The Obstetric Anal Sphincter Injury (OASI) Care Bundle A quality improvement programme to reduce the incidence of third- and fourth-degree perineal tears

Our Care Bundle aims to address these issues Current issues in OASI prevention in the UK Our Care Bundle aims to address these issues Inconsistencies in approaches to preventing OASIs Inconsistencies in training and skills Lack of awareness of risk factors and long-term impact of OASIs Variation in practice between midwives and doctors 1 Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOP). Int Urogynecol J 2011;22:1279–85 2 Ismail KM, Paschetta E, Papoutsis D, Freeman RM. Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey. Acta Obstet Gynecol Scand.2015 Feb;94(2):165-74. 3 Andrews V, Sultan AH, Thakar R, Jones PW. Risk factors for obstetric anal sphincter injury: a prospective study. Birth. 2006 Jun;33(2):117-22. 4 Naidu M, Kapoor DS, Evans S, Vinayakarao L, Thakar R, Sultan AH. Cutting an episiotomy at 60 degrees: how good are we? Int Urogynecol J. 2015 Jun;26(6):813-6. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol. 2002 Feb 10;101(1):19-21.

What is a Care Bundle? A care bundle is a small set of evidence-based interventions for a defined patient segment or population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually. Institute for Healthcare Improvement

Such as posters, pens, balloons, memory aids There are three major components to the intervention which will be implemented together: Multi-disciplinary skills development module Campaign materials The care bundle 4 evidence-based interventions that, when implemented together, will result in significantly better outcomes than when implemented individually. A Care Bundle Guide will be provided Such as posters, pens, balloons, memory aids Champions will attend a Skills Development Day Training in interventions Guidance and support in rolling out in their units Training materials provided: E.g. videos, visual aids and a quiz

The OASI Care Bundle Inform the woman about OASI and what steps can be taken to minimize her risk. (an information leaflet will be provided) Use of manual perineal protection Spontaneous births if position allows it (women who give birth in water are excluded) All assisted births (forceps and ventouse) Medio-lateral episiotomy (60 degree angle) at crowning to be used when indicated. Perineum must be examined after delivery and any tears graded according to the RCOG guidelines. Examination should include a per rectum check, even when the perineum appears intact. 1 2 3 4

The intervention will be facilitated by: 1. Local clinical champions (one midwife and one obstetrician from each unit). They will champion the project including: ensuring that staff have completed the multi-disciplinary skills development module, monitoring local compliance with the care bundle, reporting on unit-level OASI rates, and participating in shared learning days with the other units in their block. 2. Leadership and support from professional organisations will be provided by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) who will actively promote the project and will provide a joint statement endorsing the use of care bundle. In addition, the professional and educational networks of the Colleges will be actively used to support the skills development module. 3. Continuous monitoring and feedback will allow participant units to measure their progress, by reporting their OASI rates, compliance with the care bundle, and uptake of the skills development module. Units will participate in shared learning days with other units to provide a forum to discuss the project as it progresses.

Evaluation of implementation outcomes Acceptability Satisfaction with intervention Survey of champions on Skills Development Day (A, F) Improved knowledge, awareness & skills Routine monitoring of basic data (F, C) Feasibility Extent to which intervention can be applied Standardised delivery of the evidence based intervention Focus groups with clinicians during site visits (A, F, S) Coverage Extent to which population receive the intervention Continued uptake & sustainability of the intervention Focus groups with champions at Shared Learning Day (A, F, S) Sustainability Extent to which intervention is maintained Follow-up interviews with champions (S)

Number of eligible women in each time period 32,800 women are potentially eligible to receive the care bundle over a 12 month period.

Overall programme plan Project set-up Block 1 Roll-out Implementation Block 2 Block 3 Block 4 Evaluation Practice outcomes Clinical outcomes Dissemination Where we are now Stages in each block Planning Roll-out Implementation Skills development day Shared learning day

Our project team Ranee Thakar Croydon Health Services NHS Trust Clinical lead Vivienne Novis RCOG; Frimley Health NHS Foundation Trust Midwifery lead Anita Dougall RCOG Director, Clinical Quality Louise Silverton RCM Director for Midwifery Jan van der Meulen RCOG; London School of Hygiene and Tropical Medicine Senior Methodology Advisor Nick Sevdalis Kings College London Quality Improvement Lead Ipek Gurol-Urganci Evaluation lead Alexandra Hellyer RCOG Project manager Posy Bidwell Research Fellow Louise Thomas Head of Quality Improvement Anita Dougall Senior Director, Clinical Quality Alison Elderfield Head of the Lindsay Stewart Centre

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