How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis

Published:January 20, 2021DOI:



      A care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one – warm perineal compresses – has highest level evidence. There is scant published research about the impact of implementation of perineal bundles.


      How does a perineal care bundle impact midwifery practice in Australian maternity hospitals?


      Purposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power.


      We interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission.


      The bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants’ responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences.


      The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy – women’s and their own – by using clinical judgement, evidence, and woman-centred care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Women and Birth
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Institute for Healthcare Improvement
        Evidence-Base Care Bundles.
        (Available from:) Institute for Healthcare Improvement, 2016
        • Aasheim V.
        • Nilsen A.B.V.
        • Reinar L.M.
        • Lukasse M.
        Perineal techniques during the second stage of labour for reducing perineal trauma.
        Cochrane Database Syst. Rev. 2017;
        • Australian Institute of Health and Welfare
        Australia’s Mothers and Babies 2018.
        (in brief) AIHW, Canberra2020
        • Woolner A.M.
        • Ayansina D.
        • Black M.
        • Bhattacharya S.
        The impact of third-or fourth-degree perineal tears on the second pregnancy: a cohort study of 182,445 Scottish women.
        PLoS One. 2019; 14: e0215180
        • Thiagamoorthy G.
        • Johnson A.
        • Thakar R.
        • Sultan A.
        National survey of perineal trauma and its subsequent management in the United Kingdom.
        Int. Urogynecol. J. 2014; 25: 1621-1627
        • Australian Institue of Health and Welfare
        National Core Maternity Indicators 2017: Summary Report.
        AIHW, Canberra2019
        • Ampt A.J.
        • Ford J.B.
        • Roberts C.L.
        • Morris J.M.
        Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001–2009.
        Aust. N. Z. J. Obstet. Gynaecol. 2013; 53: 9-16
        • Gurol-Urganci I.
        • Cromwell D.
        • Edozien L.
        • Mahmood T.
        • Adams E.
        • Richmond D.
        • et al.
        Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.
        BJOG Int. J. Obstet. Gynaecol. 2013; 120: 1516-1525
      1. Women’s Healthcare Australasia. WHA CEC Perineal Protection Bundle© Women’s Hospitals Australasia Incorporated; Available from:

        • Women’s Healthcare Australasia
        The How to Guide: WHA CEC Perineal Protection Bundle©.
        • Bidwell P.
        • Thakar R.
        • Sevdalis N.
        • Silverton L.
        • Novis V.
        • Hellyer A.
        • et al.
        A multi-centre quality improvement project to reduce the incidence of obstetric anal sphincter injury (OASI): study protocol.
        BMC Pregnancy Childbirth. 2018; 18: 331
      2. Gurol-Urganci I., Bidwell P., Sevdalis N., Silverton L., Novis V., Freeman R., et al. Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design.n/a(n/a).

        • Thornton J.G.
        • Dahlen H.G.
        The UK obstetric anal sphincter injury (OASI) care bundle: a critical review.
        Midwifery. 2020; 90: 102801
        • Royal College of Midwives
        Report of a Survey Exploring the Position of Midwives’ Hands during the Birth of the Baby’s Head.
        Royal College of Midwives, London2014
        • Hals E.
        • Oian P.
        • Pirhonen T.
        • Gissler M.
        • Hjelle S.
        • Nilsen E.B.
        • et al.
        A multicenter interventional program to reduce the incidence of anal sphincter tears.
        Obstet. Gynecol. 2010; : 116
        • Laine K.
        • Pirhonen T.
        • Rolland R.
        • Pirhonen J.
        Decreasing the incidence of anal sphincter tears during delivery.
        Obstet. Gynecol. 2008; : 111
        • Stedenfeldt M.
        • Øian P.
        • Gissler M.
        • Blix E.
        • Pirhonen J.
        Risk factors for obstetric anal sphincter injury after a successful multicentre interventional programme.
        BJOG Int. J. Obstet. Gynaecol. 2014; 121: 83-91
        • Poulsen M.Ø
        • Madsen M.L.
        • Skriver-Møller A.-C.
        • Overgaard C.
        Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature.
        BMJ Open. 2015; 5
        • Skriver-Møller A.-C.
        • Madsen M.L.
        • Poulsen M.Ø
        • Overgaard C.
        Do we know enough? A quality assessment of the Finnish intervention to prevent obstetric anal sphincter injuries.
        J. Matern. Neonatal Med. 2016; 29: 3461-3466
        • Pierce-Williams R.A.M.
        • Saccone G.
        • Berghella V.
        Hands-on versus hands-off techniques for the prevention of perineal trauma during vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.
        J. Matern. Neonatal Med. 2019; : 1-9
      3. Hildebrand E., Nelson M., Blomberg M. Long-term effects of the nine-item list intervention on obstetric and neonatal outcomes in Robson group 1- a time series study.n/a(n/a).

        • Basu M.
        • Smith D.
        • Edwards R.
        Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience.
        Eur. J. Obstetrics Gynecol. Reprod. Biol. 2016; 202: 55-59
        • Lee N.
        • Firmin M.
        • Gao Y.
        • Kildea S.
        Perineal injury associated with hands on/hands poised and directed/undirected pushing: A retrospective cross-sectional study of non-operative vaginal births, 2011–2016.
        Int. J. Nurs. Stud. 2018; 83: 11-17
        • El-Din A.S.S.
        • Kamal M.M.
        • Amin M.A.
        Comparison between two incision angles of mediolateral episiotomy in primiparous women.
        A Randomized Controlled Trial. 2014; 40: 1877-1882
        • Pirhonen T.
        • Gissler M.
        • Hartgill T.
        • Pirhonen J.
        Experiences of expert midwives in a training program aimed at decreasing perineal tears.
        Int. J. Nurs. Mid. 2011; 3: 70-75
        • Bidwell P.
        • Thakar R.
        • Gurol-Urganci I.
        • Harris J.M.
        • Silverton L.
        • Hellyer A.
        • Sevdalis N.
        Exploring clinicians’ perspectives on the ‘Obstetric Anal Sphincter Injury Care Bundle’ national quality improvement programme: a qualitative study.
        BMJ Open. 2020; 10
        • Braun V.
        • Clarke V.
        What can “thematic analysis” offer health and wellbeing researchers?.
        Int. J. Qual. Stud. Health Wellbeing. 2014; 9: 26152
        • Clarke V.
        • Braun V.
        Thematic analysis.
        in: Teo T. Encyclopedia of Critical Psychology. Springer New York, New York, NY2014: 1947-1952
        • Braun V.
        • Clarke V.
        Reflecting on reflexive thematic analysis. Qualitative research in sport, exercise and health.
        Qual. Res. Sport, Exercise and Health. 2019; 11: 589-597
        • Fahy K.
        Reflecting on practice to theorise empowerment for women: using Foucault’s concepts.
        Aust. J. Midwifery. 2002; 15: 5-13
        • Lupton D.
        Perspectives on power, communication and the medical encounter: implications for nursing theory and practice.
        Nurs. Inq. 1995; 2: 157-163
        • Newnham E.
        • McKellar L.
        • Pincombe R.M.
        A critical literature review of epidural analgesia.
        Evidence Based Midwifery. 2016; 14: 22-28
        • Newnham E.
        • McKellar L.
        • Pincombe J.
        Queensland Department of Health (Statistical Services Branch).
        Perinatal Statistics Queensland 2015. Queensland Health, Brisbane2017
        • Patton M.Q.
        Qualitative Research and Evaluation Methods.
        Sage Publications, 2002
        • Clarke V.
        • Braun V.
        Thematic analysis.
        J. Posit. Psychol. 2017; 12: 297-298
        • Schwandt T.A.
        The SAGE Dictionary of Qualitative Inquiry.
        SAGE Publications, 2007
        • Women’s Healthcare Australasia
        Accompanying Bundle Booklet.
        (Available from:)2017
        • Westfall R.
        • Benoit C.
        Interpreting compliance and resistance to medical dominance in women’s accounts of their pregnancies.
        Sociol. Res. Online. 2008; 13: 62-77
        • Sandall J.
        Choice, continuity and control: changing midwifery, towards a sociological perspective.
        Midwifery. 1995; 11: 201-209
        • Dahlen H.G.
        • Homer C.S.E.
        • Leap N.
        • Tracy S.K.
        From social to surgical: historical perspectives on perineal care during labour and birth.
        Women Birth. 2011; 24: 105-111
        • International Confederation of Midwives
        Philosophy and Model of Midwifery Care.
        (Available from:)2014
        • Nursing and Midwifery Board of Australia (NMBA)
        National Competency Standards for the Midwife.
        NMBA, Melbourne2006
        • Roberts S.J.
        Oppressed group behavior.
        Adv. Nurs. Sci. 1983; 5: 21-30
        • Howick J.
        • Chalmers I.
        • Glasziou P.
        • Greenhalgh T.
        • Heneghan C.
        • Liberati A.
        • et al.
        The 2011 Oxford CEBM Evidence Levels of Evidence (Introductory Document).
        (Available from:)2011
        • Reiger K.
        • Morton C.
        Standardizing or individualizing? A critical analysis of the "discursive imaginaries" shaping maternity care reform.
        Int. J. Childbirth Educ. 2012; 2: 173-186
        • Greenhalgh T.
        • Howick J.
        • Maskrey N.
        Evidence based medicine: a movement in crisis?.
        Br. Med. J. 2014; 348: 3725
        • Lavallee J.F.
        • Gray T.A.
        • Dumville J.
        • Russell W.
        • Cullum N.
        The effects of care bundles on patient outcomes: a systematic review and meta-analysis.
        Implement. Sci. 2017; 12
        • Katz Rothman B.
        Childbirth management and medical monopoly: midwifery as (almost) a profession.
        J. Nurse. 1984; 29: 300-306
        • Fahy K.M.
        An Australian history of the subordination of midwifery.
        Women Birth. 2007; 20: 25-29
        • Reiger K.M.
        Domination or mutual recognition? Professional subjectivity in midwifery and obstetrics.
        Soc. Theory Health. 2008; 6: 132-147
        • Murphy-Lawless J.
        Reading Birth and Death: A History of Obstetric Thinking.
        Cork University Press, 1998
        • Licqurish S.
        • Evans A.
        ‘Risk or right’: a discourse analysis of midwifery and obstetric colleges’ homebirth position statements.
        Nurs. Inq. 2016; 23: 86-94
        • Leap N.
        Making sense of ‘horizontal violence’ in midwifery.
        Br. J. Midwifery. 1997; 5: 689
        • Roberts S.J.
        • DeMarco R.
        • Griffin M.
        The effect of oppressed group behaviours on the culture of the nursing workplace: a review of the evidence and interventions for change.
        J. Nurs. Manag. 2009; 17: 288-293
        • Lovell M.C.
        Silent but perfect “partners”.
        Adv. Nurs. Sci. 1981; 3: 25-40
        • Timmins F.
        • McCabe C.
        Nurses’ and midwives’ assertive behaviour in the workplace.
        J. Adv. Nurs. 2005; 51: 38-45
        • Hildingsson I.
        • Gamble J.
        • Sidebotham M.
        • Creedy D.K.
        • Guilliland K.
        • Dixon L.
        • et al.
        Midwifery empowerment: national surveys of midwives from Australia, New Zealand and Sweden.
        Midwifery. 2016; 40: 62-69
        • Allen J.
        • Kildea S.
        • Hartz D.L.
        • Tracy M.
        • Tracy S.
        The motivation and capacity to go’ above and beyond’: qualitative analysis of free-text survey responses in the [email protected] randomised controlled trial of caseload midwifery.
        Midwifery. 2017; 50: 148-156
        • Kruske S.
        • Young K.
        • Jenkinson B.
        • Catchlove A.
        Maternity care providers’ perceptions of women’s autonomy and the law.
        BMC Pregnancy Childbirth. 2013; 13: 84
        • Newnham E.
        • Kirkham M.
        Beyond autonomy: care ethics for midwifery and the humanization of birth.
        Nurs. Ethics. 2019; 26: 2147-2157
        • Nowell L.S.
        • Norris J.M.
        • White D.E.
        • Moules N.J.
        Thematic analysis: striving to meet the trustworthiness criteria.
        Int. J. Qual. Methods. 2017; 16 (1609406917733847)