Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design

I. Gurol-Urganci; P. Bidwell; N. Sevdalis; L. Silverton; V. Novis; R. Freeman; A. Hellyer; J. van der Meulen; R. Thakar

doi:10.1111/1471-0528.16396

Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design

I. Gurol-Urganci^*, P. Bidwell, N. Sevdalis, L. Silverton, V. Novis, R. Freeman, A. Hellyer, J. van der Meulen, R. Thakar

^*Corresponding author for this work

Health Service & Population Research

Research output: Contribution to journal › Article › peer-review

45 Citations (Scopus)

Abstract

Objective: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. Design: Multicentre stepped-wedge cluster design. Setting: Sixteen maternity units located in four regions across England, Scotland and Wales. Population: Women with singleton live births between October 2016 and March 2018. Methods: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). Main outcome measures: Obstetric anal sphincter injury in singleton live vaginal births. Results: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26–34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65–0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. Conclusions: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. Tweetable abstract: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.

Original language	English
Pages (from-to)	584-592
Number of pages	9
Journal	BJOG: An International Journal of Obstetrics and Gynaecology
Volume	128
Issue number	3
DOIs	https://doi.org/10.1111/1471-0528.16396
Publication status	Published - Feb 2021

Keywords

Obstetric anal sphincter injury
perineal tear
quality improvement

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10.1111/1471-0528.16396

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Gurol-Urganci, I., Bidwell, P., Sevdalis, N., Silverton, L., Novis, V., Freeman, R., Hellyer, A., van der Meulen, J., & Thakar, R. (2021). Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design. BJOG: An International Journal of Obstetrics and Gynaecology, 128(3), 584-592. https://doi.org/10.1111/1471-0528.16396

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title = "Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design",

abstract = "Objective: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. Design: Multicentre stepped-wedge cluster design. Setting: Sixteen maternity units located in four regions across England, Scotland and Wales. Population: Women with singleton live births between October 2016 and March 2018. Methods: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). Main outcome measures: Obstetric anal sphincter injury in singleton live vaginal births. Results: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26–34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65–0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. Conclusions: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. Tweetable abstract: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.",

keywords = "Obstetric anal sphincter injury, perineal tear, quality improvement",

author = "I. Gurol-Urganci and P. Bidwell and N. Sevdalis and L. Silverton and V. Novis and R. Freeman and A. Hellyer and {van der Meulen}, J. and R. Thakar",

note = "Funding Information: All authors have completed the Unified Competing Interests form (available on request from the corresponding author). NS reports grants from National Institute for Health Research and personal fees from London Safety and Training Solutions Ltd, during the conduct of the study, and grants from Sanofi Pasteur and King{\textquoteright}s Health Partners, outside the submitted work. IGU, PB, NS, LS, VN, AH, RT and JvdM report a grant from the Health Foundation Scaling Up Improvement Programme during the conduct of the study. RF has nothing to disclose. Funding Information: The OASI Project had patient and public involvement throughout inception, implementation and evaluation stages to ensure that care bundle development and implementation were informed by the perspective of women. The project was supported by an Independent Advisory Group, including lay representatives. The antenatal information sheet (first component of the OASI Care Bundle) was developed together with patient and public involvement groups in order to ensure that the material was appropriate. Patient and public involvement representatives were present at all skills development days. Funding Information: The OASI Project was funded by The Health Foundation Scaling Up Improvement Programme (award number 7674). The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. NS? research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King?s College Hospital NHS Foundation Trust. NS is a member of King?s Improvement Science, which offers co-funding to the NIHR ARC South London and comprises a specialist team of improvement scientists and senior researchers based at King?s College London. Its work is funded by King?s Health Partners (Guy?s and St Thomas? NHS Foundation Trust, King?s College Hospital NHS Foundation Trust, King?s College London and South London and Maudsley NHS Foundation Trust), Guy?s and St Thomas? Charity and the Maudsley Charity. We are grateful to the obstetric and midwifery champions at each of the 16 maternity units, for their hard work and dedication to improving outcomes for women. Publisher Copyright: {\textcopyright} 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",

year = "2021",

month = feb,

doi = "10.1111/1471-0528.16396",

language = "English",

volume = "128",

pages = "584--592",

journal = "BJOG: An International Journal of Obstetrics and Gynaecology",

issn = "1470-0328",

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Gurol-Urganci, I, Bidwell, P, Sevdalis, N, Silverton, L, Novis, V, Freeman, R, Hellyer, A, van der Meulen, J & Thakar, R 2021, 'Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design', BJOG: An International Journal of Obstetrics and Gynaecology, vol. 128, no. 3, pp. 584-592. https://doi.org/10.1111/1471-0528.16396

TY - JOUR

T1 - Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury

T2 - a multicentre study with a stepped-wedge design

AU - Gurol-Urganci, I.

AU - Bidwell, P.

AU - Sevdalis, N.

AU - Silverton, L.

AU - Novis, V.

AU - Freeman, R.

AU - Hellyer, A.

AU - van der Meulen, J.

AU - Thakar, R.

N1 - Funding Information: All authors have completed the Unified Competing Interests form (available on request from the corresponding author). NS reports grants from National Institute for Health Research and personal fees from London Safety and Training Solutions Ltd, during the conduct of the study, and grants from Sanofi Pasteur and King’s Health Partners, outside the submitted work. IGU, PB, NS, LS, VN, AH, RT and JvdM report a grant from the Health Foundation Scaling Up Improvement Programme during the conduct of the study. RF has nothing to disclose. Funding Information: The OASI Project had patient and public involvement throughout inception, implementation and evaluation stages to ensure that care bundle development and implementation were informed by the perspective of women. The project was supported by an Independent Advisory Group, including lay representatives. The antenatal information sheet (first component of the OASI Care Bundle) was developed together with patient and public involvement groups in order to ensure that the material was appropriate. Patient and public involvement representatives were present at all skills development days. Funding Information: The OASI Project was funded by The Health Foundation Scaling Up Improvement Programme (award number 7674). The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. NS? research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King?s College Hospital NHS Foundation Trust. NS is a member of King?s Improvement Science, which offers co-funding to the NIHR ARC South London and comprises a specialist team of improvement scientists and senior researchers based at King?s College London. Its work is funded by King?s Health Partners (Guy?s and St Thomas? NHS Foundation Trust, King?s College Hospital NHS Foundation Trust, King?s College London and South London and Maudsley NHS Foundation Trust), Guy?s and St Thomas? Charity and the Maudsley Charity. We are grateful to the obstetric and midwifery champions at each of the 16 maternity units, for their hard work and dedication to improving outcomes for women. Publisher Copyright: © 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/2

Y1 - 2021/2

N2 - Objective: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. Design: Multicentre stepped-wedge cluster design. Setting: Sixteen maternity units located in four regions across England, Scotland and Wales. Population: Women with singleton live births between October 2016 and March 2018. Methods: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). Main outcome measures: Obstetric anal sphincter injury in singleton live vaginal births. Results: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26–34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65–0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. Conclusions: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. Tweetable abstract: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.

AB - Objective: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. Design: Multicentre stepped-wedge cluster design. Setting: Sixteen maternity units located in four regions across England, Scotland and Wales. Population: Women with singleton live births between October 2016 and March 2018. Methods: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). Main outcome measures: Obstetric anal sphincter injury in singleton live vaginal births. Results: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26–34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65–0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. Conclusions: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. Tweetable abstract: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.

KW - Obstetric anal sphincter injury

KW - perineal tear

KW - quality improvement

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U2 - 10.1111/1471-0528.16396

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JF - BJOG: An International Journal of Obstetrics and Gynaecology

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ER -

Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design

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