Open Access Research article

How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice

Debra E Bick1*, Khaled M Ismail2, Sue Macdonald3, Peter Thomas4, Sue Tohill5 and Christine Kettle6

Author Affiliations

1 Professor of Evidence Based Midwifery Practice Kings College London, Florence Nightingale School of Nursing and Midwifery, 57 Waterloo Road, London SE1 8WA, UK

2 School of Clinical & Experimental Medicine, College of Medical & Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK

3 Education and Research Manager, Royal College of Midwives, 15 Mansfield Street, London WIG 9NH, UK

4 Centre of Postgraduate Medical Research and Education, School of Health and Social Care, Bournemouth University, R506A Royal London House, Christchurch Road, Bournemouth, Dorset BH1 3LT, UK

5 Research Manager West Midlands (South) Comprehensive Local Research Network, University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Clifford Bridge Road, Coventry CV2 2DX, UK

6 Maternity Centre, Professor of Women’s Health Staffordshire University and University Hospital of North Staffordshire, Newcastle Road, Stoke-on-Trent, Staffordshire ST4 6QG, UK

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BMC Pregnancy and Childbirth 2012, 12:57  doi:10.1186/1471-2393-12-57

Published: 25 June 2012



The accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.


A descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.


405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.


There are considerable gaps with implementation of evidence to support management of perineal trauma.

Perineal trauma; Episiotomy; Suturing methods; Maternal morbidity; Midwifery practice