OASI care bundle- What does it mean for your perineum?

OASI bundle- Obstetric anal sphincter injury bundle. What the hell is that?!
Well if you have had a baby recently or are currently over 34 weeks pregnant you should be well aware of what it is. However reading though the feedback I have received recently it seems this may not be the case.
So here is an outline of what is involved- 

“The elements of the OASI bundle include informing each woman about OASI and what can be done to minimize her risk, performing an episiotomy (a cut in the perineum to assist birth and prevent tears) when required, using the hands to enable perineal protection at the time of birth and a thorough examination after birth to detect tears not all of which will be immediately obvious. All elements of the care bundle are underpinned by good communication with the woman before, during and after birth.”
So lets break that down-
Element 1- This all about information and discussing with the woman or birthing person during pregnancy, there is an OASI information leaflet that should be given out by a midwife between 32-36 weeks, this should be discussed and a woman’s decision documented in her notes. This is a person’s chance to ask questions, listen to evidence and rationale and make decisions about their own care. There should be an explanation of perineal trauma, the different grades, what it means, how it is identified and treated, things that a person can do to reduce the chance of injury and the different interventions offered.
Element 2-  Use of episiotomy. OASI care bundle suggests that an episiotomy should be used in all cases of forceps assisted birth and if severe perineal trauma is imminent in non assisted births. The care bundle is clear that routine use of episiotomy is not recommended and any episiotomy should only be done with full informed consent form the birthing person and consent and reason documented in their notes. When performed the episiotomy should be done at 60 degree angle to the right when baby’s head is crowning. This should all be documented in the notes. 

Element 3-  Using hands on approach to manually protect the perineum. In basic terms this means using particular techniques to both ensure baby’s head is born slowly and the perineum is protected. This includes the clinician putting one hand on the baby’s head to control and slow down progress and using the other to put firm pressure on the perineum and manipulate it to stretch and direct the most stretch to other areas. This also includes using fingers to assist the baby’s chin to be born, coaching the birthing person to control their pushing to reduce risk of expulsive pushing and quick birth. It does make mention that a birthing person should not be restricted in choice of birthing positions and be allowed to mobilise freely but should be coached in pushing. Consent for hands on approach should be documented and clear.
Element 4-  Examinations after birth. This is about assessing and identifying any trauma to the perineum and/or rectum. The care bundle says that every person should have a thorough examination of the perineum and this must include a rectal exam even if the perineum appears intact. Full explanation must be given and consent gained before any examination is performed and discussion and findings documented clearly in the notes.  

​So as you can see the first, and in my opinion most important part of this care bundle is about communicating with the woman and ensuring that every birthing person understands and gives fully informed consent. So I posted on my social media to ask some people that have recently birthed in Cornwall or are currently in the last few weeks of pregnancy, according to this care bundle they should all have received a OASI leaflet and had a full discussion with their community midwife about the risks of perineal trauma and what choices they have to try and reduce those risks as well as what to expect after birth. How many do you think said this had happened for them? None. Not one person I have spoken to has ever seen an OASI leaflet, none had anything more than a very brief conversation about perineal tearing during pregnancy, none knew what OASI was or that hands on and coached pushing was recommended and more worryingly none had a full discussion and gave consent for a PR exam after birth even though some remember having it!! Clearly much more work needs to be done on training staff to have effective and meaningful conversations and ensuring that all birthing people are informed on risks, evidence and choice. 

​What now? If you are currently pregnant and were unaware of this care bundle until now, you are probably thinking “Well what the hell do I do now?”. So I am going to look at a few of the concerns people have about this care bundle and give you lots of links to information, evidence and explanations about it so you can inform yourself and be prepared to ask your midwife about it.
Many of the concerns that have been raised about this bundle are based on information that we already knew, for example we already knew that women who birth on their backs have a higher rate of perineal trauma, we know that people who birth in water have a lower rate of perineal trauma, we know that women that birth after receiving pharmaceutical pain relief often have more risk of serious tears than those that had none, we know that people who experience continuity of carer (i.e knowing the midwife who cares for them during labour) experience a lower risk of perineal trauma- could this explain why IM’s have lower rates of perineal trauma? Undisturbed birth and total freedom to move and follow their bodies cues seems to reduce the rate of severe tears, a women may automatically try to close her legs to slow down baby’s descent but this is not supported when on your back in hospital with a midwife telling you to open your legs and make room for baby.
There are also some valid concerns about the finnish grip which is the main technique advocated for with OASI, this involves pinching the perineum and can cause the pressure to move to the anterior of the vulva causing a tear towards the clitoris or urethra, these tears may be classed as less serious but can lead to sexual dysfunction long term and can be difficult to repair, sometimes needing theatre and a specialist. Without this information it is impossible for a birthing person to make an informed decision on their care. 

So what else can you do apart from OASI to reduce the risk of perineal trauma?  Here are some things to think about and discuss with your midwife-
Water birth
Community birth- i.e home birth or midwife unit
Knowing your care giver and having continuity at your birth
Upright, forward leaning and mobile birth positions
Avoiding pharmaceutical pain relief that may interfere with your body’s instincts
Breathing baby down without forced, coached pushing
Warm Compress on the perineum

Ask your midwife about OASI, ask for more information about other options, after birth do not be afraid to ask the clinician to explain everything they want to do before they do. Ask questions and know that your consent at each stage is imperative and you have the control to stop the exam at any point without question.
 
Below are some links to learn more about OASI care bundle, more about perineal trauma in general and more about people’s opinions of this.


OASI Care bundle 

OASI Study protocol 

Video about OASI

​Opinion piece about OASI

WHO recommendations for preventing perineal trauma

Cochrane review for preventing perineal trauma

Hannah Dahlen Warm compress video