What are the views of midwives in relation to perineal repair?
Article Outline
- Summary
- Introduction
- Method
- Results
- Discussion
- Conclusion
- Disclosure statement
- Acknowledgements
- References
- Copyright
Summary
Purpose
To determine the views of midwives towards perineal repair and the most effective way to teach and support midwives in developing this skill.
Procedure
A questionnaire was distributed to 111 midwives who attended a 1-day seminar. Information was sought on a range of views relating to perineal repair, including experience, confidence, education and accreditation, attitudes and trends.
Findings
One hundred and six (96%) questionnaires were returned. All respondents (100%) believed midwives should be taught to undertake perineal repair. The most important reason was to provide continuity of care for women. Experience increased confidence and enjoyment in undertaking perineal repair as well as lessening fears over the impact of suturing on women. Experience did not significantly impact on concerns regarding legal implications associated with perineal repair. Three quarters of respondents reported that midwifery students should have practical experience of perineal repair. There was strong support for doctors and midwives to undertake perineal repair education together (96%), preferably in a 1-day workshop format (56%); for standards to be set by the professional colleges (midwifery and obstetrics) (66%); for midwives and doctors to be accredited as competent before performing perineal repair independently (>90%) and for regular updates in perineal repair (93%). The majority of midwives (73%) felt that they were more likely to suture than 5 years ago, due mainly to a greater appreciation of woman centred care (35%). Over 60% of midwives said they would not suture a first-degree tear more than half of the time and 13% would not suture a second-degree tear more than half of the time.
Principle conclusion
A desire to provide continuity of care appears to be a major motivator for midwives to learn to undertake perineal repair. There is need for standards to be set for perineal repair to encourage consistency in education. Perineal repair programs that involve midwives and doctors training together have strong support from midwives but it is unclear if doctors would also support this. Further research is needed to support or refute the trend for midwives to not suture some perineal trauma.
Keywords: Perineal repair, Perineal trauma, Midwives, First degree tear, Second degree tear, Suture
Introduction
Trauma to the genital tract commonly accompanies vaginal birth.1, 2, 3 In Australia, 66% of women have some form of perineal trauma.4 A large number of these women will have perineal suturing performed. A first- or second-degree laceration or graze was reported in 44.2% of vaginal births, a third- or fourth-degree laceration in 1.3% of women having vaginal births and an episiotomy was performed in 17.2% of women who had a vaginal birth.4
In recent years, the role of the midwife has been extended to incorporate a broader range of clinical skills into practice. Perineal repair is one of these skills. Midwives are increasingly expected to undertake perineal repair on their own responsibility and to provide women with advice regarding perineal care. This falls within the scope of practice for a midwife.5 Women prefer to be sutured by the same professional who assisted with the birth.6, 7, 8 This is due to many factors including, decreased waiting times, continuity of care, empathy and good communication of information regarding expected outcomes and care of the repaired perineum.
The way perineal repair is taught to midwives and the supervision, accreditation and frequency of updates for these health professionals is managed differently in different organisations and under different models of care. For example, in midwifery-led units and birth centres, the proportion of midwives performing perineal repair appears to be higher than in traditional labour ward settings.9, 10, 11 The lack of consistency, particularly with education and accreditation, means midwives will often undergo another process of accreditation if they move their place of employment.
While the type of suturing material and technique of the repair is important, the skill of the operator has also been recognised as one of three main factors that influence the outcome of perineal repair.12 The Royal College of Obstetricians and Gynaecologists states that practitioners who are appropriately trained are more likely to provide a consistent and high standard of perineal repair.12 They also recommend a 24-hour cover by an experienced practitioner to facilitate training and provide support and supervision.12 A UK survey highlighted the deficiency and dissatisfaction among trainee doctors and midwives with their training in perineal anatomy and repair.13 Despite this, much of the perineal repair research is focussed on suture material and technique, rather than skill or training. Draper and Newell studied the consequences and outcomes of perineal trauma management and found that the skill of the operator, regardless of profession (doctor, midwife, student midwife), was the most important factor for a successful repair, if not more important than the method chosen or the material used.14 This is supported by findings from other research.15, 16
Consumers of midwifery services have also raised concerns following their own personal experiences of perineal repair, which were mostly related to issues such as the operator being inexperienced, unsupervised, having learnt by trial and error or simply being indifferent.17, 18, 19 As indicated by researchers, part of the problem may be that once the repair is completed, most practitioners are unable to monitor the long-term effects so have no way of auditing their practice.20 Sadly the only feedback some midwives receive is in the form of litigation years following the event. The lack of contemporary research into clinical support, education around perineal repair and resulting maternal morbidity needs to be addressed. Many of the studies previously conducted are now quite old and contemporary issues for clinicians and consumers need to be further explored.
In recent years changes in perineal repair practice has been observed, particularly with midwives choosing not to suture certain perineal trauma. McCandlish21 noted that universal repair of perineal trauma has been standard practice for many years until journals aimed at midwives began to publish reports of observational studies in the 1990s, highlighting the potential benefits of not suturing perineal trauma that did not involve the anal sphincter.22, 23 A large RCT was carried out comparing a policy of a two-staged repair, where the skin was left unsutured and a policy of a three-staged repair, where the skin was sutured, amongst women who had a first- or second-degree tear. At 3 months after birth, among women who resumed intercourse, there was a significant difference in reports of dyspareunia with fewer women reporting this outcome in the two-stage repair group. Fewer women at 1-year follow up reported that their perineum felt different from before the birth in the two-stage repair group.24 Two other RCTs followed, comparing women who had undergone suturing to those who had not. The researchers concluded that non-suturing was acceptable and that minor lacerations can be left to heal.25 In 2003, findings from another RCT investigated outcomes for 74 primiparous women randomised to being sutured or not.26 At 6 weeks there remained a significant difference in wound closure between the two groups with women who had been sutured showing poorer wound approximation. The small sample sizes in these RCTs have been a limitation and evidence from a larger trial is needed. It is currently unknown how often and for what reasons midwives in Australia decide not to suture perineal trauma.
Despite increased numbers of midwives being able to undertake perineal repair as part of their role in the last 10 years, there is limited information available about the views of midwives towards perineal repair and their views on the most effective way to teach this skill. The aim of this study was to elicit information from midwives on their experience with perineal repair, the reasons for undertaking perineal repair; the processes for education and accreditation in perineal repair; their attitudes towards undertaking perineal repair and levels of confidence.
Method
This study was undertaken by way of convenience sampling and use of a questionnaire. The questionnaire contained both open and closed questions. Closed (categorical) questions sought specific information about characteristics and experience, attitudes and observations of respondents, education format and competency and trends in perineal repair management. Open questions asked about the place of work and profession and invited suggestions as to who should set standards if they did not select the options of the state Health Department or Professional Colleges. Questionnaires were piloted on five midwives prior to the seminar day and minor changes were made following this. The changes were predominantly to improve clarity of the questions and possible responses.
Participants
Questionnaires were distributed at a seminar titled “Perusing the Perineum”, in May 2007. The seminar was designed to update midwives, doctors and physiotherapists on recent research and developments in perineal care and repair. One hundred and thirty-one participants attended the seminar; 111 midwives, 20 physiotherapists and 5 doctors. When the midwives and doctors registered for the seminar at the start of the day they were given the questionnaire and invited to complete it before the lunch break. It was optional to complete the questionnaires and they were anonymous and confidential with no identifying information recorded. The physiotherapists were not given a questionnaire. Formal ethics approval was not obtained as this questionnaire was designed as an adjunct to a seminar day and the primary ethical considerations of informed consent, confidentiality and anonymity were assured. Participation of the questionnaire was voluntary and completion of the questionnaire was taken as implied consent. The preamble of the questionnaire acknowledged the researchers, the purpose of the survey, and that preliminary results would be reported back to the attendees during the workshop in an open forum session. Furthermore, it was made clear in the questionnaire preamble that in order to generate discussion and encourage policy development the results may be published in a midwifery journal in the future. Whilst it was initially anticipated that the results would be made available online or in a midwifery newsletter, the large number of returned questionnaires and interesting findings where thought to be beneficial to the profession of midwifery and therefore published in this peer reviewed journal. Whilst there were a small number of responses from doctors (n
=3), this paper will only present the responses provided by the midwife participants (n=111).
Analysis
All data were analysed with Statistical Package for Social Sciences (SPSS) version 12.27 Alpha was set at 0.05 for all analyses. Simple descriptive statistics were used for analysis. A Chi-squared test was used to examine group differences with regards to level of experience with perineal repair and responses given. The three levels of experience with perineal repair were defined as (1) inexperienced (none–1 year); (2) moderate experience (1–9 years); or (3) very experienced (10 or more years).
Results
Characteristics and experience
Of the 111 questionnaires distributed to midwives, 106 were completed (96%). Respondents came from 28 different hospitals in four different States and Territories in Australia (New South Wales, Australian Capital Territory, South Australia, Victoria). Ninety-five of the midwives worked in public hospitals (90%), four worked in private practice (4%) and the remaining seven (6%) either did not complete the question or indicated ‘other’ as place of work.
Forty-five (43%) of respondents were classed as inexperienced—that is they had never preformed perineal repair (n=26), were currently learning (n=6), had not preformed a perineal repair for several years (n=11), or had been performing perineal repair for less than a year (n=2). Thirty of the respondents (28%) had between 1 and 9 years experience in perineal repair (classified as moderate experience) and 31 (29%) had 10 or more years of experience (classified as very experienced).
When asked about their current level of practice in perineal repair, 25 (24%) midwives said they were conducting between 1 and 9 repairs a year, 33 (31%) midwives between 10 and 20, and 5 (4%) midwives undertook more than 20 per year. Forty-three midwives (41%) did not perform perineal repair or had not done so for several years.
Attitudes and observations of respondents
All respondents agreed that midwives should be taught to undertake perineal repair. The statement ranked as the most important reason was that it ‘gives women continuity’. Least important was the fact that there were ‘too few doctors now’ (Fig. 1). Three quarters of respondents felt that midwifery students should have practical experience with perineal repair during their training. The level of experience with perineal repair did not significantly influence this response. Nearly half (48%) of the midwives said they worried ‘sometimes’ about the legal implications of performing perineal repair, 18% said they ‘never’ worried and 11% said they worried about the legal implications ‘all the time’. Level of experience did not significantly alter the level of worry.
Figure 1.
Reasons why midwives should be taught to undertake perineal repairs ranked from 1 (most important) to 5 (least important).
Midwives were more likely to say they worried ‘all the time’ (45%), about doing a good job and the possible impact of the repair on women. More than a quarter of midwives said they worried ‘often’ (27%). The more experienced the respondents were with perineal repair the less they reported worrying about the impact on women (Fig. 2).
Figure 2.
Years of experience performing perineal repair and level of worry over impact on women. A Chi-squared test was performed to examine differences between allocated groups: P
>0.002.
One-third of respondents reported feeling ‘reasonably confident’ when performing perineal repair with one-fifth saying they did ‘not feel confident at all’. Just over a one-third of midwives felt very confident. Respondents were more likely to report higher levels of confidence the more experienced they were with perineal repair (Fig. 3).
Figure 3.
Years performing perineal repair and level of confidence reported. A Chi-squared test was performed to examine differences between allocated groups: P
>0.0001.
The majority of midwives said they got ‘some’ to ‘a lot’ of enjoyment out of performing perineal repair (65%), while 15% of respondents said they ‘did not enjoy’ undertaking perineal repair at all. The more experienced midwives reported enjoying performing perineal repair more (Fig. 4). Over three quarters of respondents (79%) felt that the perineal repair they observed being repaired were mostly, or always, done well. Whether the midwives thought repairs were done well or not was not significantly affected by years of experience (Table 1).
Figure 4.
Years of experience and level of enjoyment undertaking perineal repairs. A Chi-squared test was performed to examine differences between allocated groups: P
>0.0001.
Table 1. Attitudes and observations of respondents regarding perineal repair
| Attitudes and observations of respondents | Numbers of response (n=106) | Percentage |
|---|---|---|
| Do you, or did you, worry about legal implications of conducting perineal repair? | ||
| Never | 19 | 18 |
| Sometimes | 51 | 48 |
| Often | 18 | 17 |
| All the time | 12 | 11 |
| Not completed | 6 | 6 |
| Do you, or did you, worry about whether or not you do a good job with perineal repair and the possible impact on women? | ||
| Never | 4 | 4 |
| Sometimes | 17 | 16 |
| Often | 29 | 27 |
| All the time | 48 | 45 |
| No completed | 8 | 8 |
| Do you, or did you, feel confident performing perineal repair? | ||
| Not at all | 22 | 21 |
| Somewhat | 12 | 11 |
| Reasonably confident | 35 | 33 |
| Very confident | 22 | 21 |
| Not completed | 15 | 14 |
| Do you, or did you, enjoy undertaking perineal repair? | ||
| Not at all | 16 | 15 |
| Somewhat | 38 | 36 |
| A lot | 31 | 29 |
| Not completed | 21 | 20 |
| When witnessing perineal repair I would say | ||
| Many are not done well | 7 | 7 |
| Half are poorly done | 12 | 11 |
| Most are well done | 79 | 75 |
| All are done well | 4 | 4 |
| Not completed | 4 | 4 |
Education format and competency
Almost all of the midwives (96%) said midwives and doctors should undertake perineal repair workshops together. The most popular format for perineal repair workshops was over ‘1 day’ (56%) followed by ‘several 1 or 2h sessions’ (31%). Over 90% of respondents agreed with the statement that midwives and doctors should be accredited as competent before being able to repair perineal trauma independently. When asked how many repairs they should be supervised for, 29% said 5–9 repairs, 27% said 1–4 repairs and 24% said the number depended on skills and confidence. Level of experience did not significantly impact on the response. There was strong agreement that there be a state-wide standard for teaching perineal repair courses (88%) and the professional colleges were seen to be the most appropriate bodies to set these standards (66%). There was also strong agreement that midwives and doctors should have regular updates in perineal repair (93%). The most popular time frame for these updates was every 2 years (47%). Over a one-third of respondents (35%) said they thought around 10 repairs a year were needed to remain competent with 26% saying five a year was adequate and 18% saying numbers were irrelevant (Table 2).
Table 2. Education format and competency
| Attitudes and observations of respondents | Numbers of response (n=106) | Percentage |
|---|---|---|
| How many repairs should midwives or doctors be supervised for while learning? | ||
| 1–4 repairs | 29 | 27 |
| 5–9 repairs | 31 | 29 |
| 10–14 repairs | 17 | 16 |
| 15–20 repairs | 1 | 1 |
| 20+ repairs | 0 | 0 |
| Depends on skills and confidence | 25 | 24 |
| Not completed | 3 | 3 |
| Should there be a state-wide standard set for teaching perineal repair courses? | ||
| Yes | 93 | 88 |
| No | 8 | 8 |
| Not competed | 5 | 5 |
| Who should set these standards? | ||
| NSW Health Department | 9 | 9 |
| The Professional Colleges | 70 | 66 |
| Other | 2 | 2 |
| Both NSW Health and Professional Colleges | 7 | 7 |
| Not competed | 18 | 17 |
| Once deemed competent, should midwives and doctors have regular updates in perineal repair? | ||
| Yes | 98 | 93 |
| No | 5 | 5 |
| Not completed | 3 | 3 |
| How often should they have updates? | ||
| Yearly | 31 | 29 |
| Every 2 years | 50 | 47 |
| Every 4 years | 4 | 4 |
| Every 5 years | 12 | 11 |
| Not completed | 9 | 9 |
| How many perineal repair a year do you think a midwife or doctor need to do in order to remain competent? | ||
| Numbers are irrelevant | 19 | 18 |
| 1 | 0 | 0 |
| 5 | 28 | 26 |
| 10 | 37 | 35 |
| 20 | 17 | 16 |
| 100 | 0 | 0 |
| Not completed | 5 | 5 |
Trends in perineal repair
The majority of respondents (64%) felt perineal trauma rates had not altered over the time of their career. Nearly a one-fifth (19%) felt that perineal trauma was less common now than in the past and 14% felt it was more common now. Level of experience did not significantly alter the responses.
The majority of respondents (73%) felt midwives were more likely to suture now than 5 years ago. The most common reason given for the increase in midwives suturing was a ‘greater appreciation of woman centred care’ (35%) followed by greater professional recognition (20%) and support in the workplace (16%). Only 4% of respondents selected ‘shortage of doctors’ as a reason why more midwives were suturing now than 5 years ago. Twenty-three percent felt that ‘all the above’ had led to this increased rate of perineal suturing. Respondents who felt they were less likely to suture now than 5 years ago (n=20) were most likely to say this was due to the fact they were not supported in the workplace.
Respondents were asked to indicate how often they would decide not to suture a first-degree perineal tear. Almost two-thirds (60%) said they would not repair a first-degree tear more than half of the time. Nine percent said they never repaired a first-degree tear and 9% always repaired a first-degree tear. With second-degree tears, 52% said they would always repair the tear while 24% said they would repair a second-degree tear 90% of the time. Over 13% of respondents said they would not repair a second-degree tear 50% or more of the time (Table 3).
Table 3. Trends in perineal repair
| Attitudes and observations of respondents | Numbers of response (n=106) | Percentage |
|---|---|---|
| Midwives are more likely to suture now than 5 years ago | ||
| Yes | 77 | 73 |
| No | 20 | 19 |
| No difference | 7 | 7 |
| Not completed | 2 | 2 |
| Midwives are more likely to suture now than 5 years ago due to | ||
| (a) Greater professional recognition | 16a | 20b |
| (b) Shortage of doctors | 3 | 4 |
| (c) Support in the workplace | 12 | 16 |
| (d) Greater appreciation of woman centred care | 27 | 35 |
| All the above | 18 | 23 |
| Not competed | 1 | 1 |
| Midwives are less likely to suture now than 5 years ago due to | ||
| (a) Being too busy | 5c | 25d |
| (b) Worried about consequences | 4 | 20 |
| (c) Not supported in the workplace | 6 | 30 |
| (d) All the above | 4 | 20 |
| Not completed | 1 | 5 |
| How often you would decide not to suture a first-degree tear? | ||
| Never | 10 | 9 |
| 10% of the time | 19 | 18 |
| 50% of the time | 28 | 26 |
| 75% of the time | 26 | 25 |
| 100% of the time | 10 | 9 |
| Not completed | 13 | 12 |
| How often you would decide not to suture a second-degree tear? | ||
| Never | 55 | 52 |
| 10% of the time | 25 | 24 |
| 50% of the time | 4 | 4 |
| 75% of the time | 4 | 4 |
| 100% of the time | 5 | 5 |
| Not competed | 13 | 12 |
aNumber adds up to 77 as these are the respondents that said midwives were more likely to suture now than 5 years ago. |
bPercentage out of 77 responses not 106. |
cNumber adds up to 20 as these are the respondents that said midwives are less likely to suture now than 5 years ago. |
dPercentage out of 20 responses not 106. |
Discussion
There are significant limitations with this study. Firstly, the group of midwives who responded to the questionnaire were interested in perineal repair, as they had taken the time to come to a seminar on this topic. They may not be a representative sample of midwives in relation to perineal repair. Secondly, the majority of midwives attending the seminar were from medium to large public teaching hospitals where perineal repair is supported as part of the role of the midwife. Thirdly, there was a significant range of experience amongst the midwives completing the survey. Some had no experience whilst others had significant experience.
Despite these limitations, this is one of the first surveys done in Australia of midwives’ attitudes to perineal repair. The response rate (96%) was high. This may have been partly to do with the fact respondents were given the questionnaire at the beginning of the seminar when they had time to complete it and also that we undertook to feedback some results in a session during the day. The opportunity to complete a questionnaire and access the results so quickly could have made midwives more enthusiastic about completing the questionnaire. It may yet again be evidence that this group of midwives had a strong interest in perineal repair.
Respondents strongly supported the incorporation of perineal repair into midwifery practice. The most important reason given for midwives undertaking perineal repair was it provided continuity of care. This is supported by research indicating women prefer to be sutured by the same professional who assisted with the birth.6, 7, 8 More research is needed to explore current women's views in Australia as this research is now quite old and from the UK. Continuity of care for childbearing women is recognised as best practice and increasingly midwifery models that offer continuity of care are being supported.28, 29, 30 Midwives’ ability to perform perineal repair makes them more autonomous, as well as enabling the expansion of midwifery-led models of care. In midwifery-led units and birth centres, the proportion of midwives performing perineal repair also appears to be higher than in traditional labour ward settings.9, 10, 11 Questions were raised in this research about the support for midwives to undertake perineal repair. For example, of the 20 midwives who said they thought midwives were less likely to suture now than 5 years ago, one-third said they were not supported in the workplace and one quarter said they were too busy now to suture.
Three quarters of respondents felt midwifery students should have practical experience with perineal repair during their training. Midwives supported the concept that learning perineal repair as a student midwife made this skill seem a part of midwifery practice rather than an advanced skill. This may mean midwives incorporate it more easily into their practice and see it as part of their role. This is supported by the fact midwives responded that the second most important reason (after continuity of care) for midwives to undertake perineal repair was because it is part of the professional role of a midwife.
There was strong support for midwives and doctors to undertake perineal repair training together. There was support to move back to a collaborative and multidisciplinary approach where both doctors and midwives teach one another. This would provide an opportunity for both professions to share skills and learn together, potentially enhancing collaboration and may lead to greater consistency in practice.
A 1-day workshop format, followed by the several 1 or 2 hour sessions was most favoured for education. This may be because it is easier for midwives to be away from their clinical responsibilities altogether (1 day), or away for a short period (1 or 2h sessions). The half-day workshop was least popular. The difficulty with several 1 or 2h sessions is getting the same people to attend all the sessions.
There was strong support for a system of accreditation for competence in perineal repair for midwives and doctors and for this to be a state-wide or nationally consistent standard. Midwives expressed frustration with the fact that if they were deemed competent in one area health service they might not be deemed competent in another. A state-wide standard would mean this problem could be eliminated. Midwives expressed support for perineal repair to continue to be taught locally but wanted standards set for what would be taught and how they would be evaluated. The professional colleges (Australian College of Midwives and Royal Australian and New Zealand College of Obstetrics and Gynaecology) were seen to be the most appropriate bodies to set these standards. Ideally competencies should also be set by the professional colleges in order to encourage a nationally consistent standard. There was also strong support for ongoing second yearly updates so midwives remained current in practice and knowledge. There seemed to be less agreement about how many repairs midwives needed to undertake whilst under supervision. There seemed to be almost an equal number of midwives selecting the option ‘1–4’ repairs as there those selecting 4–10 repairs, as there were those selecting ‘depends on skills and confidence’. It appears from this between 1 and 9 is seen as ideal but this depends on skills and confidence as well. The number of supervised repairs will depend on individual learning needs as well as minimum requirements.
Midwives were less likely to worry about the legal implications of performing a perineal repair than they were to worry about doing a good job and the impact of the repair on women. The incorporation of follow up as a component of perineal repair education may help alleviate this worry in midwives. Many midwives only ever see the perineal repair at the time they undertake it, when odema is likely to be present and anatomy can appear distorted. Following up a woman over subsequent days and weeks to see the healing process and be able to receive feedback from the woman herself may reduce this anxiety in midwives. This is most practical in continuity of care models where midwives provide postnatal care.
Confidence in carrying out perineal repair was associated with experience. The more experienced midwives were more confident and enjoyed undertaking the procedure. This is reassuring for midwives who are beginners in perineal repair. It is important to inform midwives that the more skilled they become, the more confident they will be and they will experience more satisfaction. Experience also lessens worry about the quality of the procedure and the impact it has on women. All these factors can influence midwives enthusiasm in learning this important skill. Reassurance is needed that practice not only makes perfect but also makes the skill more enjoyable and rewarding.
The majority of midwives believed they were more likely to suture now than 5 years ago and that this was due mostly to a greater appreciation of woman centred care. This was supported by the fact that the majority of respondents acknowledged that being able to perform perineal repair provided women with midwifery continuity of care. Continuity of care motivates midwives to undertake perineal repair training and this is what has influenced the uptake of this skill into midwifery practice.
The rate of perineal trauma that is not sutured varies from organisation to organisation and between individual midwives. Midwives in this study were asked how often they would decide not to suture a first or second-degree tear. While one in ten midwives would always suture a first-degree tear, one in two would always suture a second-degree tear. Sixty percent of midwives said more than half the time they would not repair a first-degree tear and this dropped to 13% of midwives for a second-degree tear. The small sample sizes in the trials to date on this issue25, 26 is a limitation and evidence from larger trials is needed. Until this evidence is available caution is needed, as evidence is not conclusive with regards to non-suturing of perineal trauma. The results of this study indicate that while it is less common not to suture second-degree tears it is quite common not to suture first-degree tears. Choosing not to suture second-degree tears, where muscle integrity is a consideration, is arguably more concerning. Midwives will argue that the key to this decision is embedded in the experience of a midwife in being able to identify the difference between simple (small, aligned and not bleeding) and complex (large, ragged, misaligned and bleeding) second-degree tears.31 Unfortunately there is no good evidence to help childbearing women and midwives make this decision so caution must be taken and research needs to be undertaken urgently into this question.
Conclusion
The results of this study into midwives views about perineal repair provide a useful insight into practice and opinions. A greater appreciation of woman-centred care appears to be a major motivator for midwives to learn perineal repair. There is a need for standards and competencies to be set by the professional colleges (Australian College of Midwives and Royal Australian and New Zealand College of Obstetrics and Gynaecology) for perineal repair, to encourage consistency in education and ensure quality and safety for childbearing women. Perineal repair programs that involve midwives and doctors training together have strong support from midwives but it is unclear how doctors would view this. More extensive research is needed to clarify this and determine whether the findings of this survey reflect the wider midwifery and obstetric opinion in Australia. Further research is also needed to support or refute the trend for midwives to not suture some perineal trauma.
Disclosure statement
No financial support was received for this research.
Acknowledgements
We would like to thank all the midwives who participate in the survey. We would also like to thank Priya Nair for entering the data on Excel for us.
References
- . UK study of intrapartum care for low risk primigravidas: a survey of interventions. J Epidemiol Community Health. 1998;52(8):494–500
- . Incidence, severity and determinants of perineal pain after vaginal delivery: a prospective cohort study. Am J Obstet Gynecol. 2004;191(4):1119–1204
- A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol. 1998;105:1262–1272
- . Australia's mothers and babies 2004. Sydney: AIHW National Perinatal Statistics Unit; 2006;
- ICM. International definition of a midwife. The Hague, The Netherlands: International Confederation of Midwives; 2005.
- . Should midwives be repairing episiotomies?. Midwives Chron Nurs Notes. 1985;98(174):296
- . Repairing the tear. Nurs Times. 1991;35:60–61
- . The perineum in childbirth: a survey of women's experiences and midwives’ practices. London: The National Childbirth Trust; 1993;
- Dahlen H. Perineal repairs by midwives in the Delivery ward and Birth Centre of Royal Prince Alfred and Canterbury Hospital: an audit. Unpublished; 2004.
- Tracy SK, Hartz D. The quality review of Ryde Midwifery Group Practice, September 2004 to October 2005. Final report: Northern Sydney and Central Coast Health; 2005.
- . Belmont Birthing service: evaluation and clinical outcomes July 2005–January 2006. Newcastle: Hunter New England Health; 2006;
- RCOG. Methods and materials used in perineal repair. Guideline No 23. London: Royal College of Obstetricians and Gynaecologists; 2004.
- . Obstetric perineal trauma: an audit of training. J Obstet Gynecol. 1995;15:19–23
- . A discussion of some of the literature relating to history, repair and consequences of perineal trauma. Midwifery. 1996;2:140–145
- . The choice of suture materials and techniques for repair of perineal trauma: an overview of the evidence from controlled trials. BJOG: Int J Obstet Gynaecol. 1989;96(11):1281–1289
- . West Berkshire perineal management trial. Br Med J Clin Res Ed. Sep 8 1984;289(6445):587–590
- Brimacombe J. Reaping the pain which others have sewn. The Independent; 1995
- Rix JA. Painful and perineal problem. Daily Telegraph; 1992
- . The management of perineal trauma. In: Henderson C, Bick D editor. Perineal care: an international issue. Wiltshire: Quay Books MA Healthcare Limited; 2005;
- . Are you sitting comfortably?. Midwifery Matters. 1995;66:3–5
- . Perineal trauma: prevention and treatment. J Midwifery Womens Health. 2001;46(6):396–401
- . To stitch or not to stitch?. Pract Midwife. 1999;2:20–28
- . Dropping stitches. Nurs Times. 1993;33:64–65
- . The Ipswich childbirth study: 1. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. BJOG: Int J Obstet Gynaecol. 1998;105(4):435–440
- . Is it necessary to suture all lacerations after a vaginal delivery?. Birth. 2000;27(2):79–85
- . Does perineal suturing make a difference? The SUNS trial. BJOG: Int J Obstet Gynaecol. 2003;110(7):684–689
- . Statistical Package for Social Sciences (SPSS) for Windows. Chicago, Illinois, USA: SPSS inc.; 2003;
- . Options for effective care in childbirth. Canberra: Australian Government Printing Service; 1996;
- NSW Health Department. Final Report of the Ministerial Task Force on Obstetric Services in NSW: the Shearman Report. State Health Publication No. (HSU) 89-007 ed. Sydney: NSW Department of Health; 1989.
- . The NSW framework for maternity services. Sydney: NSW Department of Health; 2000;
- . Healing passage: a midwife's guide to the care and repair of the tissues involved in birth. 5th ed.. Portland: Labrys Press; 1995;
PII: S1871-5192(07)00122-9
doi:10.1016/j.wombi.2007.12.003
Crown Copyright © 2008. Published by Elsevier Inc. All rights reserved.
