Perineal trauma management and follow-up: Are we meeting the standard of care?

Abstract

Birth-related third- and fourth-degree perineal trauma is common and associated with short- and long-term complications. To conduct a review of clinical audits investigating management of women with perineal trauma. We identified all audits undertaken in eight New Zealand public hospitals between 2005 and 2014 that investigated whether women with birth-related third- and fourth-degree perineal trauma were receiving care according to clinical guidelines. We aggregated audit results and calculated the proportion of women receiving the recommended standard of care. During the review period, 25 audits investigated intra-operative (n=11), post-operative (n=14) and outpatient care (n=18). Baseline audits showed variation in care by site; intra-operative care (range 39-96% for repair conducted under anaesthesia, 60-96% for repair by or under supervision of a senior clinician, and 33-54% for completion of Accident Compensation Corporation forms); post-operative care (range 40-93% for prescribed antibiotics and 33-96% for stool softeners) and outpatient care (45-84% for referral to outpatient clinic and 54-78% for physiotherapy follow-up). Sustained high quality of care and improvements in adherence with recommendations were seen for most of the follow-up audits (eg 90% adherence for prescribed stool softeners over three audits; over 50% increase in prescribed antibiotics over seven years). These clinical audits exemplify the need to measure patient care against standards, learn from the findings, implement changes to improve patient experience and reduce life-long sequelae from perineal trauma. This review showed some progress in some care services and highlighted where further changes are needed to close evidence-practice gaps.