AIMS Commentary: the OASI care bundle debate
AIMS Commentary: the OASI care bundle debate by the AIMS Campaign team The prospect of sustaining perineal trauma during birth remains a topic that has, until recently, been seen as relatively taboo; an issue seldom shared socially, with the consequences of severe perineal trauma rarely discussed. Tears, of course, vary in severity and the subsequent management and treatment for this injury is dependent on accurate clinical identification and recognition, followed by the offer of appropriate treatment. On that basis, the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) have come forward with ‘an OASI care bundle’,1 with OASI standing for ‘obstetric anal sphincter injury’. This article explores some of the controversy surrounding this bundle. Estimates of the incidence of perineal trauma vary, with an estimated 90% of first-time labouring women and birthing people sustaining some degree of tear, graze or surgical incision (episiotomy)2, reducing in incidence in subsequent pregnancies. Most of these injuries will not be severe and will heal without long term consequence. These are classified as 1st or 2nd degree tears. However, some injuries will be identified as a 3rd or 4th degree tear, affecting the tissue around the anus. These are commonly associated with long labours, instrumental birth and prolonged pushing, although they may also occur during spontaneous births. Approximately 3.5 out of 100 tears (6/100 in first time labours, <2/100 in subsequent births) will be classified as a 3rd or 4th degree tear.3 These Obstetric Anal Sphincter Injuries (OASI) require accurate identification, specialist repair, and post birth support and rehabilitation. This usually includes obstetric follow up appointments and physiotherapy. Sustaining an OASI can have profound implications for those experiencing them, both from an emotional and physical health perspective, with many women and birthing people reporting chronic and acute pain, sensitivity, faecal and flatus incontinence, bladder and bowel dysfunction, sexual dysfunction, anxiety, depression, post-traumatic stress disorder and tokophobia4. Support networks and charities, including AIMS, Birthrights, The Birth Trauma Association and the MASIC foundation, exist to provide specialist support and information to women and birthing people in this regard, as well as to support decision making and to offer practical advice. Criticism has been levelled against national healthcare policies and guidelines and this continues to gain momentum. Concerns exist around their failure to provide appropriate antenatal education about the risks and consequences of sustaining not only OASI, but perineal trauma as a whole. There are concerns about the clinical detection of, and the prevention of OASI across maternity systems, and about the provision of suitable support for those having sustained an injury. The stigma associated with the range of consequences of perineal tearing, is also a concern. Urgent action was therefore needed not only to contribute to reducing OASI across the childbearing population, but also robust information and antenatal support that enables informed decision making. It is for this reason that the OASI care bundle was launched in 16 maternity units between January 2017 and March 2018. The bundle has become a troublesome area of debate across disciplines with regards to not only the evidence upon which it is based, but the way in which the bundle has been introduced and the omission of robustly evidenced interventions such as warm compresses and massage. This has left many clinicians, academics and birth workers scratching their heads as there is evidence that these simple measures reduce the incidence 1 OASI Care Bundle Project Team. (2018) Implementation guide for maternity sites in the roll-out phase 2017-2018. RCOG London. www.rcog.org.uk/ globalassets/documents/guidelines/research--audit/oasi-care-bundle/oasi-care-bundle-guide-final-_-050118.pdf 2 COG (2019) Perineal tears during childbirth. Available at: ww.rcog.org.uk/en/patients/patient-leaflets/perineal-tears-during-childbirth/ 3 RCOG (2021) Third- and fourth-degree tears (OASI). Available at: www.rcog.org.uk/en/patients/tears/third-fourth/ 4 Editor’s note: Tokophobia is a morbid fear of childbirth and/or of the experience and consequences of medicalised birth care.
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