The effect of implementing a new guideline and operative pro forma on the detection and management of third- and fourth-degree perineal tears

Kristin Cornell,1 Alison De Souza,2 Mark Tacey,3 David M Long,4 Mayooran Veerasingham5 1Department of Obstetrics and Gynaecology, The Northern Hospital, Epping, VIC, 2Department of Urogynecology, Mercy Hospital for Women, Melbourne, VIC, 3Northern Clinical Research Centre, The Northern Hospital and Department of Medicine, University of Melbourne, Melbourne, VIC, 4Department of Emergency Medicine, The Austin Hospital, Melbourne, VIC, 5The Department of Obstetrics and Gynaecology, Ipswich General Hospital, Ipswich, QLD, Australia Background: Obstetric anal sphincter injury (OASI) is a serious complication of vaginal births, resulting in possible long-term consequences such as incontinence and pain. Adequate detection and management of these injuries is vital in minimizing the impact they have on women. Aim: To assess the rates of detection, management, and outcomes of OASI before and after the implementation of a new clinical practice guideline and operative pro forma. Materials and methods: A 12-month audit of the incidence, management, and outcomes of OASI was conducted in 2009. An operative pro forma and practice guideline were implemented in 2010 followed by a further audit undertaken between 2010 and 2012. Statistical analysis was performed to determine any significant change in practice. Results: The distribution of risk factors for OASI including primiparity, birthweight, and type of vaginal delivery was similar between the two audited groups. After implementation of the pro forma, the reported incidence of OASI increased from 1.62% to 3.1% (P=0.004). Significant changes in management included an increase in the use of recommended suture material (48% vs 80%, P=0.002), postoperative antibiotics (78% vs 99%, P=0.001), postoperative catheterization (52% vs 90%, P<0.001), and inpatient physiotherapy consultations (44% vs 97%, P=<0.001). An increase was seen in women attending their 6-week follow-up appointment (33% vs 54% P=0.058); however, this was just below the level of statistical significance. Conclusion: The introduction of the new pro forma and guideline resulted in an increase in the reported incidence of OASI, improved management, and follow-up of patients. Keywords: perineal tear, obstetric anal sphincter injury (OASI), pro forma, guideline, anal incontinence, episiotom