Arch Gynecol Obstet DOI 10.1007/s00404-014-3574-0
MATERNAL-FETAL MEDICINE
The knowledge, practice and opinion of midwives’ in the UK on their training in obstetric perineal repair Dan Selo-Ojeme • Sonu Pathak • Vaishali Joshi
Received: 26 May 2014 / Accepted: 3 December 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To investigate the knowledge and practice of perineal repair by midwives’ in the UK, as well as their perception of the adequacy of their training. Methods An anonymous structured questionnaire survey was conducted. Standard statistical comparative analysis was performed between groups. Significant differences were quantified by calculating odds ratios and 95 % confidence intervals. P \ 0.05 was considered significant. Results Analysis of 592 responses revealed that midwives who believed that they had adequate training were ten times more likely to report that they have an adequate knowledge of pelvic floor anatomy (OR 9.8, 95 % CI 6.4–14.9, P \ 0.001), six times more likely to be aware of recommended techniques of perineal repair (OR 6.1, 95 % CI 3.8–9.7, P \ 0.001) and 16 times more likely to feel competent to perform a repair (OR 16.1, 95 % CI 9.3–27.2, P \ 0.001). Midwives who had formal hands-on perineal repair training were four times more likely to report that they have an adequate knowledge of pelvic floor anatomy (OR 4.1, 95 % CI 2.8–5.8, P \ 0.001) and four times more likely to feel competent enough to perform a repair (OR 3.6 95 % CI 2.4–4.9, P \ 0.001). Conclusion The majority of midwives in the study sample report that they were unable to identify key perineal anatomy and believed that their pre-qualification training on perineal repair was inadequate. They also believed that midwives should routinely repair simple second-degree perineal tears.
D. Selo-Ojeme (&) S. Pathak V. Joshi Women’s Health Division, Department of Obstetrics and Gynaecology, Barnet and Chase Farm Hospitals NHS Trust, Wellhouse Lane, Barnet EN5 3DJ, UK e-mail: [email protected]
Keywords Perineal trauma Perineal repair Episiotomy Maternal morbidity Suturing methods Midwifery practice
Introduction In the United Kingdom (UK), approximately 350,000 women per annum sustain perineal trauma at vaginal birth and three quarters of these women will need suturing [1]. Majority of these perineal traumas are first- and seconddegree perineal tears and these are usually managed by midwives. Conducting a proper perineal repair requires specific skills and a detailed knowledge of perineal anatomy. Thus, the outcome of a perineal repair is dependent on the skill of the operator and the technique of repair. An inadequately repaired perineal tear is often associated with short- and long-term morbidity, including perineal pain and dyspareunia. Such morbidity has a significant impact on the quality of life [2, 3]. Although the assessment and management of perineal trauma are a routine part of maternity care, some studies have shown that there are considerable gaps in the application of relevant evidence to guide the management of perineal trauma [4, 5]. It is for these reasons that the Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institute for Health and Clinical Excellence (NICE) produced evidence-based recommendations on the management of birth-related perineal trauma [6, 7]. Despite these guidelines, there are disparities in the methods of repair used by midwives [6–8]. Among the UK universities, there appears to be a wide variation in the midwifery education curriculum concerning the teaching of relevant perineal anatomy and training in suturing skills [5]. As a result, some authors have highlighted the need for set standards to encourage
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uniformity in midwifery education [9]. This strategy can be strengthened by the provision of supplementary educational programs in post qualification years. Mahmud et al. [10] developed the first validated perineal trauma management e-learning package called ‘MaternitPEARLS’. It had the benefit of ensuring the delivery of a standardized, continuously updated curriculum with global accessibility. The Perineal Assessment and Repair Longitudinal Study (PEARLS) [11] was the first randomized controlled trial to demonstrate that educational training packages improved the implementation of evidence-based recommendations in the clinical management of perineal trauma. The PEARLS projects confirmed earlier findings that educational training programs and structured, hands-on training packages were effective in improving the perineal repair competencies of midwives [12, 13]. Nevertheless, only a few studies [14] have investigated the perception of midwives of their preparation for and practice in the assessment and management of perineal trauma. Such information is valuable for the design of future pre-registration training curriculum. The aim of this study was to ascertain the perception of midwives in the UK about their training, knowledge and practice concerning the management of perineal trauma.
Materials and methods Between May 1, 2012 and September 30, 2012, midwives working in 65 randomly selected hospitals in the UK were requested to complete an anonymous self-administered structured questionnaire that were returned by hand, post and email. The questionnaire was designed to capture information on four domains: (a) perception of adequacy of the training received, (b) knowledge of relevant perineal anatomy, (c) practical experience on perineal repairs and (d) opinion on who should repair a simple second-degree tear. The study was approved by the Institutional Review Board and all participants gave their consent to participate in the study. Statistical analyses were performed using Stata statistical software package (Stata Corp., Texas, version 7.0). Frequency tables were calculated for various variables, and comparative analysis was performed between midwives who received formal training on perineal repair and those who did not. A comparison was also made between midwives who thought that their training was adequate with those who did not feel the same. Differences between groups were tested for significance using the v2 test for categorical variables. Significant differences were quantified by calculating the odds ratios (OR) and 95 % confidence intervals (CI). P [ 0.05 was considered significant.
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Results Five hundred and ninety-two of the 800 midwives responded, providing a response rate of 74 %. Table 1 shows that the majority of responders (305, 51.3 %) had equal to, or more than 5 years of post-qualification experience, worked in a consultant led unit (432, 72.9 %), and worked in a unit with an annual delivery rate of over 5,000 (310, 52.4 %). Table 2 shows the number of positive responses to the questions in the various domains. In the training domain, only a minority 228 (38.5 %) felt that their training on perineal repair was adequate, while 372 (62.8 %) reported that they had received hands-on training on perineal repair. 340 (57.5 %) reported that they attended a perineal repair workshop post qualification. In the knowledge domain, only 320 (54 %) and 340 (57.4 %), respectively, indicated that they have an adequate knowledge of relevant perineal anatomy or know the names of relevant muscles of the pelvic floor. In addition, only 324 (54.7 %) indicated that they could identify the relevant perineal muscles when examining a second-degree perineal tear. 176 (29.7 %) were not aware of the NICE and or the RCOG evidence-based recommendations on perineal repair, and 98 (16.6 %) indicated that they did not know the grading of perineal tears. In the opinion domain, only a minority of the responders (220, 37.6 %) were of the opinion that midwives received enough training updates on perineal repair. 516 (87.2 %) felt that midwives should be the primary clinicians Table 1 Background details of responders Variable
n (%)
Years of qualification \5 years
270 (45.6)
C5 years
322 (54.4)
Primary location of work Consultant led unit
432 (72.9)
Midwifery led unit
32 (5.4)
Community Antenatal/postnatal wards Delivery rate of hospital
56 (9.5) 72 (12.2)
\5,000
292 (49.3)
C5,000
274 (46.3)
Do not know
26 (4.4)
Episiotomy rate of hospital \20 % C20 % Do not know Values presented as n (%)
252 (42.6) 24 (4.0) 316 (53.4)
Arch Gynecol Obstet Table 2 Number of positive responses from 592 midwives to questions relating to perineal repair Domain
Derived statements from questions
n (%)
Training
Felt that training received was adequate
228 (38.5)
Received formal hands-on perineal repair training
372 (62.8)
Attended any perineal repair workshop since qualification
340 (57.5)
Have adequate knowledge of pelvic floor anatomy
320 (54)
Know the names of relevant muscles of the pelvic floor
340 (57.4)
Can identify relevant perineal muscles on examining second-degree tear
324 (54.7)
Can identify the fourchette and or posterior commissure
272 (45.9)
Aware of recommended evidenced-based technique of repair
416 (70.3)
Know the grades of perineal trauma Can recognize a third-degree perineal tear
494 (83.4) 408 (68.9)
Thinks midwives received enough training updates on perineal repair
220 (37.6)
Knowledge
Opinion
Practical experience
Thinks doctors should primarily repair simple episiotomies and second-degree tear
76 (12.8)
Thinks midwives should primarily repair simple episiotomies and second-degree tear
516 (87.2)
Feels competent to repair a seconddegree perineal tear
376 (63.5)
Performed\10 perineal repairs in the last month
380 (64.2)
Performed C10 perineal repairs in the last month
212 (35.8)
Values presented as n (%)
responsible for the assessment and repair of routine episiotomies and second-degree perineal tears. In the practical experience domain, 376 (63.5) felt that they were competent to repair a second-degree tear. In the preceding month, 388 (65.5 %) performed less than ten perineal repairs, while 40 (6.8 %) performed ten or more repairs. The comparison of those who received training with those who did not is shown in Table 3. When compared to those who did not have training, midwives who received hands-on perineal repair training were significantly more likely to state that they have an adequate knowledge of pelvic floor anatomy (P \ 0.001), able to identify relevant perineal muscles when examining second-degree tears (P \ 0.001), feel competent to repair a second-degree tear (P \ 0.001), are aware of recommended techniques of perineal repair (P \ 0.001) and to have attended an update workshop on perineal repair (P \ 0.001).
Compared to midwives who believed that their training was inadequate, those who felt that their training was adequate were more likely to report that they have an adequate knowledge of relevant pelvic floor anatomy (P \ 0.001), and know the names (P \ 0.001) and identify (P \ 0.001) the relevant pelvic floor muscles. They were also more likely state that they know the grading of perineal tear (P \ 0.001), feel competent to repair a seconddegree tear (P \ 0.001), be aware of the evidence-based recommendations of NICE and or the RCOG (P \ 0.001) and were more likely to have attended an update workshop on perineal repair (P \ 0.001). The results from the quantification of the significant differences between groups [odds ratios (OR) and 95 % confidence intervals (CI)] are also shown in Tables 3 and 4.
Discussion Perineal pain remains one of the most common complaints following vaginal delivery and it is often associated with perineal trauma [3, 8]. The vast majority of perineal trauma sustained at birth falls in the minor category (grades 1 and 2) and in the UK, these are mostly managed by midwives. Clinicians managing post-partum perineal trauma are expected to possess adequate levels of competency [7]. Thus, it is imperative that perineal repair competences are acquired and maintained by midwives, if a reduction in the avoidable burden of morbidity associated with birth-related perineal trauma is to be realized. This study investigated the perception of midwives regarding their educational preparation and clinical practice concerning repair of birthrelated perineal trauma. We looked at the domains of training, knowledge, experience as well as their opinion on who should repair episiotomies and second-degree perineal trauma. A third of our responders reported that they had no formal hands-on training and two-thirds felt that the training they received regarding the management of perineal trauma was inadequate. Although we did not objectively assess their clinical performance, it is conceivable that clinical performance reflects perceived adequacy of the training received. Other authors have also noted the dissatisfaction expressed by midwives on how midwifery education prepared them for clinical practice [14, 15]. Despite this perceived poor pre-qualification preparation, a third of the respondents in this survey reported that they have not attended any update course on perineal repair since their qualification. This may, in part, be due to the fact that in the UK, there is no formal requirement for midwives to undergo structured training on the management of perineal trauma. Also, they are not required to perform any minimum number of perineal repairs to
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Arch Gynecol Obstet Table 3 Comparison of midwives who were trained on perineal repairs and those who were not Derived statements from questions
Trained (n = 372)
Not trained (n = 220)
OR (95 % CI)
P value
Have adequate knowledge of relevant pelvic anatomy
248 (75.8)
72 (32.7)
4.1 (2.8–5.8)
\0.001
Know the names of relevant pelvic floor muscles
240 (64.5)
100 (45.5)
4.0 (2.9–5.4)
\0.001
Aware of evidence-based technique of perineal repair
296 (79.6)
120 (54.5)
3.2 (0.2–4.6)
\0.001
Can identify relevant perineal muscle on examining 2DT
232 (62.4)
92 (41.8)
2.3 (1.6–3.2)
\0.001
Can identify the fourchette and or posterior commissure
196 (52.7)
76 (34.5)
2.1 (1.4–2.9)
\0.001
Know the grades of perineal tear
340 (91.4)
184 (83.6)
2.1 (1.3–3.4)
0.004
Feels competent to repair second-degree perineal tear
276 (74.2)
100 (45.5)
3.5 (2.4–4.9)
\0.001
Can recognize a third-degree perineal tear
268 (72.0)
140 (63.6)
1.4 (1.0–2.1)
0.03
Thinks midwives receive enough training Updates on perineal repair
144 (38.7)
76 (34.5)
1.1 (0.8–1.6)
0.3
Thinks that midwives should repair simple 2DT Attended a perineal repair workshop since qualification
328 (88.2) 252 (67.7)
188 (85.5) 88 (40)
1.2 (0.7–2.1) 3.1 (2.2–4.4)
0.3 \0.001
Values expressed as n (%) 2DT second-degree perineal tear
Table 4 Comparison of midwives who thought that the training they received was adequate and those that did not think so Variable
Training adequate (n = 228)
Training inadequate (n = 364)
OR (95 % CI)
P value
Have adequate knowledge of relevant pelvic anatomy
192 (84.2)
128 (35.2)
9.8 (6.4–14.9) \0.001
Know the names of relevant pelvic floor muscles
176 (77.2)
164 (45.1)
4.1 (2.8–5.9)
\0.001
Aware of evidence-based technique of perineal repair
204 (89.4)
212 (58.2)
6.1 (3.8–9.7)
\0.001
Can identify relevant perineal muscle on examining 2DT
172 (75.4)
152 (41.8)
4.3 (2.9–6.8)
\0.001
Can identify the fourchette and or posterior commissure
128 (56.1)
144 (39.1)
2.0 (1.4–2.7)
\0.001
Know the grades of perineal tear
216 (94.7)
308 (84.6)
3.2 (1.7–6.2)
0.01
Feels competent to repair second-degree perineal tear
212 (93.0)
164 (45.1)
Can recognize third-degree perineal tear
188 (82.5)
220 (60.4)
3.1 (2.1–4.5)
\0.001
Updates on perineal repair
100 (43.8)
120 (33.0)
1.6 (1.1–2.7)
0.007
Thinks midwives should repair simple 2DT
200 (87.7)
316 (86.8)
1.1 (0.6–1.7)
0.6
Attended any perineal repair workshop since qualification
192 (84.2)
148 (40.7)
7.8 (5.1–11.7) \0.001
Received formal hands-on training
204 (89.5)
168 (46.2)
9.9 (6.1–15.8) \0.001
16.1 (9.3–27.2) \0.001
Thinks midwives receive enough training
Values expressed as n (%) 2DT second-degree perineal tear
maintain their clinical competencies and in addition, students are not even required to have performed a certain number of perineal repairs before graduating [5]. A likely consequence of this perceived poor training in perineal assessment and repair is exemplified by the fact that the rate of undiagnosed major perineal trauma is higher among midwives than among doctors [16]. Formal training on perineal repair is mandatory for trainee obstetricians and studies have shown that such dedicated training improves the performance of clinicians in the management of perineal trauma [17]. Our data also showed that significantly
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more respondents who reported that they received training and that the training was adequate were more likely to have attended an update course on perineal repair. Presumably, an awareness of the significance of the risks associated with poorly managed perineal trauma drives the desire to acquire and improve on perineal repair skills. A detailed knowledge of perineal anatomy was identified as one of the cues that support the decision making on whether to suture a perineal trauma or not [18]. In this survey, over a third of the respondents indicated that they had an inadequate knowledge of perineal anatomy, and a
Arch Gynecol Obstet
fifth did not know the classification of perineal trauma. The RCOG and NICE recommendations stipulate that clinicians are expected to classify perineal trauma anatomically to conduct an appropriate repair and provide standardized care [7, 19]. A third of the study sample reported that they were not even aware of these evidence-based recommendations regarding perineal repair. The concern regarding the poor knowledge of perineal anatomy amongst midwives was highlighted by Sultan et al. [4] in an audit conducted almost two decades ago. This reported paucity of knowledge may be a consequence of the limited focus placed on the anatomy of the perineum and pelvic floor in the pre-registration midwifery education curriculum in the UK universities [5]. Indeed, the participants in a previous study indicated that they would have preferred more time to be dedicated to the acquisition of such knowledge and skills [14]. Furthermore, some authors have suggested that the pre-registration training curriculum should be improved to enhance the ability of midwives to perform at the expected levels of competence [20]. This also re-emphasizes the need to have a set standard for training in the assessment and management of birth-related perineal trauma. Majority of midwives in this study performed less than ten perineal repairs in the preceding months to the survey and a third reported that they were not competent to undertake a perineal repair. This lack of experience may stem from the fact that the opportunities for perineal repair has shrunken because of decreasing rates of episiotomy and an increasing use of the ‘hands-off’ technique to manage the perineum at birth [21]. This can create a ripple effect with less and less competent midwives being available to pass on the experience of perineal repair. Ideally, effective mechanisms should be in place to identify and address any knowledge and skills gap in the midwife’s post-registration years. Such mechanisms could include a regular assessment of competencies with a recommendation to attend skills update workshops. The current NICE guideline [7] suggests that ‘all relevant healthcare professionals should attend training in perineal/ genital assessment and repair, and ensure that they maintain these skills’. Indeed, there is evidence to show that attendances at dedicated training workshops leads to an improvement in the diagnosis and management of perineal trauma [17]. Such structured hands-on training also led to a significant increase in the use of the recommended evidence-based techniques of repair and a modification of clinical practice [12, 13]. Such modification in clinical practice can potentially have an impact on the high and rising negligence claims due to poor care [22]. With the advent of the internet, e-learning modules targeted at gaps in quality of care have been found to be feasible and acceptable to learners [10, 23, 24]. Similarly,
advances in high fidelity simulation are thought to be effective in improving midwifery practical skills [25]. More research is needed concerning the application of these developments in improving the competency of midwives in the area of perineal repair. Hopefully, this would facilitate the reduction of the burden of morbidity associated with inadequate perineal repair. This study’s strength lies in the fact that information was gathered from midwives across the UK and some of our findings were consistent with the few available data. There are several potential limitations to this study. Firstly, a survey of this sort is prone to a low response rate and this can reduce the study’s validity and increase bias [26, 27]. A response rate of 75–80 % is considered a good rate for postal surveys [28, 29]. Our response rate was 74 %. Secondly, we asked midwives about their perception of the teaching and training that they received. This does not actually address the context of care. Furthermore, the responses received are subjective and might be different from what is practiced. Conflict of interest of interest.
The authors declare that they have no conflict
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management of perineal trauma following childbirth: maternityPEARLS. Postgrad Med J 89(1053):382–389 Ismail KM, Kettle C, Macdonald SE, Tohill S, Thomas PW, Bick D (2013) Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster randomized trial. BMC Med 11(209):1–11 Selo-Ojeme D, Ojutiku D, Ikomi A (2009) Impact of a structured, hands-on, surgical skills training program for midwives performing perineal repair. Int J Gynaecol Obstet 106(3):239–241 Wilson AE (2012) Effectiveness of an educational programme in perineal repair for midwives. Midwifery 28(2):236–246 East CE, Lau R, Biro MA (2014) Midwives’ and doctors’ perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey. Midwifery. doi:10.1016/j.midw.2014.07.002 [Epub ahead of print] Schytt E, Waldenstro¨m U (2013) How well does midwifery education prepare for clinical practice? Exploring the views of Swedish students, midwives and obstetricians. Midwifery 29(2):102–109 Andrews V, Sultan AH, Thakar R, Jones PW (2006) Occult anal sphincter injuries—myth or reality? BJOG 113(2):195–200 Andrews V, Thakar R, Sultan AH (2009) Structured hands-on training in repair of obstetric anal sphincter injuries (OASIS): an audit of clinical practice. Int Urogynecol J Pelvic Floor Dysfunct 20(11):1397 Cioffi JM, Swain J, Arundell F (2010) The decision to suture after childbirth: cues, related factors, knowledge and experience used by midwives. Midwifery 26(2):246–255 Royal College of Obstetricians and Gynaecologists (2007) Management of third and fourth degree perineal tears. Green Top Guidelines, No. 29. RCOG, London Skirton H, Stephen N, Doris F, Cooper M, Avis M, Fraser DM (2012) Preparedness of newly qualified midwives to deliver
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MATERNAL-FETAL MEDICINE
The knowledge, practice and opinion of midwives’ in the UK on their training in obstetric perineal repair Dan Selo-Ojeme • Sonu Pathak • Vaishali Joshi
Received: 26 May 2014 / Accepted: 3 December 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To investigate the knowledge and practice of perineal repair by midwives’ in the UK, as well as their perception of the adequacy of their training. Methods An anonymous structured questionnaire survey was conducted. Standard statistical comparative analysis was performed between groups. Significant differences were quantified by calculating odds ratios and 95 % confidence intervals. P \ 0.05 was considered significant. Results Analysis of 592 responses revealed that midwives who believed that they had adequate training were ten times more likely to report that they have an adequate knowledge of pelvic floor anatomy (OR 9.8, 95 % CI 6.4–14.9, P \ 0.001), six times more likely to be aware of recommended techniques of perineal repair (OR 6.1, 95 % CI 3.8–9.7, P \ 0.001) and 16 times more likely to feel competent to perform a repair (OR 16.1, 95 % CI 9.3–27.2, P \ 0.001). Midwives who had formal hands-on perineal repair training were four times more likely to report that they have an adequate knowledge of pelvic floor anatomy (OR 4.1, 95 % CI 2.8–5.8, P \ 0.001) and four times more likely to feel competent enough to perform a repair (OR 3.6 95 % CI 2.4–4.9, P \ 0.001). Conclusion The majority of midwives in the study sample report that they were unable to identify key perineal anatomy and believed that their pre-qualification training on perineal repair was inadequate. They also believed that midwives should routinely repair simple second-degree perineal tears.
D. Selo-Ojeme (&) S. Pathak V. Joshi Women’s Health Division, Department of Obstetrics and Gynaecology, Barnet and Chase Farm Hospitals NHS Trust, Wellhouse Lane, Barnet EN5 3DJ, UK e-mail: [email protected]
Keywords Perineal trauma Perineal repair Episiotomy Maternal morbidity Suturing methods Midwifery practice
Introduction In the United Kingdom (UK), approximately 350,000 women per annum sustain perineal trauma at vaginal birth and three quarters of these women will need suturing [1]. Majority of these perineal traumas are first- and seconddegree perineal tears and these are usually managed by midwives. Conducting a proper perineal repair requires specific skills and a detailed knowledge of perineal anatomy. Thus, the outcome of a perineal repair is dependent on the skill of the operator and the technique of repair. An inadequately repaired perineal tear is often associated with short- and long-term morbidity, including perineal pain and dyspareunia. Such morbidity has a significant impact on the quality of life [2, 3]. Although the assessment and management of perineal trauma are a routine part of maternity care, some studies have shown that there are considerable gaps in the application of relevant evidence to guide the management of perineal trauma [4, 5]. It is for these reasons that the Royal College of Obstetricians and Gynaecologists (RCOG) and the National Institute for Health and Clinical Excellence (NICE) produced evidence-based recommendations on the management of birth-related perineal trauma [6, 7]. Despite these guidelines, there are disparities in the methods of repair used by midwives [6–8]. Among the UK universities, there appears to be a wide variation in the midwifery education curriculum concerning the teaching of relevant perineal anatomy and training in suturing skills [5]. As a result, some authors have highlighted the need for set standards to encourage
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uniformity in midwifery education [9]. This strategy can be strengthened by the provision of supplementary educational programs in post qualification years. Mahmud et al. [10] developed the first validated perineal trauma management e-learning package called ‘MaternitPEARLS’. It had the benefit of ensuring the delivery of a standardized, continuously updated curriculum with global accessibility. The Perineal Assessment and Repair Longitudinal Study (PEARLS) [11] was the first randomized controlled trial to demonstrate that educational training packages improved the implementation of evidence-based recommendations in the clinical management of perineal trauma. The PEARLS projects confirmed earlier findings that educational training programs and structured, hands-on training packages were effective in improving the perineal repair competencies of midwives [12, 13]. Nevertheless, only a few studies [14] have investigated the perception of midwives of their preparation for and practice in the assessment and management of perineal trauma. Such information is valuable for the design of future pre-registration training curriculum. The aim of this study was to ascertain the perception of midwives in the UK about their training, knowledge and practice concerning the management of perineal trauma.
Materials and methods Between May 1, 2012 and September 30, 2012, midwives working in 65 randomly selected hospitals in the UK were requested to complete an anonymous self-administered structured questionnaire that were returned by hand, post and email. The questionnaire was designed to capture information on four domains: (a) perception of adequacy of the training received, (b) knowledge of relevant perineal anatomy, (c) practical experience on perineal repairs and (d) opinion on who should repair a simple second-degree tear. The study was approved by the Institutional Review Board and all participants gave their consent to participate in the study. Statistical analyses were performed using Stata statistical software package (Stata Corp., Texas, version 7.0). Frequency tables were calculated for various variables, and comparative analysis was performed between midwives who received formal training on perineal repair and those who did not. A comparison was also made between midwives who thought that their training was adequate with those who did not feel the same. Differences between groups were tested for significance using the v2 test for categorical variables. Significant differences were quantified by calculating the odds ratios (OR) and 95 % confidence intervals (CI). P [ 0.05 was considered significant.
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Results Five hundred and ninety-two of the 800 midwives responded, providing a response rate of 74 %. Table 1 shows that the majority of responders (305, 51.3 %) had equal to, or more than 5 years of post-qualification experience, worked in a consultant led unit (432, 72.9 %), and worked in a unit with an annual delivery rate of over 5,000 (310, 52.4 %). Table 2 shows the number of positive responses to the questions in the various domains. In the training domain, only a minority 228 (38.5 %) felt that their training on perineal repair was adequate, while 372 (62.8 %) reported that they had received hands-on training on perineal repair. 340 (57.5 %) reported that they attended a perineal repair workshop post qualification. In the knowledge domain, only 320 (54 %) and 340 (57.4 %), respectively, indicated that they have an adequate knowledge of relevant perineal anatomy or know the names of relevant muscles of the pelvic floor. In addition, only 324 (54.7 %) indicated that they could identify the relevant perineal muscles when examining a second-degree perineal tear. 176 (29.7 %) were not aware of the NICE and or the RCOG evidence-based recommendations on perineal repair, and 98 (16.6 %) indicated that they did not know the grading of perineal tears. In the opinion domain, only a minority of the responders (220, 37.6 %) were of the opinion that midwives received enough training updates on perineal repair. 516 (87.2 %) felt that midwives should be the primary clinicians Table 1 Background details of responders Variable
n (%)
Years of qualification \5 years
270 (45.6)
C5 years
322 (54.4)
Primary location of work Consultant led unit
432 (72.9)
Midwifery led unit
32 (5.4)
Community Antenatal/postnatal wards Delivery rate of hospital
56 (9.5) 72 (12.2)
\5,000
292 (49.3)
C5,000
274 (46.3)
Do not know
26 (4.4)
Episiotomy rate of hospital \20 % C20 % Do not know Values presented as n (%)
252 (42.6) 24 (4.0) 316 (53.4)
Arch Gynecol Obstet Table 2 Number of positive responses from 592 midwives to questions relating to perineal repair Domain
Derived statements from questions
n (%)
Training
Felt that training received was adequate
228 (38.5)
Received formal hands-on perineal repair training
372 (62.8)
Attended any perineal repair workshop since qualification
340 (57.5)
Have adequate knowledge of pelvic floor anatomy
320 (54)
Know the names of relevant muscles of the pelvic floor
340 (57.4)
Can identify relevant perineal muscles on examining second-degree tear
324 (54.7)
Can identify the fourchette and or posterior commissure
272 (45.9)
Aware of recommended evidenced-based technique of repair
416 (70.3)
Know the grades of perineal trauma Can recognize a third-degree perineal tear
494 (83.4) 408 (68.9)
Thinks midwives received enough training updates on perineal repair
220 (37.6)
Knowledge
Opinion
Practical experience
Thinks doctors should primarily repair simple episiotomies and second-degree tear
76 (12.8)
Thinks midwives should primarily repair simple episiotomies and second-degree tear
516 (87.2)
Feels competent to repair a seconddegree perineal tear
376 (63.5)
Performed\10 perineal repairs in the last month
380 (64.2)
Performed C10 perineal repairs in the last month
212 (35.8)
Values presented as n (%)
responsible for the assessment and repair of routine episiotomies and second-degree perineal tears. In the practical experience domain, 376 (63.5) felt that they were competent to repair a second-degree tear. In the preceding month, 388 (65.5 %) performed less than ten perineal repairs, while 40 (6.8 %) performed ten or more repairs. The comparison of those who received training with those who did not is shown in Table 3. When compared to those who did not have training, midwives who received hands-on perineal repair training were significantly more likely to state that they have an adequate knowledge of pelvic floor anatomy (P \ 0.001), able to identify relevant perineal muscles when examining second-degree tears (P \ 0.001), feel competent to repair a second-degree tear (P \ 0.001), are aware of recommended techniques of perineal repair (P \ 0.001) and to have attended an update workshop on perineal repair (P \ 0.001).
Compared to midwives who believed that their training was inadequate, those who felt that their training was adequate were more likely to report that they have an adequate knowledge of relevant pelvic floor anatomy (P \ 0.001), and know the names (P \ 0.001) and identify (P \ 0.001) the relevant pelvic floor muscles. They were also more likely state that they know the grading of perineal tear (P \ 0.001), feel competent to repair a seconddegree tear (P \ 0.001), be aware of the evidence-based recommendations of NICE and or the RCOG (P \ 0.001) and were more likely to have attended an update workshop on perineal repair (P \ 0.001). The results from the quantification of the significant differences between groups [odds ratios (OR) and 95 % confidence intervals (CI)] are also shown in Tables 3 and 4.
Discussion Perineal pain remains one of the most common complaints following vaginal delivery and it is often associated with perineal trauma [3, 8]. The vast majority of perineal trauma sustained at birth falls in the minor category (grades 1 and 2) and in the UK, these are mostly managed by midwives. Clinicians managing post-partum perineal trauma are expected to possess adequate levels of competency [7]. Thus, it is imperative that perineal repair competences are acquired and maintained by midwives, if a reduction in the avoidable burden of morbidity associated with birth-related perineal trauma is to be realized. This study investigated the perception of midwives regarding their educational preparation and clinical practice concerning repair of birthrelated perineal trauma. We looked at the domains of training, knowledge, experience as well as their opinion on who should repair episiotomies and second-degree perineal trauma. A third of our responders reported that they had no formal hands-on training and two-thirds felt that the training they received regarding the management of perineal trauma was inadequate. Although we did not objectively assess their clinical performance, it is conceivable that clinical performance reflects perceived adequacy of the training received. Other authors have also noted the dissatisfaction expressed by midwives on how midwifery education prepared them for clinical practice [14, 15]. Despite this perceived poor pre-qualification preparation, a third of the respondents in this survey reported that they have not attended any update course on perineal repair since their qualification. This may, in part, be due to the fact that in the UK, there is no formal requirement for midwives to undergo structured training on the management of perineal trauma. Also, they are not required to perform any minimum number of perineal repairs to
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Arch Gynecol Obstet Table 3 Comparison of midwives who were trained on perineal repairs and those who were not Derived statements from questions
Trained (n = 372)
Not trained (n = 220)
OR (95 % CI)
P value
Have adequate knowledge of relevant pelvic anatomy
248 (75.8)
72 (32.7)
4.1 (2.8–5.8)
\0.001
Know the names of relevant pelvic floor muscles
240 (64.5)
100 (45.5)
4.0 (2.9–5.4)
\0.001
Aware of evidence-based technique of perineal repair
296 (79.6)
120 (54.5)
3.2 (0.2–4.6)
\0.001
Can identify relevant perineal muscle on examining 2DT
232 (62.4)
92 (41.8)
2.3 (1.6–3.2)
\0.001
Can identify the fourchette and or posterior commissure
196 (52.7)
76 (34.5)
2.1 (1.4–2.9)
\0.001
Know the grades of perineal tear
340 (91.4)
184 (83.6)
2.1 (1.3–3.4)
0.004
Feels competent to repair second-degree perineal tear
276 (74.2)
100 (45.5)
3.5 (2.4–4.9)
\0.001
Can recognize a third-degree perineal tear
268 (72.0)
140 (63.6)
1.4 (1.0–2.1)
0.03
Thinks midwives receive enough training Updates on perineal repair
144 (38.7)
76 (34.5)
1.1 (0.8–1.6)
0.3
Thinks that midwives should repair simple 2DT Attended a perineal repair workshop since qualification
328 (88.2) 252 (67.7)
188 (85.5) 88 (40)
1.2 (0.7–2.1) 3.1 (2.2–4.4)
0.3 \0.001
Values expressed as n (%) 2DT second-degree perineal tear
Table 4 Comparison of midwives who thought that the training they received was adequate and those that did not think so Variable
Training adequate (n = 228)
Training inadequate (n = 364)
OR (95 % CI)
P value
Have adequate knowledge of relevant pelvic anatomy
192 (84.2)
128 (35.2)
9.8 (6.4–14.9) \0.001
Know the names of relevant pelvic floor muscles
176 (77.2)
164 (45.1)
4.1 (2.8–5.9)
\0.001
Aware of evidence-based technique of perineal repair
204 (89.4)
212 (58.2)
6.1 (3.8–9.7)
\0.001
Can identify relevant perineal muscle on examining 2DT
172 (75.4)
152 (41.8)
4.3 (2.9–6.8)
\0.001
Can identify the fourchette and or posterior commissure
128 (56.1)
144 (39.1)
2.0 (1.4–2.7)
\0.001
Know the grades of perineal tear
216 (94.7)
308 (84.6)
3.2 (1.7–6.2)
0.01
Feels competent to repair second-degree perineal tear
212 (93.0)
164 (45.1)
Can recognize third-degree perineal tear
188 (82.5)
220 (60.4)
3.1 (2.1–4.5)
\0.001
Updates on perineal repair
100 (43.8)
120 (33.0)
1.6 (1.1–2.7)
0.007
Thinks midwives should repair simple 2DT
200 (87.7)
316 (86.8)
1.1 (0.6–1.7)
0.6
Attended any perineal repair workshop since qualification
192 (84.2)
148 (40.7)
7.8 (5.1–11.7) \0.001
Received formal hands-on training
204 (89.5)
168 (46.2)
9.9 (6.1–15.8) \0.001
16.1 (9.3–27.2) \0.001
Thinks midwives receive enough training
Values expressed as n (%) 2DT second-degree perineal tear
maintain their clinical competencies and in addition, students are not even required to have performed a certain number of perineal repairs before graduating [5]. A likely consequence of this perceived poor training in perineal assessment and repair is exemplified by the fact that the rate of undiagnosed major perineal trauma is higher among midwives than among doctors [16]. Formal training on perineal repair is mandatory for trainee obstetricians and studies have shown that such dedicated training improves the performance of clinicians in the management of perineal trauma [17]. Our data also showed that significantly
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more respondents who reported that they received training and that the training was adequate were more likely to have attended an update course on perineal repair. Presumably, an awareness of the significance of the risks associated with poorly managed perineal trauma drives the desire to acquire and improve on perineal repair skills. A detailed knowledge of perineal anatomy was identified as one of the cues that support the decision making on whether to suture a perineal trauma or not [18]. In this survey, over a third of the respondents indicated that they had an inadequate knowledge of perineal anatomy, and a
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fifth did not know the classification of perineal trauma. The RCOG and NICE recommendations stipulate that clinicians are expected to classify perineal trauma anatomically to conduct an appropriate repair and provide standardized care [7, 19]. A third of the study sample reported that they were not even aware of these evidence-based recommendations regarding perineal repair. The concern regarding the poor knowledge of perineal anatomy amongst midwives was highlighted by Sultan et al. [4] in an audit conducted almost two decades ago. This reported paucity of knowledge may be a consequence of the limited focus placed on the anatomy of the perineum and pelvic floor in the pre-registration midwifery education curriculum in the UK universities [5]. Indeed, the participants in a previous study indicated that they would have preferred more time to be dedicated to the acquisition of such knowledge and skills [14]. Furthermore, some authors have suggested that the pre-registration training curriculum should be improved to enhance the ability of midwives to perform at the expected levels of competence [20]. This also re-emphasizes the need to have a set standard for training in the assessment and management of birth-related perineal trauma. Majority of midwives in this study performed less than ten perineal repairs in the preceding months to the survey and a third reported that they were not competent to undertake a perineal repair. This lack of experience may stem from the fact that the opportunities for perineal repair has shrunken because of decreasing rates of episiotomy and an increasing use of the ‘hands-off’ technique to manage the perineum at birth [21]. This can create a ripple effect with less and less competent midwives being available to pass on the experience of perineal repair. Ideally, effective mechanisms should be in place to identify and address any knowledge and skills gap in the midwife’s post-registration years. Such mechanisms could include a regular assessment of competencies with a recommendation to attend skills update workshops. The current NICE guideline [7] suggests that ‘all relevant healthcare professionals should attend training in perineal/ genital assessment and repair, and ensure that they maintain these skills’. Indeed, there is evidence to show that attendances at dedicated training workshops leads to an improvement in the diagnosis and management of perineal trauma [17]. Such structured hands-on training also led to a significant increase in the use of the recommended evidence-based techniques of repair and a modification of clinical practice [12, 13]. Such modification in clinical practice can potentially have an impact on the high and rising negligence claims due to poor care [22]. With the advent of the internet, e-learning modules targeted at gaps in quality of care have been found to be feasible and acceptable to learners [10, 23, 24]. Similarly,
advances in high fidelity simulation are thought to be effective in improving midwifery practical skills [25]. More research is needed concerning the application of these developments in improving the competency of midwives in the area of perineal repair. Hopefully, this would facilitate the reduction of the burden of morbidity associated with inadequate perineal repair. This study’s strength lies in the fact that information was gathered from midwives across the UK and some of our findings were consistent with the few available data. There are several potential limitations to this study. Firstly, a survey of this sort is prone to a low response rate and this can reduce the study’s validity and increase bias [26, 27]. A response rate of 75–80 % is considered a good rate for postal surveys [28, 29]. Our response rate was 74 %. Secondly, we asked midwives about their perception of the teaching and training that they received. This does not actually address the context of care. Furthermore, the responses received are subjective and might be different from what is practiced. Conflict of interest of interest.
The authors declare that they have no conflict
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