six months on preventing perineal tears. They also introduced a Reflection on Practice tool and a colleague debriefing process for practitioners involved in the care of women who sustained severe perineal tears

During the intervention period, the team posted progress reports on ward quality boards to show performance in rates of severe perineal trauma, as well as use of forceps, vacuum, and episiotomy.

Step 6. Monitor and report
Step 6. Monitor and report

Looking at the impact – celebrate success and build on it

The rate of women sustaining severe perineal tears during their first vaginal birth fell from 6.1% over the two years before the intervention to 3.9% in the two years after the intervention was introduced. Since then, there has been a further steady decline in the rates of the tears.

Rates of severe perineal tears continue to be reported routinely to:

  • the Department’s Quality and Safety Committee
  • the Divisional Quality and Safety Committee 
  • monthly morbidity and mortality meetings
  • the Hospital’s Executive – which also monitors the rates against the Health Roundtable data. 

Any deviation from the expected rate is examined and if rates increase, an audit is carried out and further review of practice is conducted. All cases of severe tears are also recorded in the hospital’s incident management system (Riskman).

To sustain the improvements, severe perineal trauma was added to the agenda of staff meetings and all cases were discussed at multidisciplinary meetings. The Quality and Safety Committee continues to review rates and discuss strategies to sustain the improvements.

At a glance

Issues
  • A high rate of severe perineal tears in childbirth at the hospital
Barriers
  • Variable use of risk-reduction strategies
  • Instrumental births
  • Inappropriately performed episiotomies
  • Malposition
Enablers
Solutions
  • Regular staff workshops on strategies to prevent perineal tears
  • Use of a Reflection on Practice tool, and colleague debriefing, after cases of severe perineal tears
  • Discussion of all severe perineal tear cases at multidisciplinary meetings