PEACHES care bundle: reducing OASI Julie Frohlich Guy’s and St Thomas’ NHS FT

OASI: HES data 2000-2012 1.8%-5.9% OASI Risk factors for nulliparous women: Maternal age >25 Asian women Birth weight >4kg Forceps without episiotomy: highest rate (22%) Ventouse without episiotomy x3 compared to with episiotomy Higher socio-economic status Shoulder dystocia (11%) Birth with ML episiotomy was associated with lowest rate of OASIS Gurol-Urganci BJOG 2013 Acknowledge Bob Freeman, Plymouth for following four slides Hands poised and reluctance to use episiotomy

Other OASI risk considerations Additional risk factors for nulliparous women: Occipito posterior (OP) delivery (OR 3.35, 95% CI 1.75–6.41) Prolonged second stage (OR 1.98, 95% CI 1.46–2.68) Protective factors: Epidural analgesia (OR 0.72, 95% CI 0.54–0.96) Preterm birth (OR 0.40, 95% CI 0.23–0.72) Episiotomy (OR 0.54, 95% CI 0.39–0.74) protective in nulliparous women (Hauck et al 2015) 10.408 births in Western Australia

And more to consider… (Elvander et al 2015) Nulliparous women OASI = 5.7% Multiparous women OASI = 1.3% VBAC OASI = 10.6% Lateral position had a slightly protective effect in nulliparous women Increased risk among women in the lithotomy position, irrespective of parity Squatting and birthing seats involved an increase in risk among parous women Swedish data =base of 113000 births 2008-2014

The GSTT OASI audit Our initial audit highlighted the following potential ‘dangers’: Instrumental delivery Birthing stool Pool births (not consistent with other data) Squatting and other upright positions Lithotomy position Student midwife attended birth

1. Birth Position: all vaginal deliveries Majority of births semi-reclined Least common is birthing stool

% rate of OASI by delivery position Birth stool known to increase OASI therefore not recommended Birth pool most common practice is a ‘hands off’ technique Lithotomy – associated with OASI

Midwife and student midwife OASI rates Student midwife rates for OASI higher than RCOG guidelines and five fold midwife facilitated SVBs: they attended 10% of all SVBs but 26% of SVB OASI

OASIS affects women’s lives Anal incontinence Urgency Pain and sexual problems Psychological and social Pelvic floor problems post menopause A significant proportion have elective CS for all subsequent births

Can we prevent trauma? Cochrane reviews endorse: Perineal massage for nulliparous women Warm compresses during the birth Lateral position

Can we prevent OASIS? Recent meta analysis: Currently, evidence from the meta-analysis of RCTs is insufficient to drive change in practice; however, NRS meta-analysis results suggest that there might be a significant benefit in a ‘hands on’ policy. (Bulchandani et al 2015)

PEACHES P = Position E = Extra midwife (present at birth) A = Assess the perineum (throughout) C = Communication H = Hands-on technique E = Episiotomy if required S = S-L-O-W-L-Y

Progress so far… All clinicians attending births at GSTT are expected to adopt PEACHES The PDMs, senior midwives and senior obstetricians are available to support and advise less experienced staff PEACHES training at all new staff induction and at mandatory training Monitoring OASIS on an ongoing (monthly) basis and regularly report progress to all staff PEACHES has been adopted by GSTT as a Sign up to Safety initiative PEACHES was awarded a Health Innovation network award in December 2015 to fund a PEACHES training video OASI risk assessment labels about to be introduced

PEACHES training video https://vimeo.com/202243547 Password: gstt99

Additional risk factors for OASI identified in the ongoing in GSTT audit Low BMI Precipitate first / second stage Pushing for >1 hour

GSTT audit 2015-16

OASI rates at GSTT The OASI % is as a % of all vaginal birth not all birth (so CS has been excluded). Since August 2016 the OASI rate has been sustained below 3% - half of the January 2015 rate when PEACHES was introduced.

Summary OASI is a potentially avoidable morbidity Every OASI prevented is an important gain Our evidence suggests that the PEACHES care bundle or similar can make a difference

References Andrews A, Thakar R, Sultan AH and Jones PW. Are mediolateral episiotomies actually mediolateral? BJOG 2005 112:1156-8 Bulchandani S, Watts E, Sucharitha A, Yates D, Ismail KM. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG 2015; DOI: 10.1111/1471-0528.13431. Cortes E, Basra R, Kelleher CJ. Waterbirth and pelvic floor injury: a retrospective study and postal survey using ICIQ modular long form questionnaires. European Journal of Obstetrics and Gynecol and Reproductive Biology 155 (2011) 27 -30 Eogan M, Daly L, O’Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? Am J Obstet Gynecol 2005: 556;S157 Charlotte Elvander1, Mia Ahlberg, Li Thies-Lagergren, Sven Cnattingius, Olof Stephansson Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births. BMC Pregnancy and Childbirth (2015) 15:252 Gurol-Urganci I1, Cromwell DA, Edozien LC, Mahmood TA, Adams EJ, Richmond DH, Templeton A, van der Meulen JH BJOG. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. 2013 Nov;120(12):1516-25. Epub 2013 Jul 3. Hals E, Oian P, Pirhonen T et al (2010). A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstetrics and Gynecology 116(4):901-8. Hauck YL et al Risk factors for severe perineal trauma during vaginal childbirth: A Western Australian retrospective cohort study. Women and Birth Volume 28, Issue 1, March 2015, Pages 16–20 Ten Years of Maternity Claims An Analysis of NHS Litigation Authority Data. NHSLA October 2012 Tincello DG, Williams A, Fowler GE, Adams EJ, Richmond DH, Alfirevie Z. Differences in episiotomy technique between midwives and doctors BJOG 2003: 110;1041-4