1. The Obstetric Anal Sphincter Injury (OASI) Care Bundle A quality improvement programme to reduce the incidence of third- and fourth-degree perineal tears

2. Our Care Bundle aims to address these issues
Current issues in OASI prevention in the UK
Our Care Bundle aims to address these issues
Inconsistencies in approaches to preventing OASIs
Inconsistencies in training and skills
Lack of awareness of risk factors and long-term impact of OASIs
Variation in practice between midwives and doctors
1 Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOP). Int Urogynecol J 2011;22:1279–85
2 Ismail KM, Paschetta E, Papoutsis D, Freeman RM. Perineal support and risk of obstetric anal sphincter injuries: a Delphi survey. Acta Obstet Gynecol Scand.2015 Feb;94(2):
3 Andrews V, Sultan AH, Thakar R, Jones PW. Risk factors for obstetric anal sphincter injury: a prospective study. Birth Jun;33(2):
4 Naidu M, Kapoor DS, Evans S, Vinayakarao L, Thakar R, Sultan AH. Cutting an episiotomy at 60 degrees: how good are we? Int Urogynecol J Jun;26(6):813-6.
Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol Feb 10;101(1):19-21.

3. What is a Care Bundle?
A care bundle is a small set of evidence-based interventions for a defined patient segment or population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually.
Institute for Healthcare Improvement

4. Such as posters, pens, balloons, memory aids
There are three major components to the intervention which will be implemented together:
Multi-disciplinary skills development module
Campaign materials
The care bundle
4 evidence-based interventions that, when implemented together, will result in significantly better outcomes than when implemented individually.
A Care Bundle Guide will be provided
Such as posters, pens, balloons, memory aids
Champions will attend a Skills Development Day
Training in interventions
Guidance and support in rolling out in their units
Training materials provided:
E.g. videos, visual aids and a quiz

5. The OASI Care Bundle
Inform the woman about OASI and what steps can be taken to minimize her risk. (an information leaflet will be provided)
Use of manual perineal protection
Spontaneous births if position allows it (women who give birth in water are excluded)
All assisted births (forceps and ventouse)
Medio-lateral episiotomy (60 degree angle) at crowning to be used when indicated.
Perineum must be examined after delivery and any tears graded according to the RCOG guidelines. Examination should include a per rectum check, even when the perineum appears intact. 1 2 3 4

6. The intervention will be facilitated by:
1. Local clinical champions (one midwife and one obstetrician from each unit). They will champion the project including: ensuring that staff have completed the multi-disciplinary skills development module, monitoring local compliance with the care bundle, reporting on unit-level OASI rates, and participating in shared learning days with the other units in their block. 2. Leadership and support from professional organisations will be provided by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) who will actively promote the project and will provide a joint statement endorsing the use of care bundle. In addition, the professional and educational networks of the Colleges will be actively used to support the skills development module. 3. Continuous monitoring and feedback will allow participant units to measure their progress, by reporting their OASI rates, compliance with the care bundle, and uptake of the skills development module. Units will participate in shared learning days with other units to provide a forum to discuss the project as it progresses.

7. Evaluation of implementation outcomes
Acceptability
Satisfaction with intervention
Survey of champions on Skills Development Day (A, F)
Improved knowledge, awareness & skills
Routine monitoring of basic data (F, C)
Feasibility
Extent to which intervention can be applied
Standardised delivery of the evidence based intervention
Focus groups with clinicians during site visits (A, F, S)
Coverage
Extent to which population receive the intervention
Continued uptake & sustainability of the intervention
Focus groups with champions at Shared Learning Day (A, F, S)
Sustainability
Extent to which intervention is maintained
Follow-up interviews with champions (S)

8. Number of eligible women in each time period
32,800 women are potentially eligible to receive the care bundle over a 12 month period.

9. Overall programme plan
Project set-up
Block 1
Roll-out
Implementation
Block 2
Block 3
Block 4
Evaluation
Practice outcomes
Clinical outcomes
Dissemination
Where we are now
Stages in each block
Planning
Roll-out
Implementation
Skills development day
Shared learning day

10. Our project team Ranee Thakar Croydon Health Services NHS Trust
Clinical lead
Vivienne Novis
RCOG; Frimley Health NHS Foundation Trust
Midwifery lead
Anita Dougall
RCOG
Director, Clinical Quality
Louise Silverton
RCM
Director for Midwifery
Jan van der Meulen
RCOG; London School of Hygiene and Tropical Medicine
Senior Methodology Advisor
Nick Sevdalis
Kings College London
Quality Improvement Lead
Ipek Gurol-Urganci
Evaluation lead
Alexandra Hellyer
RCOG
Project manager
Posy Bidwell
Research Fellow
Louise Thomas
Head of Quality Improvement
Anita Dougall
Senior Director, Clinical Quality
Alison Elderfield
Head of the Lindsay Stewart Centre

11. Any questions?