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

2. OASI: HES data %-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

3. 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)
births in Western Australia

4. 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 births

5. 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

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

7. % 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

8. 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

9. 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

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

11. 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)

12. 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

13. 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

14. PEACHES training video
Password: gstt99

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

16. GSTT audit

17. 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.

18. 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

19. References
Andrews A, Thakar R, Sultan AH and Jones PW. Are mediolateral episiotomies actually mediolateral? BJOG :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: /
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)
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 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 Nov;120(12): 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