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 sustain perineal trauma , with midwives deemed to be responsible for the suturing of trauma sustained following spontaneous vaginal delivery unless there has been anal sphincter involvement . This finding could explain why so many midwives reported a lack of confidence 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 protocols 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  resulted in UK episiotomy rates falling from 52% of all vaginal births in England in 1980 to 15% in 2010–2011 . 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  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 . 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 urgent need to consider the subsequent impact that change in practice has on the content of pre registration midwifery training and the development of skills and competencies in perineal management.
The majority of midwives in the current study were using suturing materials for perineal repair associated with reduced maternal morbidity . 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 differences between groups and perineal pain at three months, or dyspareunia at three or at six to 12 months . This may be an area of evidence based practice relatively easy to disseminate and implement, as use of suturing 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 suturing technique is not evidence based. Only a small proportion 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 maternity units , with the rationale for the suturing technique 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 . Our data suggest that this continues to be the method most commonly taught, although it has been reported that the continuous technique is simple to perform and could be easily taught to inexperienced clinicians . Use of evidence based suturing techniques was not associated with midwife characteristics examined in the current study, indicating that is a profession wide issue. The failure to promote 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 .
Whilst gaps in practice and evidence implementation are indicative of need for improved basic and on-going training in clinical skills and competencies, conversely 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 . Two small randomised controlled trials compared suturing versus non-suturing of second-degree tears [19, 20] although both lacked statistical power. Lundquist et al 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’ lacerations 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 randomised 74 primparous women who sustained a first or second degree 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 postpartum. 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 suturing 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 . 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 sustained using a specific proforma.
Epidemiological and pathophysiological studies generally concur that the two main factors associated with the occurrence of faecal incontinence are instrumental delivery 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  estimating the incidence 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 . The NICE Intrapartum guideline  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 examination as part of routine assessment. Midwife comments illustrate some confusion over their responsibility for completing the examination, with reference to the importance 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 suturing, most midwives would perform the examination.
Midwives were able to access training in perineal management, with just over half reporting that their organisation 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 practice, the quality and impact of training on uptake of evidence based practice is unknown.
Perineal pain is a commonly reported symptom of maternal 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  which highlighted a lack of appropriate information for women on this aspect of their post-birth recovery. 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 Enquiries (CMACE) found that, although very rare in the UK, sepsis was the leading cause of direct maternal deaths during 2006 – 2008 . CMACE recommended that all antenatal and postnatal women should be offered advice on the signs and symptoms of life threatening conditions, 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 opportunity to address the context of care and are subject to potential responder bias . Despite the low overall response rate which was a consequence of up to date details on RCM members not being collated by the College and thus not available to the authors, a high number 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 midwifery workforce, with around 4% of midwives working outside of the NHS . The numbers of midwives working in different models of care was also reflective of current maternity service organisation , although it is less clear if the geographic location of care was representative of current service availability.