Last year, a consultant obstetrician told me there was ‘loads of evidence’ for the OASI care bundle. It was in response to me saying that I hadn’t discussed the OASI care bundle with my client due to a lack of strong evidence. What we had discussed was: perineal trauma and care, what that means and looks like; the value of physiological birth; different birthing positions; avoiding directed pushing where possible and the instances where an episiotomy might be indicated. In other words, we had had a very in depth discussion that went far beyond the OASI care bundle. This interaction got me thinking about the OASI care bundle, the evidence behind it and what it says about women.

Women’s bodies aren’t broken, the system is.

The OASI Care Bundle is a well-intentioned intervention, but it reinforces the centuries old message that women’s birthing bodies are faulty and that they need to be managed by medical professionals because they are a danger to themselves. It sees women’s bodies as the problem, ignoring the system within which they’re giving birth. A system that has completely medicalised childbirth, with rapidly rising rates of interventions and a sharp reduction in physiological birth in recent years. The OASI Care bundle fails to take into account the iatrogenic effects of unnecessary interventions and the impact these have on the likelihood of a woman or birthing person sustaining a third or fourth degree tear. The most recent NHS statistics show that less than 45% of women and birthing people experience an unassisted vaginal birth in England - and we don’t have the data to know how many of those are truly physiological.

The OASI Care Bundle ignores the protective factors and benefits that come with physiological birth. This includes ‘allowing’ women to push spontaneously instead of directing them to push, to birth in the position that feels right to them, as opposed to dictating they must be on their back or in lithotomy, and avoiding unnecessary intervention. It ignores the impact of place of birth - research has shown that overall where women with uncomplicated pregnancies plan to birth at home, they were 40% less likely to sustain a third or fourth degree tear compared to those planning to birth in hospital. The UK version of the care bundle ignores the evidence on warm compresses in reducing severe perineal trauma.

Perhaps these things are ignored because they don’t, save for the warm compresses, involve much ‘doing’ on the part of the midwife? Perhaps it’s because midwifery skills are considered ‘soft’ – waiting patiently, following the woman’s cues, observing unobtrusively. None of these skills can be measured or have statistical analysis applied. And in terms of home birth, well - it’s just not in the systems interest to promote that now, is it?

We’re not denying the harm.

To be clear, there is no denying that an OASI can be life-changing after childbirth and it’s not the intention of this blog to ignore the very real and very damaging effect they can have for some women. The recent APPG Inquiry into Birth Trauma shared some incredibly sad stories of women who had experienced an OASI that severely impacted their physical and mental health and, in some cases, changed their plans about having more children. So it makes sense to strive to reduce their incidence, to reduce morbidity for women and birthing people to ensure they can thrive after having a baby.

But it also can’t be denied that aspects of the OASI care bundle are invasive - notably manual perineal protection and the recommendation for all women, even those with an intact perineum, to have a rectal examination after birth. And the evidence to support the care bundle is patchy. There have been some fantastic critiques of OASI care bundles and it’s specific components and I’m not going to repeat what they say - but I would encourage you to read the following articles:

• The UK OASI Care Bundle: the results are out but so is the jury by Gill Moncrieff and Hannah Dahlen
• Perineal 'Bundles' (OASI) and Midwifery by Rachel Reed
• Congratulations on your new baby by Jim Thornton
• Perineal care bundles by Sara Wickham.

Where did the OASI Care Bundle come from?

There are variations of OASI Care Bundles around the world, but the one referred to in this blog is based on the UK version that was developed and endorsed by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives. It came about in 2014 in response to a threefold increase (1.8% - 5.9%) in the rate of OASI between 2000 - 2012 in the UK. It was right to be concerned about rising rates of OASI given the long standing impact they can have on women, and it was right to look at what could be done to try and reduce harm - there’s no question about that.

The OASI Care Bundle was rolled out across 16 NHS Trusts between 2016 -2018 as part of a research study, which compared the rates of 3rd and 4th degree tears before and after the implementation of the care bundle. Over 55’000 women were included in the study. The researchers found that after the implementation of the care bundle, the rate of 3rd and 4th degree tears reduced from 3.3% to 3% - which was a 20% case-mix-adjusted reduction and clinically significant. And that does sound pretty good, on paper.

The Four Components of the OASI Care Bundle (UK):

1. Antenatal education.

2. Manual perineal protection for all vaginal births. 

3. Mediolateral episiotomy, if clinically indicated.

4. Systematic examination of the perineum after birth, including a rectal examination.

The RCOG say that ‘Good communication with the woman before, during and after birth underpins all elements of the care bundle.’ They’re not wrong, but with fragmented care, women often not seeing the same midwife throughout their pregnancy, and a very stretched maternity service - I’m confident this isn’t happening for all women. I’m confident because I’ve witnessed poor communication and a lack of consent time and time again.

What’s the actual rate of OASI?

The most recent statistics from the National Maternity and Perinatal Audit Report, based on 2024 data in England, Scotland and Wales, showed an OASI rate of 3.5%. Below are the rates of third and fourth degree tears since the NMPA started collecting the data:

2020 - 3.2%

2021 - 3.1%

2022 - 3.1%

2023 - 3.3%

2024 - 3.5%

Blanket Policies Do Not Good Maternity Care Make

I don’t know how many NHS Trusts have implemented the OASI Care Bundle into their maternity care policies, but it particularly doesn’t make sense to apply blanket policies and invasive procedures in the event of a physiological birth. If birth is unfolding by itself - why are we intervening? On the other hand, where there is perineal trauma, it does make sense to offer a rectal examination to determine what type of tear has been sustained and to rule out severe perineal trauma and so the woman receives the appropriate aftercare.

Some NHS Trusts have included the OASI care bundle (or a version of it) in hospital policy, which can then impact practice, for better or worse. I’ve worked in Trusts where in the computerised documentation that has to be completed after a birth, there is a question about what technique was used at birth - ‘hands on’ or ‘hands off’ - and if ‘hands off’ (or something similar) is documented, you have to explain why this approach was used. By contrast, no explanation was required if ‘hands on’ aka manual perineal protection is selected.

Can you see how this could influence midwives’ practice? Fear of being ‘told off’ or not following policy could lead some midwives to routinely apply the OASI care bundle to all women they’re caring for, which then brings into question consent and erodes clinical judgement. I have witnessed a lack of consent for manual perineal protection or a ‘hands on’ technique at hospital births both by midwives and doctors. Generally these were kind, well-intentioned healthcare professionals. No amount of kindness or good intention means you can touch someone’s perineum without their consent.

We need to be looking at every woman and every birth through an individual lens, rather than applying blanket policies to ALL women and birthing people. We need to be having discussions during pregnancy about perineal trauma, the likelihood, ways to minimise the chance of OASI, what things increase the chance of OASI. So that women can then make an informed choice about if they want such a care bundle applied to them during their birth - and that decision might change depending on the circumstances of their birth. If they have a straightforward homebirth they might very much welcome a hands-off approach, but if they are having an instrumental birth they might choose to have hands on support and an episiotomy to try to reduce their chance of sustaining an OASI because we know instrumental birth, particularly forceps is a risk factor for OASI.

The Care Bundle in Practice

Before becoming an independent midwife I worked at several hospitals mostly in London and the care bundle was not used in all of them. One hospital I worked at was using a perineal care bundle (albeit under a different name) and I remember being called to a waterbirth as the second midwife. The lead midwife was bent over, half in the pool, attempting to apply a ‘hands on technique’ to the woman’s perineum. It looked incredibly uncomfortable for the midwife and incredibly invasive for the woman, in what otherwise should have been (in my opinion) a very ‘hands-off’, peaceful waterbirth. This was the same trust that when I called for a second midwife for a woman who was giving birth on all fours, the midwife who walked in shouted, ‘She’ll have a third-degree tear like that’. Even though upright positions are associated with lower rates of OASI. Elsewhere, as mentioned earlier, I saw midwives or doctors hands touching a woman’s vulva without consent - this is unacceptable. I’ve seen midwives beat themselves up when the woman they were caring for sustained a 3rd degree tear - being asked questions like, ‘what position was she in’, ‘did you do hands on’, which all serve to land the blame on the midwife rather than the system and the events that perhaps led up to the birth.

We should be reducing harm, but the OASI care bundle isn’t the answer.

OASIs are real. They can be devastating. But in my opinion the OASI care bundle is not the answer. We need to continue to question rising rates of interventions, the lack of continuity of care and why the things that do reduce the chance of OASI are routinely ignored. And we should always question when something is introduced with patchy evidence that can have a huge impact on someone's birthing experience.

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