The Perineal Protection Bundle explained.
Guest Blog by Kirrilee Heartman
If you are pregnant and thinking about your upcoming birth, perineal health is one part of it you may be worried about. We all want our babies to emerge safely, with as little effect on our bodies as possible. From perineal tears to a prolapse, there are a variety of things that can happen during birth or after which require treatment, however getting informed about ways to protect the perineum during birth may help prevent injury, setting you up for a easier recovery after birth and smoother transition into parenthood.
THE PPB
In major Australian hospitals such as Wollongong Hospital, The Perineal Protection Bundle (PPB) is the protocol employed for perineal care. The PPB was introduced in Australia in 2018 for protecting the integrity of the perineum during birth, and is a process that all clinicians have the skills to perform. It is intended to be offered to every birthing woman or person. The five steps of the PPB are:
1. Warm compress (to be used on the perineum);
2. Perineal support during birth (by hand);
3. Technique for episiotomy;
4. Assessment for perineal tears;
5. Grading the severity of perineal tears.
According to the official Guide for the Bundle, discussion around perineal care in birth should begin during antenatal appointments. Informed consent is the right of the birthing woman or person, and applies to each step of the Bundle.
‘Informed consent’ means that the birthing woman or person is given information about any proposed treatments or interventions, the benefits and potential adverse effects of proposed treatments or interventions, as well as the potential effect if no treatment is undertaken. Consent may be sought during antenatal appointments, or at the time of intervention during birth, or both.
Most perineal injuries are first or second degree tears, which heal naturally or with a few stitches. Third and fourth degree tears are also referred to as Severe Perineal Trauma, and occur when the muscles of the anus and possibly rectum are affected. Stitches or surgical repair is required in these cases. Faecal incontinence and sexual dysfunction are the most serious outcomes of severe perineal trauma.
The PPB Guide states that four out of every hundred women or birthing people experience a third or fourth degree tear, with risk factors including first births, perineal tears in previous births, larger babies (over 4kg/ 9lb), instrumental birth (where forceps or other instruments are required), and where the baby’s shoulders become stuck during birth. The Bundle has been implemented with the aim of reducing the rates of severe perineal trauma in Australia.
Independent research yields some mixed and negative findings about the efficacy of the Bundle. One Scandinavian study showed a 50% reduction in rates of severe perineal trauma since the introduction of a similar protocol to the PPB introduced in Australia, however their protocol included more hands-on perineal support, and episiotomies (where the perineum is cut surgically) were administered only when severe perineal trauma was imminent. Two other Scandinavian studies showed only moderate or no differences in rates of perineal trauma with the Bundle in use.
Other research shows that The PPB has no effect in preventing severe perineal trauma. One study shows that only step 1 – warm compresses – helps reduce perineal tearing, while another study reports that antenatal perineal massage (undertaken whilst pregnant) is a more effective intervention. What is clear is that for first time birthing women and people, rates of episiotomy increase where the Bundle is in effect – studies have shown this to be the case in Denmark and Norway. A recent Australian study also confirmed a concerning increase in rates of episiotomies, and showed that rates of severe perineal trauma in birthing women and people in Australia had actually increased two years from the introduction of the Bundle. This study was also critical of the quality of research provided by Women’s Healthcare Australasia in justifying the use of the PPB.
Most importantly, a 2023 Australian study into women and birthing people’s experiences with the PPB in Queensland hospitals found that the main themes expressed were not being given information about the Bundle or opportunities for consent, some coercive and disrespectful treatment, and an experience of non-autonomy.
If you are birthing in hospital, ask about the PPB during antenatal appointments. Other pertinent questions include the rate of episiotomies performed, and how informed consent is handled during the birth process. Be clear on the steps of the bundle in advance of birth and what you are likely to consent to and not consent to. Remember that as a consumer, you have the right to ask questions, be given information as well as the opportunity to provide informed consent about every aspect of your birth.
So apart from getting informed about the PPB and your options around consent, what else can you do to support your perineal health at birth? There are quite a few things you can do and Part 2 of this blog post will outline some evidence-based actions you can take.
References
Aasheim, V., Nilsen, A.B.V., Reiner, L.M., & Lukasse, M. (2017). Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2017, 6. DOI: 10.1002/14651858.CD006672.pub3
Abdelhakim, A.M., Eldesouky, E., ELmagd, I.A., Mohammed, A., Farag, E.A., Mohammed, A.E., Hamam, K.M., Hussein, A.S., Ali, A.S., Keshta, N.H.A., Hamza, M., Smay, A., & Abdel-Latif, A.A. (2020). Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: A systematic review and meta-analysis of randomised controlled trials. International Urogynecology Journal, 31, 1735-1745. https://link.springer.com/article/10.1007/s00192-020-04302-8
Barnett, B., Jenkinson, B., & Lee, N. (2023). The impact of a perineal care bundle on Women’s birth experiences in Queensland, Australia: A qualitative thematic analysis. Women and Birth: Journal of the Australian College of Midwives, 36(3), 271-280. https://doi.org/10.1016/j.wombi.2022.09.002
Jango, H., Westergaard, H.B., Kjaerbye-Thygesen, A., Langhoff-Roos, J., & Lauenborg, J. (2019). Changing incidence of obstetric and sphincter injuries – A result of formal prevention programs? Acta Obstetrica et Gynecologica Scandinavica, 98(1), 1455-1463. https://doi.org/10.1111/aogs.13672
Laine, K., Skjeldestad, F.E., Sandvik, L., & Staff, A.C. (2012). Incidence of obstetric anal sphincter injuries after training to protect the perineum: Cohort study. BMJ Open, 2(5), e001649.
Lee, N., Allen, J., Jenkinson, B., Hurst, C., Gao, Y & Kildea, S. (2023). A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives. Women and Birth. https://doi.org/10.1016/j.wombi.2023.08.003
Olza, I., Uvnas-Moberg, K., Ekstrom-Bergstrom, A., Leahy-Warren, P., Karlsdottir, S.I., Nieuwenhuijze, M., Villarmea, S., Hadjigeorgiou, E., Kazmierczak, M., Spyridou, A., & Buckley, S. (2020). Birth as a neuro-psycho-social event: An integrative model of maternal experiences and their relation to neurohormonal events during childbirth. PLoS One, 15(7), e0230992. 10.1371/journal.pone.0230992
Women’s Healthcare Australasia. (2019). The How to Guide: WHA CEC Perineal Protection Bundle, Women’s and Children’s Healthcare Australasia, NSW Government, Clinical Excellence Commission. https://women.wcha.asn.au/collaborate/breakthrough-collaboratives/perineal-tears/wha-cec-perineal-protection-bundle-how-to-guide/