Midwives' Expertise in Preserving the Perineum Intact: the 'MEPPI' study

Background: In 2010, episiotomy rates for vaginal births were 5-7% in Denmark, Sweden and Iceland, 19-24% in Norway and the UK, and 68-73% in Poland and Portugal. In New Zealand, in 2011, data from 866 midwives showed an... [ view full abstract ]

Background:
In 2010, episiotomy rates for vaginal births were 5-7% in Denmark, Sweden and Iceland, 19-24% in Norway and the UK, and 68-73% in Poland and Portugal. In New Zealand, in 2011, data from 866 midwives showed an episiotomy rate for spontaneous vaginal births for primparous women of 8.6%. Similar results from one centre in Ireland found a rate for 293 primparous women of only 8%. As these outcomes are unusually good, and differ from study findings across the world, an exploratory study was undertaken to ascertain how the most skilled of these midwives managed to achieve such good rates.

Aim:
To explore the views of expert midwives in Ireland and New Zealand on preserving the perineum intact, what skills they employ, and how they obtain such good maternal outcomes.

Method:
Ethical approval was granted by the lead author’s institution. A qualitative descriptive approach used semi-structured, recorded interviews with 21 expert, consenting midwives in Ireland and New Zealand in 2014/15. “Expert” midwives were those who had a ‘no suture’ rate (intact perineum, grazes or first degree tears) of greater than 40% in all primigravid women they had cared for in the past 3 years; episiotomy rate of less than 11.8 %; and a serious perineal tear rate of less than 3.2% (or one tear in the past 3 years). The constant comparative method of analysis was used.

Findings:
Most participants considered that the best techniques of preserving the perineum intact (PPI) involved using warm compresses, patience, and ‘breathing’ the head out over a number of contractions. Expert tips were also given on how to recognise perinea that were about to tear.

Discussion:
Some aspects of PPI described are not documented in midwifery or obstetric text-books and need to be emphasised to improve care during birth.

Conclusions and Implications:
Expert midwives are able to preserve the perineum of primigravid women intact more often than other midwives, without increasing second degree and severe perineal tears, using certain techniques. Midwifery students should be taught these techniques in theory and practice.