Episode 19 - The Perineal Bundle
Mel:
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host Dr Melanie Jackson. I'm a clinical and research midwife with my PhD and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth and postpartum journey. Gorgeous. All right, welcome everybody. We're joined by Nigel Lee who is a researcher. Are you from Queensland Nigel?
Nigel:
[0:33] Yes yep from a number of other places but currently in Queensland yes.
Mel:
[0:36] We want to discuss the perineal bundle today and people might not have heard about that but it's all going to be revealed. So could you give us a brief introduction to yourself because I feel like you keep a low profile but you've done some pretty amazing stuff.
Nigel:
[0:52] Well firstly I'm a midwife.
B:
[0:53] And I've been a
Nigel:
[0:54] Midwife for quite a long time. Did my trainee.
B:
[0:57] In the mid-80s
Nigel:
[0:58] And worked a lot in, well, predominantly in birth suites.
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B:
[1:01] But around sort of regional New South Wales and Victoria. And then went overseas and did a stint working in the UK as a midwife in what they call a fairly small hospital,
Nigel:
[1:10] But it did around about sort of three or 4,000.
B:
[1:12] Births a year and worked there as a practice development midwife. And again, predominantly on the birth suite and then came back to Australia and worked in Brisbane as
Nigel:
[1:19] A team leader on the.
B:
[1:20] Birth suite at the Mater Hospital, which is Australia's largest in a maternity hospital. We did about 10,000 births a year.
Nigel:
[1:27] And I was there for about 15 years before completing a PhD around sterile water injections. And that was kind of.
B:
[1:32] Part of a sort of a transition plan, kind of a semi-retirement plan to move into academia. The retirement bit being no nights and weekends off, which was nice. It was getting a bit old for the night shift, to get a bit old and grumpy on nights. So I thought, no, I've got to do something about this.
Mel:
[1:47] So then, so you did a PhD in sterile water injections. How old were you at that point?
Nigel:
[1:53] Oh, good grief. I was, like a lot of midwives, you know, I came to research fairly late.
B:
[1:58] So I was in my early 50s when I finished my PhD because we'd had the Queensland floods about the same time that we'd kind of finished data collection.
Mel:
[2:06] So amazing. That's inspiring for a lot of midwives, I think, actually. So then from your PhD, what happened then?
Nigel:
[2:15] Then I got a job with the University of Queensland as a midwifery lecturer, stroke sort of researcher.
B:
[2:19] And continued to do sort of my research on that.
Nigel:
[2:23] And then the last sort of 18 months.
B:
[2:24] I've been fortunate enough to be in a research-only position and recently picked up an NHMRC investigator grant, which means it'll hopefully fund me my research for the next few years.
Mel:
[2:35] Well, they are lucrative, those guys.
Nigel:
[2:37] Yes, they're pretty competitive.
B:
[2:39] And there aren't a lot of midwives that get them, so I was pretty happy to pick that up.
Mel:
[2:43] So, Nigel, do you want to explain it to everyone listening today?
Nigel:
[2:47] Well, the perineal bundle is something that has been around for quite some time in various guises in various countries.
B:
[2:54] The WHA, which I remember it stands for Women's Hospitals Australia or something along that lines, decided that they put out the idea that there was a bit of a crisis in terms of maternity care, in terms of severe perineal injury.
Nigel:
[3:08] And certainly, this is something we would all like to do something about.
B:
[3:11] But interestingly, the numbers in terms of severe perineal injury haven't really increased since 2011.
Nigel:
[3:16] But yes, it'd be good to do something about it.
B:
[3:18] You know, it has a significant impact upon women's health after birth, particularly in terms of not an ongoing sexual health, but ramifications for any current births or any subsequent births. And
Nigel:
[3:29] So they were.
B:
[3:30] Looking at ways of sort of putting together a bundle to try and reduce this. We've always had this kind of conversation primarily around sort of the hands-off, hands-poised approach to birth. And the bundles overseas that were developed initially in sort of Scandinavia were very focused on the sort of hands-on approach, which is fairly sort of traditional approach, despite the fact that many midwives use the hands-poised. The hands-poised is really the hands-on. Hands-off and hands-poised tends to go together, whether you put your hand on the fetal head and the perineum, or whether you just kind of have your hands there ready in case you think it needs it, whereas the hands-on kind of obligates the midwife to apply that pressure to
B:
[4:06] the baby's head and try and sort of pinch the perineum together to stop it from tearing.
Nigel:
[4:11] That's a big part of the bundle. All the other parts of the bundle are.
B:
[4:13] The position which the woman gives birth in needs to be such a position that the midwife can actually visualise the perineum adequately. The problem with that is that invariably it's a supine position. So realistically, you've got to have the woman on her back to visualise the perineum in that respect and certainly apply the hands-on. And one of the studies we did,
Nigel:
[4:32] We saw that the midwives who applied the hands-on approach.
B:
[4:36] Women in that group gave birth, about 98% of them gave birth on their back. as opposed to it was midwives who didn't. We had many more women who were giving birth in upright positions when the hands-on approach was not used.
Mel:
[4:49] Can we start from the very, very beginning of discussing that there's five elements to the perineal bundle and the idea is that these five elements are used together,
Mel:
[5:01] Although I can see in the perineal bundle documentation that they've kind of, they've talked about, oh, it's not mandatory. oh you have to ask women if they want all these things oh by the way oh this and that but technically a bundle is supposed to be used all together so this Australian bundle recommends the first element is warm compressors on the perineum the second element is a slow controlled birth of the head which involves that hand positioning hands-on positioning that you talked about where you cinch together the perineum and you apply a hand to the baby's head to in an attempt to somehow protect the perineum, I'm using inverted commas, and slow the birth of the baby's head. Then the third element is they talk about the technique when performing an episiotomy. The fourth element is assessment of perineal tears, which involves putting your finger in every single woman's rectum post birth to assess for any rectal damage, even if there's no perineal tear.
Mel:
[6:04] And then the fifth element is accurately grading the severity of perineal tears. So that's the bundle in a nutshell. And actually anybody who wants to see the perineal bundle listed out with detail, I'm going to put the links up as well in all the documentation for the mailing list.
Mel:
[6:22] And it will be underneath this, in the show notes underneath this podcast episode. So you've done a study that's looked at the perineal bundle?
Nigel:
[6:31] Well, we did a study that looked at hands-off and directed pushing prior to.
B:
[6:35] And this was just as the perennial bundle was being introduced. And then we did some qualitative work a couple of years after the bundle had been introduced, looking at midwives' experiences of being introduced because of the surveillance and the sort of mandatory parts of it, and also women's experiences.
Nigel:
[6:54] And what we found was basically, you know, there are essentially four.
B:
[6:57] Things that are probably, you know, wrong or not great about the perineal bundle. First one is the evidence base behind it. So as Melanie is saying, one of the aspects is warm compresses to the perineum.
Nigel:
[7:08] And that's pretty well the only component.
B:
[7:10] Of the perineal bundle that actually has any solid evidence base behind it. The others don't.
Mel:
[7:16] And so the warm compress evidence is that it decreases third and fourth degree tears, which is the whole point. So they came up with this bundle, but the only part of it, that was actually evidence-based was
B:
[7:26] The warm compress.
Nigel:
[7:27] So there's been a number of randomised trials that have looked at the.
B:
[7:30] Hands-on versus hands-poised and hands-off.
Nigel:
[7:33] They've never shown any difference in severe perineal tearing between those groups. So it doesn't seem to be.
B:
[7:38] You know, they're either
Nigel:
[7:39] Equally as effective or.
B:
[7:40] Equally as ineffective as each other in terms of reducing severe perineal tearing.
Nigel:
[7:44] The evidence behind.
B:
[7:45] The changes to episiotomy are pretty weak, but we have seen significant rises in rates of episiotomy in Australia since the bundle was introduced.
Nigel:
[7:53] And the research that we did just prior to.
B:
[7:55] The bundle coming in, we looked at episiotomy rates in midwives who used a hands-on approach as opposed to those who used a hands-on or hands-poised.
Nigel:
[8:03] And what we found that midwives who used a hands-on approach were two and a half times more likely to cut.
B:
[8:08] An episiotomy than those who didn't.
Nigel:
[8:10] But the rates of severe perineal tearing did not differ between the two.
B:
[8:14] So it was not making any impact it was not being protective of reducing severe perineal tearing
Mel:
[8:20] There was no evidence that episiotomy is reduced severe perineal tearing but we put it into the bundle and when we put it into the bundle we got specific about them didn't we so they're cut outwards away from the anal sphincter so the whole belief around episiotomies is that if you create this artificial tear that goes away from the anus then you're going to prevent tearing to the anus that's the belief around them but there is no evidence that has ever proved that
B:
[8:46] No not
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Nigel:
[8:47] In vaginal bursts there's some you know argument around forceps and vacuum bursts they're.
B:
[8:52] Really quite different because you're inserting something else into the vagina so it creates an extra room but
Mel:
[8:57] With vaginal burst without instrument no evidence that it decreases tears but we put it into the bundle anyway there
Nigel:
[9:03] Were we had there.
B:
[9:05] Were anecdotes from that and we know that some hospitals were using variations of protractors to to help midwives gauge the the angle of the um the episiotomy because it changed from about sort of 30 to 40 degree angle from the perineum to
Nigel:
[9:19] About 60 degrees.
B:
[9:20] Which is really quite significant. It's almost like cutting sideways instead of angling down. And to assist them with that, there were a few protractors hanging around and somebody sort of came up with the idea of maybe we can have a clear piece of plastic with a line drawn on it that we can put up against Norman's perineum, which has to be on her back again, of course, so then we know the angle. We can cut through the plastic and the perineum at the same time and get the angle correct. Yeah.
Mel:
[9:44] And the bundle says when, so these are the guidelines, says when an episiotomy is indicated, it should be at a minimum of a 60-degree angle. And when I had a little look into that too, there's...
Nigel:
[9:58] There's a little bit. There's been a couple of small studies.
B:
[10:00] That have suggested, you know, it might...
Nigel:
[10:02] One of the problems with.
B:
[10:03] Cutting episiotomies was that it was a risk factor for third-degree tears because you'd taken away the integrity of the perineum and then there's the chance that the episiotomy would continue to tear through and down into the sphincter. So it was always highlighted as a risk factor. So the idea of changing the angle from sort of 30 to 40 degrees, 60 degrees, was to reduce the chance of the tear continuing down and cutting through the anal sphincter. So
Nigel:
[10:29] All it really.
B:
[10:30] Did was address the risk from cutting the episiotomy in the first place as opposed to reducing the risk of third and fourth degree tears initially, which is why we never saw any real change.
Mel:
[10:41] And we've now got sorry we're saying just time to sum this up right we've now told people how to birth but i'm told them what position to take which we know is not evidence-based or comfortable because i've never seen and just so you know to people listening episiotomies are always cut with a person on their back so we've put you on your back to do the hands poise we know that hands poise increases the risk of you on the one oh i keep saying you know why because i'm like if your hands are poised they're going to be on like no that's my thinking it's different but that's like from a from a practical sense i'm like if you're poising them no it's very different hands off and hands poise the same thing intent is hands off if you need to do something so anyway to do hands on you have to be on the back and that increases the risk of a peasy on me by two and a half percent, two and a half times what you saw. Right. So just to sum that up, just so people are getting where we're getting to, that's all. The bundle was created because there's a two to three percent chance overall that a woman could have a third or fourth degree test. And so the intention, noble as it was, was to reduce that two or three percent. However, now with this bundle, we've found ourselves in a situation where one in four women, so the recent Australian women's data says that 23% to 24% of women are getting an episiotomy now in Australia.
Nigel:
[12:09] Yes. Yeah.
B:
[12:10] So it's gone from about 18% up to about 24%,
Nigel:
[12:13] Which is over a period of a couple of years.
B:
[12:15] It's a fairly significant rise.
Nigel:
[12:16] And the one thing that's missing.
B:
[12:18] Of course, is any sort of longitudinal studies that look to the impact of increasing the angle to 60%, you know, the ongoing sort of sexual health of women after giving birth and having these...
Mel:
[12:28] So the perineal bundle itself lacks the evidence to do the practice in the first place.
B:
[12:32] Oh, yes.
Mel:
[12:34] We take this opportunity to talk about how it was implemented because there are claims that the bundle is, you know, if you read any of Rachel Reid's stuff, who was very passionate about the perineal bundle or what she affectionately calls the perineal bungle. The fact is, is that they created this bundle with, as you say, very little evidence. Most of the elements don't have evidence to support them in the bundle. And then they rolled it out to 28 hospitals in order to test it. And all of the training process was focused around training the health professionals in those hospitals to administer the bundle. But women weren't involved in the study in a sense that they weren't told they were part of a research project and they didn't necessarily consent to be a part of it. Would that be right?
Nigel:
[13:23] It was, yeah, it was, in some respects, it was presented as a research project, but actually it wasn't.
B:
[13:28] It was more of a sort of a quality improvement. So there was no sort of testing against another group that weren't getting it. But certainly in terms of, there were a number of issues in the way that it was rolled out. We did a study with midwives in terms of their experiences of this. And what we
Nigel:
[13:45] Found was because there was quite a.
B:
[13:47] Bit of surveillance in the initial period after the rollout of the midwives to ensure they were using it, so there was a little checklist that they had to tick off and there were people wandering around with clipboards out of the birthing rooms, making sure that they used the hot packs and applied their hands the way they used all the elements of the bundle. So there was a lot of surveillance going on that would not normally occur within a birthing environment, which of course put people in the birthing environment that would not normally be there.
Nigel:
[14:11] And we found that probably about a third of midwives thought.
B:
[14:15] Okay, well, this is a reasonable idea.
Nigel:
[14:16] They were probably.
B:
[14:17] Hands-on midwives in a way and thought, this is kind of using parts of my practice that would normally do it. So that's okay. I'll kind of go along with that.
Nigel:
[14:24] And then there were about a third of midwives who thought.
B:
[14:26] Well, you know, I'm being told I have to do it, that it's compulsory. The catch cry was every woman, every time. And so they were really just kind of, they may not necessarily agree with it, but they were just kind of compliant because it's, you know, that's their job. And they didn't want to get moved off the birth suite if they weren't doing the right thing.
Nigel:
[14:41] And then probably a.
B:
[14:42] Slightly less than a third number of midwives were, as we often are in these situations, looking at ways to get around it. And a number of those were quite successful, even in terms of, you know, talking to women and sort of explaining and saying, okay, well, you actually have a choice, you can say no, or birthing women specifically in positions or in using water births as a means of sort of subverting some of the elements of the bundle itself.
Mel:
[15:06] The perineal bundle isn't in all hospitals, is it?
Nigel:
[15:09] No, only those who are members of the WHA. Some hospitals have.
B:
[15:12] Kind of picked
Nigel:
[15:13] Up various elements of it.
Mel:
[15:14] Asking whether the erectile exam happens routinely at your hospital is also something may want to know so i can we just explain that one just so people actually understand why that was brought in and what's it meant to achieve?
Nigel:
[15:27] Well, the ractual exam is supposed to.
B:
[15:29] Determine whether a woman has had a third degree tear or not. So whether there's an injury that's involved the anal sphincter.
Nigel:
[15:37] Sometimes these are.
B:
[15:38] And it's been quite common after a birth, there's an existing tear there that we check that tear to see whether it's actually involved the anal sphincter. And that's been routine practice for many, many years. And it's reasonable to do that. What this introduced, which was quite different, was actually doing rectal examinations on women who had intact perineum, so had no obvious or visible injury to the perineum at all. So the idea being that there may be some occult or some injury to the anal sphincter that you may not be able to see, but you might be able to feel if you put your finger in a woman's anus and actually had a good feel of the sphincter tissues themselves.
Nigel:
[16:15] So these are reasonably rare.
B:
[16:18] Certainly, they have implications for women when they're there.
Nigel:
[16:21] But the question is, if you find one.
B:
[16:24] What are you going to do about it?
Mel:
[16:25] So what would be done about it? What's the purpose of trying to find it?
B:
[16:28] They are so uncommon that we don't really have any practice guidance in terms of, okay, what do we do now? Do you actually undergo surgery? And so does it mix back together? Do you wait and see if it heals of its own accord? You then go on and do further ultrasound studies to see if you can determine more accurately whether it only involves a few fibres or whether it's completely through the sphincter itself and what you do about that.
Nigel:
[16:51] So it's difficult to sort of say, okay, we do this assessment. If we're going to do this assessment.
B:
[16:56] Then maybe we should have figured
Nigel:
[16:57] Out up before that.
B:
[16:58] What we're going to do about it once we've found it.
Mel:
[17:00] So the bundle did not advise. It just said, do the step, find it, but it doesn't advise what to do thereafter. No. No.
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Nigel:
[17:06] That's part of the problem. The research we.
B:
[17:09] Did with women and their experience of the bundle brought up two issues. The first one was that we interviewed about 15, 20 women and none of them were advised of the bundle during the antenatal period, so prior to the birth itself. There was no information prior to them. Then for a number of those women, when it came to the examination,
Nigel:
[17:26] The consent process was lacking.
B:
[17:30] It was often sort of,
Nigel:
[17:31] We need to do this exam.
B:
[17:32] Is that okay with you without actually sort of specifically saying, actually, it's going to involve a vaginal and a rectal exam, even though your perineum is intact.
Mel:
[17:41] So I'm just going to stick my finger into your anus now. And it happens without a pause or a question.
Nigel:
[17:48] Yes. And sometimes that wasn't even raised.
B:
[17:49] It was just, oh, we need to check down below sort of thing to make sure you're okay. Is that all right? Yep. And then lo and behold, that involved a rectal exam. They weren't kind of prepared for and certainly hadn't consented to.
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Mel:
[17:59] And the idea of a rectal examination, because when this was introduced, I don't think midwives were routinely doing rectal examination. And so then we're all of a sudden told, okay, now you've got to check their bottom and their anus and see if there's any tears that have gone through there. What does, I mean, I don't know about other midwives, but if they're so incredibly rare, most midwives don't know what this actually feels like on digital examination with their finger. Well, what I'm saying is, is that we've been told to assess the rectum, but like you said, we don't know what the usual integrity of the rectum is supposed to feel like because we're not used to routinely checking rectums. And then if we did find something, would we even have the capacity to recognise it with how rare it is?
Nigel:
[18:44] Yeah, it's a good point. And I think, you know, one of the points, the recommendations the.
B:
[18:47] Bundle does make is that two clinicians should be present when the perineum is being assessed to see if there's a severe perineal tearing there,
Nigel:
[18:55] Which is, you know.
B:
[18:56] Probably fair enough in terms of We're not very often very, very good at picking these up, as you say.
Nigel:
[19:01] But it doesn't really sort of specify, okay, what are the.
B:
[19:03] Qualifications and the experience and training of these clinicians are.
Nigel:
[19:06] So for midwives who've done perineal suturing for some time, they'll probably have.
B:
[19:09] A reasonable idea of what a third and fourth degree feels like because they've done perineal rectal exams as kind of a relatively routine part of undertaking perineal suturing.
Nigel:
[19:20] But for those younger midwives or those who are not.
B:
[19:22] Trained in perineal suturing, then it's going to be quite difficult, say, to get an idea of what a third and fourth degree tear is going to feel like when the rest of the perineal tissue is intact. Yeah.
Mel:
[19:33] And so I'm looking down the list now of the elements of the perineal bundle. We've already decided, yes, warm compresses, good evidence. We can do that to reduce the incidence of third or fourth degree tears.
Mel:
[19:46] And you can apply a warm compress with women in any position.
Mel:
[19:51] I can vouch for that because we do it when we give birth on land in physiological positions at home. We've determined the element two of encouraging the slow controlled birth of the head with a hands-on approach doesn't have an overwhelming level of evidence to support this hands-on idea and what compounds that issue is that when midwives adopt a hands-on approach 98% of them are doing that with women in supine and lying on their back positions and midwives and as you said midwives who are using a hands-on technique are two or three times more likely to cut an episiotomy Already element two is problematic. And then we're talking about techniques of performing episiotomies in element three, which again, you said really poor research for understanding what the best technique is for doing that. And we've then just poked holes in the assessment process that's included in the perineal bundle. And as you said too, episiotomy rates have gone up significantly since the perineal bundle has been increased. We're currently at about 23 or 24%. has the bundle noticeably reduced the percentage of women having third or fourth degree tears from what you've seen?
Nigel:
[21:04] That's a really good question.
B:
[21:06] And the thing is,
Nigel:
[21:07] We don't know. So the WHO on their website produced some.
B:
[21:10] Data from 2019, and they highlighted a 10% reduction in third and fourth degree tears amongst leprous women.
Nigel:
[21:17] Now, that sounds great. The problem with that is we don't know whether that's raw.
B:
[21:19] Data or whether it's been adjusted for things that will normally They cause greater risk of third and fourth degree tears like large babies and that sort of thing.
Nigel:
[21:28] When we look at data from overseas, in the UK.
B:
[21:31] The Royal College of Obstetricians and College of Midwives introduced a very similar bundle across the UK and they did a before and after study of just over 42,000 women.
Nigel:
[21:42] And they reported a 20% reduction.
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B:
[21:45] So they saw their rate drop from 3.3 down to 3%.
Nigel:
[21:49] And in terms of statistical analysis.
B:
[21:53] That was barely statistically significant. It just kind of crept into that statistical significant range.
Nigel:
[21:57] And that was a 20% reduction.
B:
[21:59] So if we're only seeing a 10% reduction, half of 20%, it's probably not going to be statistically significant.
Nigel:
[22:05] And that's relevant because when you say something's not statistically significant, what you're saying is that this can happen by chance, that there are.
B:
[22:13] A whole lot of other things that might be influencing it. So when you're seeing a 10% reduction,
Nigel:
[22:18] Well, that might.
B:
[22:19] Just be a kind of a rounding error or something that's occurred completely different to the bundle itself. We don't have the statistical robust processes behind it to actually demonstrate that that's occurring.
Nigel:
[22:29] And the other thing is, you know, okay, we've seen a 10% reduction. That doesn't kind of talk to the application of.
B:
[22:34] This bundle and the impact of the increasing episiotomies and giving birth on the back, et cetera,
Nigel:
[22:38] That's had upon the.
B:
[22:39] Tens of thousands of women that the bundle has been applied to, to get a fairly minimal reduction in perineal tearing.
Mel:
[22:47] And the other thing that I suspect, and here's my presupposition about the findings, because their website really says that, so they put a number of 473 women, less women, sustained the third or fourth degree tear as a result of the package. However, I'm wondering if they replace those third and fourth degree tears. So those 473 women who they say had a reduction, they've just replaced tears with episiotomies. And they haven't anywhere on the website or in their data reported on the episiotomy rate. They only keep reporting on the fact that there's been a reduction in third or fourth degree tears. But is it entirely possible that although they've reduced tears, they've done so because they increased episiotomies.
Nigel:
[23:33] Yes. And the other thing is that, you know, what we don't know is because we know that episiotomies were actually.
B:
[23:38] A risk factor for third and fourth degree tears. So the idea was increasing the angle will reduce that risk factor.
Nigel:
[23:44] So how much of that.
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B:
[23:45] Reduction in third and fourth degree tears is associated with a change in the way that episiotomies has been cut and doesn't really have any sort of reflection on the other elements.
Nigel:
[23:55] I think another really sort of important thing to talk about in terms of effectiveness is that this is not the only bundle around.
B:
[24:01] There are other bundles that are actually less prescriptive and also use a hands-poised approach. And one of those is a stomp bundle out of the UK. And they reported close to a 50% reduction in third and fourth degree tears by promoting birth in upright positions, using much better communication between midwives and women during that process to actually slow down the birth of the head. that pivotal moment and no increase in episiotomy rates. Without all the prescriptive elements that we see in the Australian bundle, they were actually much more successful. So, you know, if we're going to base this on evidence, why are we not using the STOMP bundle instead of the WHA one?
Nigel:
[24:40] And I think the limited scope of the.
B:
[24:42] Bundle is a really good point. It's, you know, it's very much about what clinicians do to women at a specific point in time and the absence of any advice around antenatal perineal massage, which again is one of these few aspects that we actually have good evidence that actually reduces all forms of perineal tearing, that wasn't included in the bundle itself. So it's kind of a, you know, what we can do to women at that point in time sort of approach.
Mel:
[25:07] So when you look at the bundle paperwork, it's all very lovely. They do a lot of lip service to, you know, don't use this perineal bundle if women are in water. You can't apply the perineal bundle at all if a woman's in water. They talk about training clinicians to make sure that they educate women about the perineal bundle and that they keep talking about in the documentation, you know, this all has to be done with consent because applying the perineal bundle is an intervention in the birth process. So we've got to understand that it's not just the unfolding of physiological birth, it's an intervention. But your study of the women that you did in your, because I read your 2002 paper, none of the women reported being educated about the perineal bundle, they didn't know that they were receiving an intervention.
Nigel:
[25:54] No, that's right. So the 15 old women that we interviewed, and they were from across various.
B:
[25:59] Hospitals in Queensland, so it wasn't just one hospital. None of them reported receiving any information antenatally and very little information during birth itself regarding the perineal bundle. It was only when the elements were sort of being applied that some of them were actually approached and provided or consent was actually sought.
Nigel:
[26:18] And sometimes that wasn't, you know, consent during labour and birth is really.
B:
[26:21] Tricky and often kind of fails the test for really informed consent. You know, if someone's just given birth and you say to them, well, we're just going to check your perineum and see if you had a third and fourth degree tear. And that involves a rectal exam. Well, you need to kind of talk about that and the pros and cons and, you know, and what are the alternatives and provide someone with some time to sort of think about that as opposed to we're
Nigel:
[26:43] Just going to do it.
Mel:
[26:43] So Nigel I so I was part of an ACM panel I attended I wasn't on the panel but you were on the panel and the ACM had invited two of the people who had created the perineal bundle and you were there and we were all there watching there was a big turnout from memory it was yes the ACM was pretty impressed which tells you you know I guess what we're trying to say is that perennial bundle is very controversial in the midwifery world, but also in the academic world. And I got the impression at that panel that the creators of the bundle were quite defensive and they kind of refused to acknowledge that although their aim and intent in creating the bundle was, you know, was wholesome and genuine, that they wanted to reduce the third and fourth degree tears, but they refused to admit that there was this unintended or unforeseeable consequence that it hasn't worked. The bundle hasn't worked in the way they intended. Can you see either on the horizon that there's going to be some actual research done on the effectiveness of the bundle, or is there a possibility that it will be dumped altogether based on the controversy around its application and implementation? It'd
Nigel:
[27:59] Be good to see some research around that.
B:
[28:01] The implementation or the effectiveness of the bundle it's
Nigel:
[28:03] Always that will always be.
B:
[28:05] Done sort of well it can now only be done retrospectively because it wasn't introduced as a research proposal which was unfortunate I just kind of jumped straight into it
Nigel:
[28:13] There are always limitations around retrospective.
B:
[28:16] Studies and just how accurate they are
Nigel:
[28:17] So collecting evidence to.
B:
[28:19] Whether it's effective or not is always going to be at this point it's going to be tricky and
Nigel:
[28:22] So what was the other part of your question was oh whether it's going to change in the future.
Mel:
[28:26] Yeah i'm wondering if in the absence of you know he wants to know if it's getting dumped i'm pretty sure yeah i mean just in light of it i mean i've delved i've looked into this there's been discussion about it we know it was implemented without any actual evidence that it worked we know that four of the elements don't have evidence to support their use we know that they haven't spoken about things like directed pushing which we know increases the risk of perineal tears they haven't addressed things that actually do reduce perineal tears. And in light of all this, is there a possibility that we can just go, oh, crap, we've actually stuffed this up. And unfortunately, there's been the unintended consequence of firstly, not reducing the rates of perineal trauma in the amounts that they had hoped, but also increasing episiotomy rates. And also, it's not very, you've done the research on the acceptability of this intervention. How do women feel about having the perineal bundle applied to their birth space?
Nigel:
[29:28] In terms of the women.
B:
[29:30] It varied considerably. So some were kind of, well, okay, it would be nice to know, you know, this was being done. And they appreciate that everyone's taking these efforts to reduce that sort of birth trauma.
Nigel:
[29:41] Others were, you know, and I think we've got to sort of acknowledge the sort of.
________________
B:
[29:44] You know, high rates of sort of sexual assault and sexual abuse in the community as well. So, there were certainly a number of women who were kind of, well, you know, I'd really like to have been asked about that because I'm, you know, a survivor of sexual assault and that kind of, you know, touching of the perinean and vagina and that sort of thing is really, who does it in what context is really quite important to me. And that was sort of one of the big issues that came through in our most recent paper in terms of, okay, we need to have a conversation around this and the consent process around the perineal bundle because of that needs to be really strong, and it currently isn't. And that was,
Nigel:
[30:17] And we argued.
B:
[30:19] In that paper and argued in that webinar that that was actually a foreseeable problem with the bundle. We know that there is an issue in terms of consent, particularly around women who are survivors of sexual assault during consent during childbirth. That exists, and there's good evidence around that, And we know that there's a lot of evidence around obstetric violence and how women perceive that as assault during labour and birth. And then into that, we dropped this bundle with saying that for every woman,
B:
[30:45] every time, with a fairly sort of, you know, with a pamphlet and not much else to support it. And the impact on midwives was grossly underestimated by the WHO as well. And they didn't respect the fact that probably upwards of about 40% of midwives were practicing a hands-off, hands-poised approach, which was effectively outlawed once the hospitals introduced the bundle, they all had to use a hands-on approach,
Nigel:
[31:07] Which was, you know.
B:
[31:08] Something that they clearly as professionals considered, rejected and developed their practice around using a hands-poised or a hands-off approach,
Nigel:
[31:17] Particularly around water births.
B:
[31:18] I mean, you know, from my perspective, the evidence around tears in water births
Nigel:
[31:22] Kind of seriously.
B:
[31:23] Calls into question the effectiveness of any of these bundles.
Nigel:
[31:26] We've known from.
B:
[31:27] Large studies overseas that giving birth in water, which invariably uses is a hands-off approach,
Nigel:
[31:32] The rates of perinealitarian are no.
B:
[31:34] Greater than those women who give birth on land using a hands-on approach.
Nigel:
[31:39] And I think in terms of longevity, well, we know there are already some hospitals.
B:
[31:43] Not many, but a small number of hospitals that are cherry-picking bits out of the bundle itself. There are a few that have kind of ditched the rectal exam or have been less prescriptive about various elements of it. And generally, midwives have had a century of practice of being subversive, so that's We're very good at kind of working around the system when we need to.
Mel:
[32:05] Nigel, is there anything that you really need to say about the perineal bundle that we haven't already fumbled through?
Nigel:
[32:11] No, I think the biggest point is the fact that, you know, it has been presented as the.
B:
[32:15] Best and only available approach. And what we know, particularly from the research we've got from overseas, that it's not. that there are other bundles that are less prescriptive that actually promote or use the physiology of birth, upright positions, really good sort of honest communication between midwives and women during birth and preparation antenatally as well that
Nigel:
[32:38] Produce better results.
B:
[32:40] So I think we just need a better bundle.
Mel:
[32:42] And the bundle says... We call it that, the better bundle. better bundle and the the perineal bundle in it says that this bundle is not mandatory yet on the ground when you spoke to the midwives because you did a research study you asked some you asked women but you also asked midwives of their experience of the bundle what were midwives experienced the bundle in in the sense that like the bundle says it's not mandatory but is that what midwives experienced no
Nigel:
[33:10] Their experience was.
________________
B:
[33:12] That they're essentially told that it was mandatory. And again, it comes back to the, you know, they were told that it was to apply to every woman every time, unless they specifically said no. So it was essentially, it was an opt-out process. And
Nigel:
[33:23] Also that there was no opportunity.
B:
[33:25] For any sort of discussion around the evidence base, around, you know, okay, this is the evidence we're applying. This is why we think it's important. That was never, never discussed. The WHO had been very opaque about what evidence they used to underpin the bundle. We've asked them for a list of their, you know, the papers and research that they considered and were using to justify it. They've never applied to us with a list of research that they used.
Mel:
[33:52] Well, the leaflet only has, the leaflet only has like 24 or 25 references, which is pitiful if you're trying to apply five element bundles.
Nigel:
[34:03] Yes. Well, of course, you know, as I say, we've got.
B:
[34:05] Randomised control trials that compared hands-poised and hands-off to hands-on and a Cochrane review of that systematic review, and they all came to the conclusion that there is no difference in terms of severe perineal injury between the two techniques.
Mel:
[34:19] So I had a look at this. I looked into this women's healthcare. It's called Women's Healthcare Australasia.
B:
[34:25] Mm-hmm.
Mel:
[34:26] W-C-H-A. W-C-H-A. W-C-H-A. Okay.
Nigel:
[34:33] Well, they're a member organisation.
B:
[34:35] So I have to say, I'm not overly familiar with their structure, but certainly there are, within their membership, there are hospitals and representatives of midwifery and obstetrics there.
Nigel:
[34:45] But whether, you know, again, part of the problem with this is a lot of the membership.
B:
[34:49] Particularly from the midwife's perspective, are either clinical or managerial and not necessarily going to have the the experience and skills to assess research evidence and argue for and against it. And I think, you know,
Nigel:
[35:00] The WHO said, well.
B:
[35:01] The panel we used was we had equal numbers of obstetricians and midwives and consumers, but equal numbers doesn't equal equity.
Mel:
[35:08] And obviously, the process hasn't been successful in the sense that they haven't used evidence to create the bundle. Okay. So five-minute wrap-up then of the Perineal Bundle. Mel wants to drop. I love... Oh, sorry. sorry oh my gosh i accidentally i accidentally muted you and i just love that you asked if it was going to be dropped because it has no evidence like i was like that with ctg it's like okay can we drop them now like can we just go back to basics i feel like there's this real oh what we're not working like i wondered because it's a relatively new intervention like 2018 is when they sort of started trying it out we're at the point where we it's not ingrained in practice like CTG is, where if we dropped it all of a sudden, clinicians would feel just ill-equipped to do their job. But if we dropped the perineal bundle, at this point, we could go back to whatever was happening before, right? We could just go, whoa, that was a blip in time. Let's forget we ever did that.
Nigel:
[36:07] And I think it's important to note that, you know, this is not a new recent conversation or discussion.
B:
[36:13] You know, we've been having this discussion now for over 150 years.
Nigel:
[36:16] You know, I've got a paper here in front of me by a.
B:
[36:18] Guy called Goodall from 1871, which is essentially a literature review of perennial protection strategies that he wrote in 1871. for a couple of years, 100 years before that.
Nigel:
[36:29] And he's putting up exactly the same thing. You know, he's saying that, you know, some people put their hands on the perineum, some don't, some point their fingers upwards, downwards, some use packs, some don't use, you know, packs on the perineum, et cetera. And this was 150 years ago. So we've had these very, very sort of cyclic approaches.
B:
[36:46] And I think probably,
Nigel:
[36:47] You know, yes.
B:
[36:47] We've had the perineal bundle in now for about three or four years.
Nigel:
[36:50] It's probably a.
B:
[36:51] Good time to take a step back. Okay, let's do some really good research around this. Let's really look at the evidence that what we've got for what actually works and what we know that kind of doesn't work. None of this needs to be applied strictly because,
Nigel:
[37:03] And I think one of the things that this always kind of bugged me about this was it denied clinicians and women the opportunity to.
B:
[37:10] Have a discussion around what was, particularly for women, what was important to them and what they might like to use and what choices and alternatives were out there.
Mel:
[37:17] So if we do a five-minute wrap-up, what have we learnt about the perineal bundle is that there's five steps, warm compresses, hands-on approach to the birth process where perineums and babies are touched and manipulated during their exit, which relies on an on-your-back position, perineal assessments using rectal examinations for all women, and oh yes, and the technique when performing an episiotomy. So do we know the numbers for how many hospitals have adopted it now? because there's quite, I had a look at the Women's Healthcare Australaser Group and quite a big number of hospitals are part of it. Yeah, I don't know if we have numbers on.
Nigel:
[38:00] I don't know how often they update their.
B:
[38:02] So we don't really know how many. And not only that, we don't know how many hospitals are using all of the bundle or only various parts of it.
________________
Mel:
[38:10] Right. So there's five elements, five elements of the perineal bundle. They say it's not mandatory, but midwives have experienced it as mandatory. The idea of the bundle is that women are supposed to be educated antenatally, but your research has shown that women don't recall being educated antenatally about the perineal bundle.
B:
[38:32] No, that doesn't seem to be happening.
Mel:
[38:33] Right. And it's anecdotally increased the episiotomy rate significantly.
Nigel:
[38:38] Well, we've had a rise in episiotomy rates that coincides in the years that coincide.
B:
[38:44] With the introduction of the bundle itself.
Nigel:
[38:47] As yet, and we've got.
B:
[38:48] You know, we'll hopefully have a look at some of this data later on in a year, but at the moment we don't have any evidence sort of directly associating one with the other. But it's a reasonable assumption at this point,
Mel:
[38:57] I think. Right. And I'm just going to read a line from a paper you wrote with Kirsten Small because I love it. This was in your paper, How a Perineal Care Bundle Impacts Midwifery Practice in Australian Hospitals. And it was said in the paper, the introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. And we recommend midwives advocate autonomy, women's autonomy and their own by using clinical judgment, evidence and woman-centered care, which to me is research language for the perineal bundle has further medicalized childbirth and midwives should use their clinical judgment and evidence of which there isn't any to guide their practice as well as obviously the women's choice. And so if we think objectively about the perineal bundle, it doesn't help with clinical care that is appropriate to women because it's a birth by numbers formula. And so it doesn't allow autonomy for women, doesn't allow autonomy for midwives. And although the bundle has wording, which suggests that it should be done with consent and that it's not mandatory, the experience of midwives and women is that's not happening. It's being applied quite heavy handedly.
Nigel:
[40:13] Yes.
Mel:
[40:14] Okay, good. Yes. All those assumptions. All right. Final words, Nigel, about the perineal bundle. What do you really think?
Nigel:
[40:22] Look, for me, it was a bit of a trip back to the future.
B:
[40:24] We were doing this sort of thing, you know, back in the 70s and 80s. And then we started getting it.
Nigel:
[40:29] And then I thought when we started doing the hands-off and hands-poised and there.
B:
[40:33] Was no dramatic increase in perineal
Nigel:
[40:35] Injuries following that.
B:
[40:36] That all seemed pretty good.
________________
Nigel:
[40:37] And then I think.
B:
[40:38] You know, we got the backlash in terms of, well, you know, it's all these midwives just doing stuff and we don't know what they're doing and that's not what we used to do. And I remember somebody commenting on the HOOP trial, which is one of the big trials that looked at hands-on versus hands-poise and saying,
Nigel:
[40:54] You know, we've been misled by this.
B:
[40:56] We know instinctively that putting the hands-on is going to be better. I'm thinking, well, actually, we're trying to get away from that sort of non-evidence-based discussion.
Nigel:
[41:05] So I think, you know, we really need to sort of respect each other's professional approach. There are probably some good elements in the bundle.
B:
[41:10] And for some people it works well, but for a lot of midwives, say, who are practicing, legitimately practicing a hands-poised approach and taking other approaches to managing perineal injury, their practice needs to be equally recognized as appropriate.
Mel:
[41:26] Amazing. That's a wrap. Episode 19, the Perineal Bundle. I can also, other resources I can recommend are, well, the Midwife's Cauldron podcast did an amazing episode on this. I think it's a great additional listen is the perineal bungle episode of the midwives cauldron rachel reed has done a great blog post addressing a lot of these issues that we've discussed as well in the if you're on the mailing list you will get full text articles from of the research papers we've been discussing today in this podcast including some of nigel's work that's a wrap thanks nigel See you next week, Nigel.
Nigel:
[42:04] Okay, see you again.
Mel:
[42:06] Gorgeous. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com. And to support the work of this podcast, wear the rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @MelanietheMidwife on socials and the show @TheGreatBirth Rebellion. all the details are in the show notes
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