How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice.

Abstract

The accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.
A descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.
405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.
There are considerable gaps with implementation of evidence to support management of perineal trauma.

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RESEARCH ARTICLEOpen Access
How good are we at implementing evidence to
support the management of birth related
perineal trauma? A UK wide survey of
midwifery practice
Debra E Bick1*, Khaled M Ismail2, Sue Macdonald3, Peter Thomas4, Sue Tohill5and Christine Kettle6
Abstract
Background: The accurate assessment and appropriate repair of birth related perineal trauma require high levels of
skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice.
Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma,
which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite
evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how
midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence
based guidance. Findings would be used to inform the content of a large intervention study.
Methods: A descriptive cross sectional study was completed. One thousand randomly selected midwives were
accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that
the midwives were in clinical practice and undertook perineal assessment and management within their current
role. Quantitative and qualitative data were collated. Associations between midwife characteristics and
implementation of evidence based recommendations for perineal assessment and management were examined
using chi-square tests of association.
Results: 405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority
worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%).
Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers
of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment.
Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the
time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal
repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified
for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based
recommendations and feel confident about perineal management.
Conclusions: There are considerable gaps with implementation of evidence to support management of perineal
trauma.
Keywords: Perineal trauma, Episiotomy, Suturing methods, Maternal morbidity, Midwifery practice
* Correspondence: debra.bick@kcl.ac.uk
1Professor of Evidence Based Midwifery Practice Kings College London,
Florence Nightingale School of Nursing and Midwifery, 57 Waterloo Road,
London SE1 8WA, UK
Full list of author information is available at the end of the article
© 2012 Bick et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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Background
One of the most commonly reported maternal health
problems after birth is perineal pain, a symptom highly
associated with sustaining perineal trauma during a vagi-
nal birth [1]. It is estimated that approximately 70% of
women who have a vaginal birth will sustain perineal
trauma which requires suturing [2]. Indeed, for some
women, the experience of perineal pain and trauma can
impact on their longer-term recovery from the birth [3].
Trauma to the external genitalia can occur spontan-
eously during a vaginal delivery or as a consequence of a
surgical incision (episiotomy) to enlarge the vaginal
opening to facilitate birth. Midwives and obstetricians in
the UK are expected to document the extent of perineal
trauma sustained using a classification system which
divides trauma into four types according to the tissues
and structures involved [4,5]. Trauma can be classified
from a first degree tear which denotes injury to the peri-
neal or vaginal skin only, to a fourth degree tear which
is the most severe degree of perineal injury that extends
to involve the anal sphincters and anal epithelium [4]. It
is essential that clinicians are able to accurately identify
and document the extent of trauma to ensure that a
woman receives the most appropriate management.
Moreover, it is also important that clinicians are able to
repair the trauma sustained using suturing methods and
materials associated with less short-term perineal pain as
recommended by Cochrane systematic reviews [6,7].
Within the UK, these recommendations are incorpo-
rated in the NICE Intrapartum Guidelines (4) which in-
form the care women giving birth in the National Health
Service (NHS) in England and Wales should expect to
receive.
The Cochrane systematic review of continuous versus
interrupted sutures for repair of episiotomy or second
degree tears presented data from seven randomised con-
trolled trials and reported that use of a continuous su-
turing technique for all layers of muscle and skin was
associated with less short-term pain compared to inter-
rupted methods. The effect size was greater if the con-
tinuous technique was used to repair all layers rather
than the skin only [6]. Suturing materials can also affect
a woman’s experience of short-term perineal pain. Data
from another Cochrane review which included 18 trials
presenting data on over 10,000 women found that use of
standard synthetic sutures were associated with less peri-
neal pain up to three days post birth and less analgesia
use up to ten days postpartum compared with catgut [7].
Rapidly absorbable synthetic sutures were less likely to
be associated with the need to remove suture materials.
Hence, a rapidly absorbable polyglactin suture (Vicryl
RapideW) is the material of choice within the UK NHS.
The accurate assessment and appropriate repair of peri-
neal trauma require a high level of skill and competency
to ensure that the tissues and structures involved are
aligned correctly to promote healing and minimise post-
natal morbidity. As midwives in the UK are responsible
for the majority of normal births, they play an important
role in promoting the effective assessment and manage-
ment of perineal trauma. However, there has been limited
attention paid to promoting a high level of skill and com-
petency in this important aspect of maternal health. Mid-
wives may not have been required to undertake further
training in perineal repair once qualified. Indeed at the
time of conducting this survey, there was no mandatory
requirement in the UK to do so. More recently, some
NHS hospitals have addressed training provision in order
to comply with recommendations of the body which han-
dles negligence claims against the NHS. The Clinical Neg-
ligence Scheme for Trusts 2011/2012 Clinical Risk
Management Standard 3 requires that a training needs
analysis for staff expected to undertake perineal assess-
ment and repair be undertaken [8]. Nevertheless, there is
no standard training package in perineal assessment and
repair.
Previous studies have highlighted a lack of knowledge
with respect to perineal anatomy, classification of
trauma and satisfaction with training in perineal repair
among midwives and trainee doctors. In one study only
20% of 75 trainee doctors and 48% of 75 midwives ques-
tioned reported that they felt their training in perineal
repair had been of a high standard [9]. Furthermore,
there is anecdotal evidence that the time allocated in the
pre-registration midwifery education curriculum in UK
universities to teaching the anatomy of the perineum
and pelvic floor and training in suturing varies widely, as
does the practical experience a student or newly quali-
fied midwife may obtain in the clinical area. There is
high quality evidence to support aspects of maternity
care globally to prevent or minimise subsequent mater-
nal morbidity, for example reduction in performance of
routine episiotomy [10], however there remains a signifi-
cant ‘evidence to practice’ gap with respect to the assess-
ment and management of the perineum during and
immediately following birth [2,11]. Conversely, there has
also been limited attention to the impact on clinical
skills and competencies of revisions to aspects of peri-
neal management. Barriers to implementing evidence
into practice have been identified at many levels includ-
ing conceptual, instrumental and persuasive use of
‘knowledge’ [12]. As part of the background to the devel-
opment of a large multi-centre matched pair cluster trial
of a quality improvement intervention to promote the
accurate assessment and evidence based management of
perineal trauma [13], a national survey of UK midwives
was undertaken. The study was funded by The Health
Foundation and formed work developed for the Perineal
Assessment and Repair Longitudinal Study (PEARLS)
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which is registered in the Current Controlled Trials
Registry: ISRCTN28960026.
Objectives
The main objectives of the survey were to identify
how midwives assessed and repaired perineal trauma,
including second degree tears and episiotomies, the
extent to which their practice ‘matched’ evidence
based recommendations, how confident they felt
with aspects of perineal management, if they were
able to access training to update and maintain their
clinical skills and competencies and if national and
local protocols to support perineal management were
available within their area of practice. The results
informed the content of the intervention tested in
the Perineal Assessment and Repair Longitudinal
(PEARL) Study which is reported separately.
Methods
A descriptive cross sectional study was undertaken dur-
ing January to May 2007. The names of 1,000 midwives
were randomly selected from the membership database
of the Royal College of Midwives, as it was considered
that this number would enable a representative sample
of midwives to be reflected in final responses. A ques-
tionnaire was specifically developed which included a
number of closed and open questions, some of which
reflected evidence based recommendations for practice.
Information on whether the midwife was in practice at
the time of the survey and whether they were directly
involved in intrapartum care was not available, as these
details were not collected by the RCM. Therefore, ques-
tions exploring these aspects were included in the ques-
tionnaire as both aspects were considered essential
criteria for inclusion in the final analyses. The question-
naire included items on confidence in assessing perineal
tears, confidence in performing perineal tears and confi-
dence in performing episiotomies rated on a 4 point
scale (all of the time, most of the time, some of the time,
and never). We were also interested in whether mid-
wives did or did not suture all second degree tears, and
the repair technique they used.
Data were entered onto an Access database and analysed
using PASW v18. Inclusion criteria included that the mid-
wife was currently in practice and involved in the assess-
ment and repair of perineal trauma. Associations between
midwife characteristics and outcomes of interest were
explored, using the chi square test for association. Charac-
teristics included number of years qualified as a midwife,
the clinical pay scale (or ‘Band’)the midwife was on (‘Band’
refers to nationally agreed pay scales, which reflect the clin-
ical role and responsibilities of midwives, nurses and allied
health professionals, a higher Band reflecting a more senior
clinical post), the model of maternity care the midwife
worked within and the location of care (inner city, urban or
rural). These were considered to be characteristics with po-
tential to influence aspects of perineal management. Quotes
to illustrate midwives’ responses are included where
appropriate.
Results
Response rate
A total of 405 (40.5%) midwives returned a question-
naire, 338 (83.5%) of whom met study inclusion criteria.
Baseline characteristics of midwives
Of the midwives eligible for inclusion, 306 provided infor-
mation on their clinical grade, 177 of whom (57.8%) were
Band 6, 116 (37.9%) Band 7 and 13 (4.3%) Band 8. A high
proportion of midwives had been qualified for over 20 years
(129, 38.2%), with 85 (25.1%) qualified for 16 to 20 years, 34
for 11 to 15 years (10.1%), 40 (11.8%) for 6 to 10 years and
50 (14.8%) for 1 to 5 years.
The majority worked in a consultant-led unit (235,
69.5%), with other respondents working in integrated or
free-standing midwifery-led units (84, 24.9%). Nineteen
(5.6%) midwives were working in independent practice
at the time of the survey. In terms of geographic location
171 (50.5%) midwives worked in a unit in an urban loca-
tion, 84 (24.9%) in an inner city unit, and 83 (24.6%) in a
rural area. Due to the small number of Band 8 midwives,
the data they provided were combined with data from
the Band 7 midwives for purposes of analyses.
Perineal trauma management
The midwives were asked what aspects of perineal assess-
ment and repair they undertook and whether they were also
required to supervise others undertaking perineal repair. All
respondents undertook some aspect of assessment (317,
93.7%) and/or repair (311, 92%), with half reporting that
they assessed, repaired and supervised colleagues in this as-
pect of practice (167/49.4%).
When asked how many perineal repairs they had
undertaken in the six month period prior to completing
the survey, of the 337 who responded to this question,
104 (30.9%) had not performed any repairs. Of the 233
midwives who had performed repairs, 17 (7.3%) had per-
formed more than 20 repairs, 38 (16.3%) had performed
between 10 and 19 repairs, 70 (30.0%) between 5 and 9
repairs and 108 (46.4%) between 1 and 4 repairs.
Confidence in approaches to perineal management
Confidence to assess perineal trauma (n=338)
Just over a third of the midwives (116, 34.3%) reported that
they felt confident to assess trauma ‘all’ the time; 186
(55.0%) felt confident ‘most’ of the time and 36 (10.7%)
‘some’ of the time. No midwives reported that they ‘never’
felt confident. There was a statistically significant association
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with midwifery band and feeling confident, with Band 8 and
7 midwives more likely to report this than Band 6 midwives
(p<0.001, chi square=21.64, df 2). Sixty-three (48.8%)
Band 8 and 7 midwives reported this compared with 43
(24.3%) of Band 6 midwives. There was also a statistically
significant association with number of years qualified as a
midwife (p<0.001, chi square=33.29, df 8); 58 (45.0%)
midwives qualified for 20 years or longer were confident ‘all’
of the time compared with 34 (40.0%) midwives qualified
for 16 to 20 years, 13 (38.2%) qualified for 11 to 15 years,
seven midwives qualified for six to ten years (17.5%) and
four (8%) midwives qualified for five years or less. There
were no associations with model (p=0.86) or location of
care (p=0.67).
Confidence to perform perineal repair (n=338)
Only 73 (21.6%) midwives reported that they felt confident
to perform perineal repair ‘all’ of the time; 183 midwives
(54.1%) felt confident ‘most’ of the time and 59 (17.5%)
‘some’ of the time. A small number, 23 (6.8%), reported that
they ‘never’ felt confident. When assessed by midwife char-
acteristics, there was a statistically significant association be-
tween confidence to perform perineal repair and length of
time qualified (p<0.001, chi square=57.45, df 12). For
those qualified for 20 years or longer 36 (27.9%) reported
that they felt confident ‘all’ of the time compared with 23
(27.1%) midwives qualified for 16 to 20 years, 9 (26.5%) of
those qualified 11 to 15 years, 3 (7.5%) qualified for 6 to
10 years, and 2 (4.0%) qualified for 1 to 5 years. There was
also an association between confidence and band of mid-
wife, with midwives on Bands 8 and 7 more confident to su-
ture than Band 6 midwives (p<0.001. chi-square =28.24, df
3); 25 (14.1%) Band 6 midwives were confident all of the
time compared with 43 (33.3%) midwives in higher bands.
Model (p=0.09) and location of care (p=0.98) were not
associated. Comments added by midwives to this section of
the questionnaire illustrated the need to seek support to
perform repairs:
‘I attempt all repairs that I feel able to perform,
however I normally have some assistance at some
stage during the repair’ (Hospital Midwife, Band 6)
‘I feel confident to suture, many colleagues do not and
this may be why so many tears are left that should be
sutured’ (Hospital Midwife, Band 7)
‘I take the responsibility seriously, always seek obstetric
guidance if needed but have tackled much more
difficult traumas than I used to in recent years’
(Hospital Midwife, Band 7)
Confidence to perform an episiotomy (n=334)
Two hundred and twelve midwives (63.5%) reported that
they were confident ‘all’ of the time to perform an
episiotomy, with 73 (21.9%) feeling confident ‘most’ and 38
(11.4%) ‘some’ of the time. Eleven midwives (3.3%) had
never performed an episiotomy (10 Band 6 midwives and
one Band 7 midwife). When confidence to perform episiot-
omy was assessed among the 323 midwives who had per-
formed the procedure, there was no association with model
(p=.97) or location of care (p=.65). However, there was a
significant association between confidence and midwife
band. Band 8 and Band 7 midwives were significantly more
likely to feel confident than Band 6 midwives (p<000, chi
square =15.21, df 2), for example, 100 (80%) Band 7 and 8
midwives felt confident ‘all’ of the time, compared with 96
(58.9%) Band 6 midwives. Being qualified for 20 years or
longer was also significantly associated with feeling
confident (p<0.001, chi square =85.51, df 8). Focussing
on being confident ‘all’ of the time, 109 (84.5%) midwives
qualified for more than 20 years reported this, compared
with 60 (72.3%) midwives qualified for 16 to 20 years, 23
(69.7%) for 11 to 15 years, 11 (32.4%) qualified for six to
ten years and eight (21.1%) qualified for five years or less.
The following quotes illustrate the lack of confi-
dence some of the respondents felt:
‘with episiotomies, I hardly ever do them, so I have
lowered confidence’ (Community Midwife, Band 7)
‘Hardly ever do an episiotomy, so circumstances would
necessitate (ie fetal distress) so less than ideal birth
with resulting ‘lowered confidence’ (Community
Midwife, Band 7)
‘I do not like performing episiotomy and always
become nervous’ (Hospital Midwife, Band 6)
Suturing materials and suturing techniques
Suture materials (n=331)
Most of the 330 midwives who responded to this question
(n=283, 85.7%) used Vicryl RapideWfor perineal repair.
Thirty four (10.3%) reported that they use VicrylWand
nine (2.7%) midwives reported that they used DexonW.
Five midwives (1.5%) did not know what suturing materi-
als were used.
Suturing techniques
The midwives were asked which suturing techniques
they would usually use to repair the vaginal wall, the
muscle layer and the perineal skin. The recommended
evidence based technique for each layer of perineal re-
pair (continuous non-locking sutures for the vaginal wall
and muscle layers, and sub-cutaneous sutures for the
perineal skin) were included as possible responses,
which enabled the researchers to assess how many mid-
wives were currently using the correct suturing tech-
nique to repair all layers of perineal trauma (Table 1).
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There were no statistically significant differences in
midwife characteristics examined and use of evidence
based suturing techniques for the repair of any layers
of perineal trauma, including continuous non-locking
sutures for the vaginal wall (p=.47 years qualified,
p=.30 location of care, p=.09 band of midwife,
p=.99 model of care); continuous non-locking sutures
for the muscle layer (p=.40 years qualified, p=.42 lo-
cation of care, p=.20 band of midwife, p=.40 model
of care) or sub-cutaneous suturing of the perineal
skin (p=.55 years qualified, p=.16 location of care,
p=.50 band of midwife, p=.81 model of care). When
responses were examined to elicit how many were
using the recommended evidenced based method of
repair for all three layers of perineal trauma, only
twenty midwives (6%) were using these, 14 of whom
had been qualified for 16 years or longer. Ten of the
midwives were Band 6.
Suturing and non suturing of second degree tears (n=331)
The midwives were asked if they ever left second de-
gree tears to heal without suturing (‘yes’ or ‘no’). Over
half of those who answered this question (192, 58.0%)
reported that they did not suture all second degree
tears, with no statistically significant differences in how
long a midwife had been qualified (p=0.49), location
of practice (p=0.09) or band of midwife (p=0.08).
When model of care was examined, there was a statis-
tically significant difference with independent midwives
more likely to report they would leave second degree
tears unsutured (p=0.009, chi square=9.52, df 2, with
27 (75.0%) independent midwives reporting this, com-
pared with 44 (67.7%) midwives working in hospital
based midwifery led care units and 121 (52.6%) who
worked in a consultant led unit. Midwife comments
with respect to non-suturing highlighted some of the
opposing views with respect to why second degree
tears should be repaired, or conversely left to heal with
no intervention:
‘As a community midwife, I have observed that they
often heal better and give less discomfort to clients if
left unsutured’ (Community Midwife, Band 7)
‘Our trust protocol requires that all second degree
tears be sutured in practice. If it is thought a small
second degree tear would be best left to nature, it
might be relabelled as first and left’. (Bank Midwife,
Band 6)
‘The healing process needs some help and support
from suturing, especially to realign muscle’. (Hospital
Midwife, Band 5)
Rectal examination (n=335)
When asked if they performed a rectal examination as part
of routine assessment of perineal trauma, 142 (42.4%) mid-
wives said they performed this examination ‘all’ of the time,
99 (27.2%) ‘some’ of the time and 44 (13.1%) ‘most’ of the
time. Fifty-eight (17.3%) midwives reported that they ‘never’
included this examination as part of the routine assessment
of trauma. Model of care (p=0.95), location of practice
(p=0.44) and years qualified as a midwife (p=0.18) were
not associated with this aspect of practice. Performing a
rectal examination was associated with band of midwife
(p=0.025, chi square=9.34, df 3). Focussing on the propor-
tion performing an examination all of the time, 64 (50.4%)
Band 8 and 7 midwives reported that they would always
perform this examination compared with 64 (35.5%) Band
6 midwives. The majority of the 58 midwives who reported
‘never’ performing rectal examination within routine as-
sessment were in the Band 6 category (40, 74.1%).
Comments from midwives highlighted some confusion
as to their role in undertaking this examination:
‘I’ve learnt from missed third degree tears from
colleagues, so now feel it is better to assess briefly than
to miss one’ (Community Midwife, Band 7)
‘usually the trauma needs suturing which is done by
the doctor (if bad enough) who would then perform a
rectal examination. I have seen senior midwives suture
and not do this’ (Hospital Midwife, Band 6)
‘I only do this if I think it is a third degree tear, not
routinely although this is perhaps a good idea’.
(Labour Ward Co-ordinator, Band 8)
Table 1 Suturing techniques to repair perineal trauma
Layer of perineal trauma
Vaginal WallN=321 (%)
Continuous locking sutures190 (59.2)
Continuous non locking sutures*115 (35.8)
Interrupted sutures16 (5.0)
Other
Muscle layer
0
N=323 (%)
Continuous locking sutures 78 (24.1)
Continuous non locking sutures* 98 (30.3)
Interrupted sutures147 (45.5)
Other
Perineal skin
0
N=323 (%)
Sub-cuticular156 (48.3)
Sub-cutaneous* 49 (15.2)
Interrupted sutures102 (31.6)
No sutures inserted 15 (4.6)
Other1 (0.3)
*the recommended evidence based suturing technique.
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With respect to performance of a rectal examination
following suturing of perineal trauma, a higher propor-
tion of the 326 midwives who responded to the question
(279, 85.6%) reported they would perform the examin-
ation ‘all’ of the time, and 33 (10.1%) ‘most’ of the time,
with much smaller proportions reporting that they
would ‘never’ perform this (7, 2.1%) or only perform the
examination ‘some’ of the time (7, 2.1%). There were no
statistically significant differences in band of midwife
(p=0.92), model of care provided (p=0.68), location
(p=0.79) or number of years qualified (p=0.10).
Provision of guidelines, protocols and access to updating
of skills and competencies
The majority of midwives (280, 82.8%) reported that
they had access to a guideline or protocol for the man-
agement and repair of second degree tears, and 267
(79.0%) for the management and repair of episiotomies.
When asked who had developed these guidelines or pro-
tocols (responses were not separated by type of trauma),
143 (42.3%) midwives reported that they had been devel-
oped by the local hospital and 120 (35.5%) that their in-
formation was a combination of hospital/RCOG Green
Top Guideline. Eleven (3.3%) midwives reported that
their organisations only issued the RCOG Green Top
Guideline.
Two thirds of the 337 midwives who responded to the
question (223, 66.2%) reported that their local maternity
service routinely provided structured training for mid-
wives on the management and repair of perineal trauma,
and 182 (54.0%) that their service routinely provided
updated training in these aspects of care. In response to
being asked when they had last undertaken any training
related to perineal assessment and repair, a higher pro-
portion of the 314 midwives who reported that they had
attended training, had received this within the previous
two years (162, 51.6%), the remaining 152 (48.4%) mid-
wives undergoing training from three to over ten years
previously. The midwives were not asked to provide
details of the content of their training. Around two
thirds of the 337 midwives (202, 60.0%) reported that
their organisation had a standardised proforma for docu-
menting perineal trauma, but only 63 (31.2%) of these
202 midwives reported that this included a diagram to
document where the trauma was sustained.
When asked if their competency to undertake assess-
ment and repair of perineal trauma had been formally
assessed, less than half of the 333 who answered the
question (153, 45.9%) reported that it had with respect
to perineal assessment and slightly over half (180, 54.1%)
with respect to perineal repair. Of the 304 midwives
who answered a question on supervision 93 (30.6%)
reported that they felt ‘very’ confident to use the sutur-
ing technique recommended in the guidelines/protocols
they had access to without supervision; 84 midwives
(27.6%) did not feel confident and 127 (41.8%) felt ‘fairly’
confident. Only a third of midwives (96, 28.4%) reported
that their organisation provided a postnatal information
leaflet for women who had sustained perineal trauma.
Final comments
At the end of the questionnaire, space was left for the
midwives who wished to add any further comments.
More frequent themes that arose from these were ‘confi-
dence’ and ‘lack of opportunity’ to develop hands-on ex-
perience, as the following illustrate:
‘I’ve done very little suturing since training, for which
supervision was almost impossible to obtain. It seemed
easier for the Band 7 midwife or obstetric registrar to
do it for you. Therefore competence/confidence
remains limited’ (Hospital midwife, Band 6)
‘It’s difficult to gain experience in perineal repair, as so
many doctors during instrumental delivery or there is
a complication for example, third degree tear/ragged
tear that needs high expertise’ (Hospital Midwife,
Band 6)
‘I participate in labour ward updates frequently and I
also inform the coordinator that I require perineal
suturing. The opportunity never arises’ (Community
Midwife, Band 7)
‘We are now advised to use continuous suturing – I
still prefer the traditional method, interrupted to
muscle and to skin, of which I feel more confident’
(Hospital Midwife, Band 6).
Discussion
This is the first national survey to assess the extent to
which UK midwives are implementing evidence based
management of birth related perineal trauma. Issues
have been identified with implications for the education
and on-going training of midwives to promote their
skills and competencies to ensure the implementation of
evidence associated with reduced maternal morbidity.
Our inclusion criteria were that midwives were currently
in clinical practice and expected to undertake perineal
assessment and repair as part of their clinical role. Most
midwives reported that they undertook assessment and
repair of perineal trauma and around half were also
supervising others to repair trauma. Despite this, around
a third of midwives had not performed any perineal
repairs within the six months prior to completing the
questionnaire, and of those who had repaired trauma,
most had only performed between one to four repairs.
Reasons for such low and infrequent numbers of repairs
are unclear, given the large number of UK women who
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sustain perineal trauma [14], with midwives deemed to
be responsible for the suturing of trauma sustained fol-
lowing spontaneous vaginal delivery unless there has
been anal sphincter involvement [6]. This finding could
explain why so many midwives reported a lack of confi-
dence to assess and repair perineal trauma, with only a
third of the midwives feeling confident to assess perineal
trauma ‘all’ of the time and fewer feeling confident to
repair trauma, despite access to guidelines and proto-
cols to support practice. Currently, there is no national
requirement for midwives or medical staff to perform a
certain number of perineal repair procedures per annum
to maintain their clinical competency.
In this survey, midwives qualified for longer and those
on higher bands (ie the more senior clinical midwives)
were more confident in managing perineal trauma. These
midwives may have completed their midwifery training
and/or been in practice when there was more emphasis
on clinical management of the perineum due to use of
routine episiotomy. The introduction of restrictive versus
routine use of episiotomy in view of the lack of evidence
of benefit following routine use [10] resulted in UK episi-
otomy rates falling from 52% of all vaginal births in Eng-
land in 1980 to 15% in 2010–2011 [14]. The change in
routine practice may have resulted in a gap in the level of
experience of ‘hands on’ perineal management midwives
can achieve. Moreover, recent changes to the pre-
registration midwifery curricula [15] recommend that for
entry onto the register as a qualified midwife, the student
must be able to initiate emergency measures if required,
including episiotomy. However students are no longer
required to perform a specific number of episiotomies
during their training, with anecdotal evidence that some
students have no experience of performing episiotomy
on qualifying. Furthermore, it could be postulated that
they lack confidence in terms of skills and competencies
to support perineal care due to workload pressures and
high obstetric intervention rates precluding learning
from mentors in practice. Interestingly, a recent postal
survey of 1,000 midwives in England, to which 607
(60.7%) replies were received, explored how common a
‘hands off’ approach to perineal management at birth
was implemented by midwives [16]. Around half of the
midwives (299 (49.3%, 95% CI 45.2-53.3%)) preferred the
“hands-off” method, with less experienced midwives more
likely to prefer this approach (72% vs. 41.4%, p<0.001).
Furthermore, a higher proportion of midwives in the
“hands-off” group would never perform an episiotomy
(37.1% vs. 24.4%, p=0.001) for indications other than fetal
distress. Undoubtedly, the above findings suggest an ur-
gent need to consider the subsequent impact that change
in practice has on the content of pre registration midwif-
ery training and the development of skills and competen-
cies in perineal management.
The majority of midwives in the current study were
using suturing materials for perineal repair associated
with reduced maternal morbidity [7]. A Cochrane review
found that compared with catgut, standard synthetic
sutures were associated with less pain up to three days
post delivery (RR 0.83, 95% CI 0.76 to 0.90) and less
need for pain relief up to ten days post birth (RR 0.71,
95% CI 0.59 to 0.87), with no evidence of significant dif-
ferences between groups and perineal pain at three
months, or dyspareunia at three or at six to 12 months
[7]. This may be an area of evidence based practice rela-
tively easy to disseminate and implement, as use of su-
turing materials would be an organisation wide decision
rather than reliant on an individual clinician.
Any potential benefits to maternal health which may
accrue from the use of appropriate suturing material are
likely to be dissipated if the individual clinician’s sutur-
ing technique is not evidence based. Only a small pro-
portion of the midwives in our survey were using
recommended, evidence based suturing techniques to
repair all layers of perineal trauma, despite availability of
evidence based guidance [4,5]. Furthermore, only a third
of the midwives were using continuous non locking
sutures to repair the vaginal wall and muscle layers, with
fewer using subcutaneous sutures to repair the perineal
skin. That only 6% of midwives were using recommended
evidence based suturing methods to repair perineal
trauma was unexpected. It is acknowledged that there are
wide variations in techniques and in materials used for
perineal repair between individual practitioners and ma-
ternity units [6], with the rationale for the suturing tech-
nique chosen appearing to evolve from the way the
clinician was taught in the first place, rather than robust
clinical evidence. Midwives and student midwives were
previously taught to repair perineal trauma using the
interrupted method because it was considered easier to
learn and may have caused fewer problems in the hands
of the inexperienced or novice clinicians [17]. Our data
suggest that this continues to be the method most com-
monly taught, although it has been reported that the con-
tinuous technique is simple to perform and could be
easily taught to inexperienced clinicians [18]. Use of evi-
dence based suturing techniques was not associated with
midwife characteristics examined in the current study, in-
dicating that is a profession wide issue. The failure to pro-
mote use of evidence based suturing methods could be
viewed as further evidence of a widespread and persistent
lack of priority accorded to promote midwifery skills and
competencies in perineal management, despite concerns
over rising negligence claims for the consequences of poor
care [8].
Whilst gaps in practice and evidence implementation
are indicative of need for improved basic and on-going
training in clinical skills and competencies, conversely
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some midwives were making decisions about perineal
management in the absence of evidence. Non-suturing
of second degree tears has persisted in UK midwifery
practice, despite current recommendations for practice,
based on a systematic review of the evidence, supporting
suturing [4]. Two small randomised controlled trials
compared suturing versus non-suturing of second-
degree tears [19,20] although both lacked statistical
power. Lundquist et al [19] randomised 80 primiparous
women to be sutured or not sutured, collecting data on
pain, discomfort and dyspareunia at 2 to 3 days, 8 days
and 6 months after birth. Results showed ‘small’ lacera-
tions left unsutured healed as well as ones which were
sutured, however the definition and measurement of
healing was not clarified, nor was a definition of a ‘small’
laceration provided. Fleming et al [20] randomised 74
primparous women who sustained a first or second de-
gree tear to be sutured (n=33) or not sutured (n=41).
Perineal pain and wound healing were assessed at 1
and 10 days and six weeks postpartum, and postnatal
depression assessed at 10 days and six weeks postpar-
tum. No significant differences were found in reported
pain or depression, but significantly more women in
the sutured group had good wound approximation at
six weeks (p<0.001), further analysis showing that su-
turing and a shorter labour increased odds of wound
approximation.
Current guideline recommendations based on limited
evidence that non-suturing is associated with poorer
wound healing at 6 weeks post-birth are that all second
degree tears should be sutured [4]. Of concern is that
the decision not to suture may be being made on the
basis of a lack of confidence to assess and repair trauma.
The comment from one midwife in the current study
that a second degree tear may be deliberately relabelled
as a first degree tear to overcome the need to suture, is
extremely concerning. The onus to promote accurate
recording of a spontaneous tear may not be viewed as
important as most midwives reported that they were not
required to document the site of perineal trauma sus-
tained using a specific proforma.
Epidemiological and pathophysiological studies gener-
ally concur that the two main factors associated with the
occurrence of faecal incontinence are instrumental deliv-
ery and third/fourth degree tear [21,22]. The incidence
of anal sphincter injury has been reported to range from
one to eight percent during vaginal birth [23-25], with a
more recent systematic review [26] estimating the inci-
dence to be around 11%. Given the increased risk of
developing faecal incontinence following anal sphincter
injury, there are concerns that more severe perineal
trauma may not be correctly identified at the time of birth
by midwives or obstetricians [9]. The NICE Intrapartum
guideline [4] recommends that systematic assessment of
genital trauma following birth should include ‘a rectal
examination to assess whether there has been any damage
to the external or internal anal sphincter if there is any
suspicion that the perineal muscles are damaged’ (p 191).
This recommendation was not routinely implemented by
the midwives in the current study, with around a fifth
reporting that they would ‘never’ perform a rectal examin-
ation as part of routine assessment. Midwife comments il-
lustrate some confusion over their responsibility for
completing the examination, with reference to the import-
ance of checking for a third degree tear only if indicated,
and a lack of supervisory lead in practice. In contrast,
when asked about this aspect of practice following sutur-
ing, most midwives would perform the examination.
Midwives were able to access training in perineal man-
agement, with just over half reporting that their organ-
isation provided updated training in aspects of perineal
care, although the content of training, for example in
terms of whether this included a ‘hands-on’ element,
was not elicited. The midwives’ competencies in aspects
of perineal management were, in some cases, formally
assessed although again the form of assessment was not
identified. As there is currently no national standardised
training programme in the UK for perineal assessment
and management, including evaluation of clinical prac-
tice, the quality and impact of training on uptake of evi-
dence based practice is unknown.
Perineal pain is a commonly reported symptom of ma-
ternal morbidity and is highly associated with perineal
trauma [2,27]. Recommendations for appropriate pain
relief and promotion of advice on perineal hygiene are
provided in the NICE guideline for routine postnatal
care [28] which highlighted a lack of appropriate infor-
mation for women on this aspect of their post-birth re-
covery. Although a commonly experienced symptom, it
was apparent that in many cases midwives did not have
access to provide women with information on how to
manage recovery of their perineal trauma post-birth.
The most recent triennial report into maternal deaths in
the UK from the Centre for Maternal and Child Enqui-
ries (CMACE) found that, although very rare in the UK,
sepsis was the leading cause of direct maternal deaths
during 2006 – 2008 [29]. CMACE recommended that all
antenatal and postnatal women should be offered advice
on the signs and symptoms of life threatening condi-
tions, including sepsis. The team also recommended that
this information should include the importance of good
hand and perineal hygiene and need to seek immediate
medical care if feeling unwell.
There are several potential limitations to this study.
Surveys are useful to collate data from a large sample
size at one point in time, but do not provide an oppor-
tunity to address the context of care and are subject to
potential responder bias [30]. Despite the low overall
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response rate which was a consequence of up to date
details on RCM members not being collated by the Col-
lege and thus not available to the authors, a high num-
ber of responders met our inclusion criteria and were
representative of the current midwifery workforce. The
larger number of midwives qualified for 20 years or
longer reflects the age profile of the current UK midwif-
ery workforce, with around 4% of midwives working out-
side of the NHS [31]. The numbers of midwives working
in different models of care was also reflective of current
maternity service organisation [32], although it is less
clear if the geographic location of care was representa-
tive of current service availability.
Conclusions
This survey has identified considerable gaps with imple-
mentation of evidence by midwives in practice to support
the management of birth related perineal trauma. Histor-
ically, it is acknowledged that the provision of training in
assessment and management of perineal trauma has been
neglected. Changes in perineal management interventions
in the UK, such as reduction in routine use of episiotomy
and the low number of repairs performed by midwives as
reported in our survey, may now be contributing to a low
level of confidence among midwives to assess trauma and
perform perineal repair, particularly among those who
qualified more recently. The low number of repairs being
undertaken by midwives is also likely to influence midwif-
ery views of their skills and competencies, with some indi-
cation from midwife comments that a lack of opportunity
was preventing them from developing these. Further ex-
ploration is required of midwives’ use of knowledge to in-
form their clinical decisions, given the relatively high
proportion who would not suture second degree tears
despite national recommendation. The need to address
these issues through provision of nationally agreed stan-
dards for training is essential if women’s short and longer-
term health is to benefit from evidence based interven-
tions. Survey findings have informed the content and de-
livery of the PEARL study national clinical quality
improvement study, results from which will be published
separately.
Details of ethics approval
Ethics approval was obtained from the Thames Valley
Ethics Committee (07/MRE12/12).
Competing interests
The members of the PEARLS study group declare they have no financial or
non-financial competing interests in the research presented.
Author’s contributions
DB and CK conceived the original study, and DB, CK, SM, KMI, ST and PT
contributed to the study design. All authors edited the manuscript and read
and approved the final manuscript. DB is the study guarantor.
Acknowledgements
The authors would like to thank all midwives who completed the
questionnaire.
Author details
1Professor of Evidence Based Midwifery Practice Kings College London,
Florence Nightingale School of Nursing and Midwifery, 57 Waterloo Road,
London SE1 8WA, UK.2School of Clinical & Experimental Medicine, College
of Medical & Dental Sciences, University of Birmingham, Birmingham B15
2TT, UK.3Education and Research Manager, Royal College of Midwives, 15
Mansfield Street, London WIG 9NH, UK.4Centre of Postgraduate Medical
Research and Education, School of Health and Social Care, Bournemouth
University, R506A Royal London House, Christchurch Road, Bournemouth,
Dorset BH1 3LT, UK.5Research Manager West Midlands (South)
Comprehensive Local Research Network, University Hospitals Coventry and
Warwickshire NHS Trust, University Hospital, Clifford Bridge Road, Coventry
CV2 2DX, UK.6Maternity Centre, Professor of Women’s Health Staffordshire
University and University Hospital of North Staffordshire, Newcastle Road,
Stoke-on-Trent, Staffordshire ST4 6QG, UK.
Received: 11 March 2012 Accepted: 1 June 2012
Published: 25 June 2012
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doi:10.1186/1471-2393-12-57
Cite this article as: Bick et al.: How good are we at implementing
evidence to support the management of birth related perineal trauma?
A UK wide survey of midwifery practice. BMC Pregnancy and Childbirth
2012 12:57.
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