Overarching theme: a patchwork of policy and process
The overarching theme that emerged from the discussion group was that health services in NSW operate within a patchwork of policy and processes when providing care for women who sustain SPT. The CMC participants reported that currently there is little consistency or standardisation of protocols, policies or guidelines across NSW to guide the treatment or follow up care for women who had sustained SPT during birth.
There was a discussion at a high risk meeting with the medical officers about where severe perineal trauma should be repaired and who should do what. There was no agreement whatsoever with them, nothing. Everybody does different things. (CMC)
CMCs believed that care for women who have experienced SPT varies and this variation ranges from local district policies and protocols to individual practitioner preferences on how immediate repair and long term care should occur. This was reported by participants from both metropolitan and rural LHD’s: “There’s not consistency. It’s more practitioner driven…”. The preferences of the individual medical practitioners were described as impacting upon the implementation of guidelines and policies. For example, it was reported that for one LHD a district wide policy existed in draft form, however this policy was unable to be progressed due to an inability to gain consensus from the area’s representative medical staff as to appropriate care guidelines.
Similarly, women described the challenges they faced in attempting to navigate treatment pathways, often reporting that the lack of identifiable and available services were inadequate in meeting their needs.
I felt like I didn’t have enough support, but I didn’t really know where to go to get it. I didn’t really know whether it actually existed. I just wished somebody would have just said, go to the GP. If there’s a problem, go and do something about it. (Indie)
Some CMC’s however described how a coherent policy guided how health professional provided care for women who had sustained SPT within their health service.
We have a policy. There is a policy in place and there is a pro forma that the midwives and doctors have to complete. (CMC)
Qualifications, skills, beliefs, and attitudes
Qualifications and skills
The CMCs described the level of skill and credentialing process required for health professionals to undertake repair of SPT to be inconsistent and unclear. In response to the survey question “Who is permitted to repair severe perineal trauma?”, participants indicated that the necessary qualifications to undertake repair ranged from resident medical officers RMO to specialist colorectal surgeons (Table
2). In individual health facilities where a credentialing process was reported to exist, the CMC’s were mostly unclear on what this process involved. It was reported that one tertiary level maternity unit had a clear credentialing process in place, whereby repairs were able to be conducted only by an obstetric and gynaecology (O&G) registrar in their third year of practice, a staff specialist or above. Some services had commenced a mentorship program for RMOs, however it was unclear what qualifications the mentor was required to have. Some facilities had no credentialing process at all:
There’s no level of credentialing for the registrars. I guess it’s left up to their individual level, just like the midwives are – “I don’t want to do this repair because it looks too big”. I’m hoping that’s what’s happening there. (CMC)
The CMC participants also expressed concern over inconsistencies around training staff to undertake a comprehensive perineal assessment following a vaginal birth. It was reported that junior staff or health professionals without current perineal assessment skills, may incorrectly diagnose the grade of perineal trauma, this may result in an inadequate repair being performed:
If the midwife is in there and she doesn’t recognise that it’s a third degree tear, that’s not going to get picked up…she’s not going to get anybody in there to do it. (CMC)
The participants discussed the roles that registrars, obstetricians and colorectal surgeons played in SPT repair. Some participants described a conflict that existed between the role and responsibilities of the registrar and colorectal surgeon: “…because there are obstetricians or VMO’s [Visiting Medical Officers] that get upset when the registrar calls in the colorectal surgeon”.
In contrast, other services described a collaborative process that had been established between the obstetricians, registrars and colorectal surgeons in identifying and repairing SPT but they were in the minority:
If they’re anything more than a 3A tear, then they [registrar] notify the colorectal surgeon. The colorectal surgeon is actually in theatre when they initially assess the tear, prior to deciding whether it’s worse than a 3B or whether it’s a four[th]. They actually work together. It’s a really, really good collaborative agreement. (CMC)
Within some LHDs the CMC representatives reported a concern at the lack of diagnostic facilities and therefore the accuracy of perineal assessment:
I’ve heard a colorectal surgeon talk about his “magic finger”. They don’t have manometry in hospital. They don’t have pudendal nerve testing and they don’t have endoanal scans specifically for women. So they’re not really assessing it properly at all. (CMC)
Some of the CMC participants believed that the inconsistencies in assessment, evaluation and repair were a result of perineal trauma not being seen as an obstetric priority and therefore standardisation of care and training was not seen as important: “There’s very little clinical review of particular cases. It’s not seen as something that they need to review. I think that needs a discussion as well”. (CMC)
In response to this, one service that conducted an audit and identified incorrect diagnosis contributing to increasing SPT statistics, introduced a policy stating that two health professionals were now required to review each women with perineal trauma (second degree tear or above), to increase the likelihood of correct identification and repair.
Beliefs about the cause of SPT
In both the survey responses and the discussion, the majority of CMC participants indicated that they believed the incidence of third and fourth degree perineal trauma was increasing, and in response to this participants indicated that at a number of health facilities internal audits had been undertaken to identify the reasons for increased reporting (Table
2). On the survey, CMCs were asked to rank in order from 1 to 10 what they believed was the most significant contributor to the incidence of SPT, with position for second stage being highlighted as the most significant cause, followed by instrumental birth and episiotomy (Table
3).
Many of the women who participated in the interviews spoke of strategies they used, or had heard of, during the antenatal period, to minimise the risks of sustaining perineal trauma. These strategies included the use of oils and massaging their perineum to make the area more flexible for birthing, while one participant described using a device to stretch the perineum. Women reflected on these strategies, often describing that they had let themselves tear by forgetting or neglecting to perform perineal massage consistently during their pregnancy which resulted in them sustaining SPT. Other women stated the perineal trauma was due to a defect in their anatomy: “I just wasn’t stretchy enough and that’s why I tore.” (Asha). Further, women described that they felt incorrect pushing techniques, the use of instruments during the birth, and a rapid birth contributed to perineal trauma.
The attitudes of health professionals
For women who have sustained SPT, they were less concerned about the method of perineal repair that was performed, and more concerned with how they were cared for during this time. During the suturing process, the women recall clearly the facial expressions, words and phrases that the midwives and obstetricians used during the suturing process. The women interviewed described how staff spoke “around them” and “about them”, often not speaking directly to the women, and this resulted in women feeling vulnerable and exposed during the procedure.
I got embarrassed at one point, I’m just thinking I can’t believe I’m just lying here like this and they’re having a little discussion about what’s going on. They didn’t discuss it with me at all. Maybe they just thought I wasn’t worth it. But maybe they think well they don’t understand it anyway so what’s the point? (Scarlett)
Falling through the gaps
The participants described that the care that women received in both the immediate and long term postnatal period varied amongst LHD’s and individual practitioners. The majority of services provided information leaflets outlining perineal care to women prior to discharge. In response to the survey question: “Is there a follow up clinic available that women are referred to?”, ten participants responded with ‘yes’, three with ‘no’, and one participant was ‘unsure’. Some of the services offered a range of counselling services for women who had sustained SPT, other services reported that there were no routine postnatal support pathways in place.
The referral process for women to access follow up anal sphincter assessment was also seen to be practitioner dependent: “So someone like a specialist obstetrician may keep the women to review himself and, maybe, other areas where there’s GP obstetricians, they might refer through… ” (CMC)
In preparation for discharge from hospital, the level of support and information provided to each woman appeared to vary based upon the individual care provider, model of care, and health service. While the focus of the practitioners was on the care that was provided to women within the health service, for the women who were interviewed, being discharged from care presented new and unfamiliar challenges.
They just checked the stitches, made sure they were clean, made sure they were dry, but they didn’t explain any ongoing process…they just said if you have any problems go to your doctor....Nobody explained anything. (Matilda)
At discharge, while some participants described receiving referrals for an endoanal ultrasound and receiving community midwifery support, other women reported that they received no support.
The endoanal ultrasound is meant to take place 5-6 months after birth. I just received a letter today stating that the appointment has been cancelled and rescheduled for 20 months after the birth. I haven’t experienced any problems (that I’m aware of, anyway)….however it’s very worrying that there is a 20 month wait for this follow up scan. (Indie)
For many women the level of support following SPT was inadequate in addressing their needs. Women described feeling confused and unsure as to when and where to seek support, particularly for women experiencing symptoms such as urinary incontinence, perineal pain and urinary retention. As they struggled to understand what degree of perineal pain and symptoms were normal and not normal following birth, they spoke of the importance of the role of health professionals in providing appropriate care, information, and reassurance to provide support in the postnatal period.
I didn’t know that it wasn’t right. I guess, you rely on the health care professionals to tell you. This is actually a pretty big thing that you’ve had, and this is the follow up you need, and this is what we need to do, and if you’re in pain let me know and I’ll get you something. (Chloe)
Support for women experiencing a subsequent pregnancy and birth appeared to vary across the NSW. CMCs reported that while some facilities offered no clear follow up services and subsequent birth planning and support for women who had sustained SPT during a previous birth, other facilities offered comprehensive support services. This appeared to be driven by motivated midwives:
It’s recognised at booking in that these women have got issues [as a result of SPT] - they’re just [scared of] the next birth and they’ve taken, maybe, five, six years even to get pregnant. So we meet and go over the last birth, it’s usually a debrief about the birth. Then there’s no set guidelines to what the birth will be. It depends on what experience was the last birth. That’s the way I make the plan, together in consultation with our clinical director. (CMC)
When asked to describe the general recommendations given to women in planning subsequent births, responses varied depending upon the opinion and preference of the individual medical officer, and the degree of ongoing morbidities experienced by the woman. For the women in this study, the decision making process for planning subsequent modes of birth was complex, with the participants describing how their decision was influenced by the advice they received and how much trust they placed in the health care provider:
The doctor that I saw when I was pregnant said you don’t need a caesarean. I said it’s really quite a sensitive subject and I really don’t want to have to explain but I think you should understand by me saying leaking and fistula. He said just don’t have a big baby this time. He said don’t eat – I swear to God – he said don’t eat so much. You won’t put on so much weight, you’ll have a smaller baby, you won’t tear. I just thought, that is the stupidest thing I have ever heard. (Lola)
Caring for women who have sustained SPT
How women were cared during the perineal repair process and in the postnatal period was a topic of concern for both the CMCs and the women. There were three identified areas of concern: the models of care within which women were cared for, whether the provision of postnatal care was focussed on the wellbeing of the newborn to the detriment of the new mother, and the provision of services for women who reside in rural and remote locations.
Continuity of carer
During the discussion, continuity of carer was considered important for women who have sustained SPT during birth. It was believed that this would provide a level of consistency and be of value to women throughout any follow up consultations or diagnostic process:
The woman possibly has symptoms – she should have an open door if she’s got problems, to come back, so that she can be assessed by a midwife. Then, if there are significant issues, then it can be – some consistent care. (CMC)
Similarly, women described the value of receiving personalised, compassionate care from a known care provider, and the importance of receiving honest and accurate information communicated in a consistent and sensitive manner.
I really like that idea with the one midwife/one person – you know, you get a chance to iron out all the little crinkly bits before… it’s this whole womanhood, sisterhood, thing that I wanted to be a part of. (Ava)
The level of trust that existed between a woman and her health care provider appeared to impact upon whether or not the women felt in control, and therefore able to advocate for what they felt was important for themselves and their newborn. For women, the location that perineal repair was performed was an important consideration, and if given the choice of location the majority of women declined going to theatre due to their concern about leaving their newborn.
…they did say, oh we’re going to have to take you away for stitching. I’m like what are you talking about taking me away? I was like, If I’m going there, where’s my baby going to be? Oh well we’ll take her to the nursery and I’m like, hang on, how long will I be gone for? I was like, whoa just back up a minute and I said Well why would you think that I would want to do that? I’ve just had my baby. (Grace)
The decisions that women made when considering location of repair were further influenced by the level of trust they had in their care providers and in the health care system. For women who were given a choice on where the repair would occur, those who trusted their care providers and trusted that their newborn would be cared for appropriately followed the advice they were given. This was particularly noted for women who had continuity of care throughout their pregnancy, labour and birth.
So they asked whether I wanted to do it just under an epidural or whether I wanted to go under a general anaesthetic. I said I didn’t really care either way. But then a doctor came in and said “No, you need it under general anaesthetic, it wouldn’t be pleasant or easy to do it under an epidural, it would be a bit too traumatic”. I was fine with that. So [the new baby] went off with Daddy, and I got wheeled off into surgery. (Sophie)
In contrast, the location where the perineal repair took place appeared to be influenced by both LHD policy and practitioner preference. It was reported in both the discussion and survey that the majority of fourth degree tears were repaired in theatre while the repair of third degree tears occurred either in theatres or in the room that the woman had birthed in. This decision was reported to be based upon both availability of theatres, staff, and individual preference of the health professional performing the suturing:
Fourth degree tears always go to the operating theatres. As far as third degree tears, for a number of years they need to go to operating theatres. The medical officers will not agree, they think they’ve done it for years and they can go ahead and keep on doing it, exactly where it is, because they think it’s perfectly alright. (CMC)
Woman centred or baby centred care?
Women felt that following the birth, the focus of the health professional moved from the woman to the wellbeing of the newborn baby, and as a result the information women received focussed upon the care of the newborn with little concern as to the wellbeing of the new mother. Receiving honest and accurate information was seen as being of particular importance during the suturing process and immediate postpartum period. Women also described the need for health professionals to be mindful of the language that they used, and their facial expressions, when caring for women undergoing assessment and suturing of SPT.
They don’t have to say anything, but if you look at someone you can tell what they’re feeling. I mean you don’t work in a factory, you’re not sitting there sewing a little jacket, you’re helping somebody birth a child. (Matilda)
It was seen as important to the women that more of a focus was given to the health of the mother, including providing information on how to care for the perineum following discharge, any potential symptoms and morbidities that can occur as a result of SPT, and what women should do if any of these were to occur. Women reported that receiving this information as a leaflet, booklet or online resource would be beneficial as it could be reviewed when they were ready, and would also be easily accessible by their partner.
It would be good to have something if you did have questions to look through. You know they teach you how to wash the baby, and there’s all sorts of diagrams –but there’s nothing about aftercare for the mother except keep it clean, and make sure you can go to the toilet. (Ava)
Following discharge from the hospital, women described a need for a postnatal appointment conducted earlier then 6 weeks for a review of the perineal trauma, at this time women felt they would also have an opportunity to debrief, ask any questions and be provided with clear treatment pathway options if ongoing support was required. The women felt that ongoing support through a support group facilitated by a health professional would be beneficial as women worked to understand the physiological and psychological impact of SPT.
Adding complexity to the picture: services in rural NSW
Support for rural women was described as being underfunded and poorly structured which resulted in inconsistent follow up with little consideration of the distances women need to travel to access care. For families living in rural and remote locations, it was acknowledged that women who required follow up care were faced with additional expenses associated with accessing follow up care, such as travel and accommodation costs, and this was reported as another reason why women were less likely to seek follow up care.
Anecdotally I would say that a lot of those women don’t take that up (referral to a continence clinic) because they don’t live locally. When you’re looking within our area the women are travelling up to 400 and 500 kilometres to get that follow up. It’s only if they develop ongoing problems that they develop a need, eventually, to some follow up. (CMC)
For immediate repairs of SPT, a lack of rural based services and minimal staffing means that for some women they require transfer to the closest tertiary facility which can occur by ambulance or using their family car. For repairs on site, repairs occur as a result of collaborative efforts by GP specialists (obstetricians, anaesthetists, surgeons) who combine specialities and conduct the perineal repair. Follow up care was reported as “variable” depending upon the location and availability of skilled professionals.
Over a very large geographic area it’s very hard to standardise practice or to track what kind of counselling or debriefing the women might get. It will entirely depend on which care provider they see. The advice they get in terms of the next pregnancy is going to be dependent on those individual care givers. (CMC)
During the interviews with women, there were no participants who resided in a rural location, therefore this perspective is limited to that of the CMCs.
Gold standard care: how would it look?
The CMC’s who participated in the discussion group clearly identified the structure and delivery of a service that would provide a comprehensive model of care to women who sustained SPT during childbirth. This was determined as important, as when asked during the discussion group if the CMCs felt that the incidence of SPT was increasing, the majority response indicated that they felt the incidence was increasing across NSW. In response to the survey question: “Rank in order from 1 to 10 (1 being most significant, 10 being least significant) what you feel contributes to the incidence of severe perineal trauma”, the most significant cause was identified as the position for second stage. The second most significant cause identified was instrumental birth (Table
3). The majority of the group identified that the key element in achieving a comprehensive level of state-wide care is consistency and standardisation of assessment, repair, treatment and ongoing care for women who sustained SPT. The implementation of mandatory reporting of cases of SPT including documentation of the degree of trauma, the method of suturing and the location at which the repair takes place, would facilitate clinical review, staff development, and the ability for audits to be conducted within the health services. It was suggested that this could be achieved through perineal repair training programs and an associated credentialing system for all health professionals who care for women who have sustained SPT, and the establishment of state-wide and national policies to guide standardised management across all health services.
I think consistency and standardisation of everything. That starts from all the psychosocial stuff, so that needs to be considered. Then there needs to be consistency with everybody; so the skills of identification, the credentialing of the people most appropriate to repair, even the materials. I mean the evidence is out there that says all that. (CMC)
In response to the survey question “If there was anything that you could incorporate into your service for women who experience SPT what would it be?” the CMCs prioritised the importance for health professionals to be competent in accurately assessing and repairing perineal trauma. Further, in the survey responses the CMC participants identified the importance of providing women who sustain SPT with a comprehensive physiological follow up including a consultation with allied health specialists, including a physiotherapist and colorectal surgeon, and associated testing to determine the existence of any anal sphincter defects. Ideally these services would be offered within a specialist pelvic floor clinic with a known care provider where women would be provided with consistent evidence-based information. It was determined that this service would provide ongoing support for women through clearly structured treatment pathways. The group also identified the benefits of establishing such a service for women contemplating, or experiencing, a subsequent pregnancy and birth following SPT:
I think for the next birth it should be that they come to a specific clinic and see a consistent practitioner in that clinic – either a midwife or an obstetrician – so that the birth plan can be formulated for them. (CMC)
It was identified that this support was also required for women who resided in rural and remote locations, ideally with the establishment of a multi-disciplinary team that would be made available for women who required assessment, support and ongoing care.