OASI Care Bundle Analysis

Introduction

Among all types of perineal injuries, obstetric anal sphincter injuries (OASI) are among the most serious that can happen during vaginal childbirth (Okeahialam, Sultan & Thakar, 2024). Such injuries may cause women to feel pain for a long time, have trouble controlling their bowels, experience sexual problems, and suffer from psychological distress, all of which can greatly reduce their quality of life (Schwartz et al., 2022). Even though OASI can be prevented in many cases, it is still not widely recognised, has been underreported in the past, and is managed differently in different maternity services in the United Kingdom (NMPA Project Team, 2022). Because of the high number of patients and differences in care, NHS England launched the OASI Care Bundle as a national quality improvement program.

The OASI Care Bundle was developed by the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), and perineal trauma experts to ensure that preventive care is given in the same way during vaginal births (Gurol-Urganci et al., 2022). The method consists of four important parts – antenatal education, manual perineal protection, precise mediolateral episiotomy, and thorough post-birth examination; it is meant to reduce injuries without increasing the use of interventions or affecting patient-centred care (Jurczuk et al., 2025). This paper will study how using structured care can make maternal care safer, encourage teamwork among professionals, and help midwifery-led care improve over time.

Care Bundle Components and Implementation

Obstetric anal sphincter injuries or OASIs are severe 3^rd and 4^th degree tears during childbirth. OASI can cause long-term pain and urinary/faecal incontinence. To reduce OASI rates, UK maternity services introduced an evidence-based OASI care bundle. The care bundle primarily deals with:

1. antenatal discussion about OASI risk and prevention (Jurczuk et al., 2025);
2. manual perineal protection (using a hand to support the perineum during delivery) (Jurczuk et al., 2025);
3. mediolateral episiotomy at a 60° angle when clinically indicated (Jurczuk et al., 2025); and
4. systematic examination of the perineum, vagina and rectum immediately after birth (Jurczuk et al., 2025).

The components were selected using consensus evidence and put together as a “package of care”. In reality, midwives and obstetricians helped to introduce the bundle at the NHS units where it was being used (Bidwell et al., 2021). Training sessions and guidelines were provided, and women were informed during labour by their clinicians. Importantly, studies assessed the bundle not in isolation but as part of a quality-improvement initiative (known as OASI1 and OASI2 projects) where uptake and compliance were monitored (Jurczuk et al., 2021b).

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Outcomes and Effectiveness

Clinical evaluations have shown the care bundle to be effective. In one large stepped-wedge study across 16 UK maternity units, introducing the bundle corresponded to a significant reduction in OASI incidence. Specifically, the raw rate of OASI fell from about 3.3% to 3.0% of births, which after risk adjustment amounted to a 20% reduction in a woman’s odds of sustaining an OASI if her unit applied the bundle (Royal College of Obstetricians and Gynaecologists, n.d.; Jurczuk et al., 2025). Crucially, this improvement did not come at the expense of other interventions: overall caesarean section rates and episiotomy rates remained essentially unchanged following implementation (Royal College of Obstetricians and Gynaecologists, n.d.; Jurczuk et al., 2025). This indicates the bundle provided extra protection without merely shifting risks to other procedures.

In qualitative terms too, women’s experiences with the bundle were generally positive or neutral; one patient survey found that receiving antenatal information was largely valued, and most women did not feel that the hands-on practices violated their autonomy. The care bundle’s structured approach involving both midwives and obstetricians likely contributed to these outcomes (Ryan, McGrinder & Smith, 2024). Overall, the evidence supports that the OASI care bundle can effectively reduce severe perineal trauma when faithfully applied, validating its adoption in NHS practice.

Implementation Barriers

Despite demonstrated benefits, several barriers to implementing the OASI care bundle have been identified. Focus-group interviews with clinicians revealed that skills gaps and resistance to change were major issues. Many midwives and obstetricians felt they lacked confidence or training in perineal management techniques such as manual protection and angled episiotomy, which made them hesitant to perform the new procedures routinely (Jurczuk et al., 2021a). There was also some reluctance to discuss the risk of perineal trauma with women antenatally: clinicians worried that raising the topic might cause anxiety, leading them to skip thorough explanations during prenatal visits (Jurczuk et al., 2021a). Organizational factors also played a role: units varied in how consistently they monitored bundle compliance, and some lacked dedicated time or feedback mechanisms to reinforce the practices. In terms of workflows, fitting all four steps into a busy labour ward was challenging unless clear protocols were embedded into routine care.

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However, several enablers helped overcome these barriers. Reported enablers included observing positive clinical outcomes like staff seeing fewer tears over time, and strong senior leadership support for the initiative (Jurczuk et al., 2021a). Importantly, improved collaboration between midwives and obstetricians was noted: working together on the bundle promoted a shared ownership of perineal protection, making teams more cohesive (Jurczuk et al., 2021a). On the patient side, having supportive materials like leaflets and posters increased women’s receptivity (Jurczuk et al., 2021a; Jurczuk et al., 2021b). Implementation science experts stress that having “local champions” is critical: in this case, midwives and obstetricians trained as champions encouraged their colleagues, providing peer-to-peer education (Gurol‑Urganci et al., 2021). Successful implementation, therefore, hinged on addressing training needs and cultural attitudes, and leveraging team-based support and feedback (Rasmussen et al., 2021).

Role of Midwives

Midwives have a pivotal role in OASI prevention. As primary caregivers during normal births, midwives are often the ones performing perineal protection and making episiotomy decisions (Olakotan et al., 2025). Their involvement in bundle training and decision-making is therefore crucial. The collaborative development of the bundle by the RCM (Royal College of Midwives) and RCOG underscores this role (Jurczuk et al., 2021a). When midwives actively participate, the bundle’s components are more consistently applied. Studies suggest that care under midwifery-led models is associated with lower OASI risk than obstetrician-led care, possibly due to more continuity and lower intervention rates; although the bundle aims to benefit all models (Burns et al., 2022; Sriram, Almutairi & Albadrani, 2024).

Practical observations show that in units where midwives helped adapt the bundle to existing practices – for instance, customizing how MPP is taught; uptake was higher (Scamell et al., 2021). Midwives also facilitate communication: they often counsel women during labour and can integrate the bundle steps naturally into second-stage care (Olakotan et al., 2025). Addressing midwives’ concerns – for example, providing simulation training so they feel skilled at MPP; can significantly improve adherence (Ferrari et al., 2024; Theodosopoulos et al., 2024). Midwives, therefore, are both implementers and ambassadors of the care bundle; their attitudes and competencies directly influence its effectiveness.

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Outcomes for Midwifery Practice

Overall, the introduction of the OASI care bundle has influenced midwifery practice by raising awareness of perineal safety. Many midwives report that the care bundles formalized steps they were already doing informally, leading to more systematic perineal support (Diko et al., 2021). The emphasis on teamwork also helped clarify roles: midwives often handle MPP while obstetricians are poised to perform episiotomy if needed (Rodrigues et al., 2021). Importantly, midwives’ own feedback through audits and focus groups was used to refine guidance, making the bundle more midwife-friendly (Allen, Small & Lee, 2022); for example, allowing some flexibility in how MPP is applied or ensuring discussions happen at a comfortable time. This bidirectional process, where midwives shape implementation as much as they enact it; has been noted as a strength of the NHS rollout (Bidwell et al., 2023).

Conclusion

It is now clear from recent studies that the care bundles help to prevent severe perineal tears in vaginal births: using it in NHS units was linked to a 20% lower risk of OASI, without affecting other birth outcomes. The main parts of the bundle – prenatal information, manual support, selective episiotomy, and post-birth examination; are all part of a well-designed prevention strategy. Midwives are key to this strategy, as they teach women and provide hands-on care, and their involvement is very important for the plan to work. Still, issues such as lacking skills, reluctance to talk about trauma, and organizational inaction can make it harder for adoption to happen. To handle these obstacles, we should use specific training, rely on strong leadership in the clinic, and keep evaluating our progress. In reality, when midwives and obstetricians both take responsibility for the bundle, it helps bring about positive changes. Moving ahead, keeping an eye on the bundle through audits and making changes will help it remain effective. All in all, the evidence from 2021-2025 shows that care bundles are helpful in midwifery-led birth care and lead to better outcomes when used properly and together. The NHS experience proves that when midwives are trained and agree to use care bundles, they can follow the best evidence on OASI prevention.

References

Allen, J., Small, K., & Lee, N. (2022). How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis. Women and Birth, 35(1), e1–e9. https://doi.org/10.1016/j.wombi.2021.01.012

Bidwell, P., Sevdalis, N., Silverton, L., Freeman, R., Hellyer, A., Novis, V., Thakar, R., & Gurol-Urganci, I. (2021). Women’s experiences of the OASI Care Bundle: A package of care to reduce severe perineal trauma. International Urogynecology Journal, 32(7), 1807–1816. https://doi.org/10.1007/s00192-020-04653-2

Bidwell, P., Thakar, R., Gurol-Urganci, I., Harris, J. M., Silverton, L., Hellyer, A., Freeman, R., Morris, E., Novis, V., & Sevdalis, N. (2023). Exploring clinicians’ perspectives on the ‘Obstetric Anal Sphincter Injury Care Bundle’ national quality improvement programme: A qualitative study. ISRCTN Registry. https://doi.org/10.1186/ISRCTN12143325

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Diko, S., Sheeder, J., Guiahi, M., Nacht, A., Reeves, S., Connell, K. A., & Hurt, K. J. (2021). Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: A national survey of nurse-midwives. International Urogynecology Journal, 32(6), 1745–1753. https://doi.org/10.1007/s00192-020-04304-6

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Rasmussen, O. B., Yding, A., Andersen, C. S., Boris, J., & Lauszus, F. F. (2021). Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study. BMC Pregnancy and Childbirth, 21, 781. https://doi.org/10.1186/s12884-021-04260-z

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