| Module Code: NUR3067 |
Module Title: THE PRINCIPLES + PRACTICE OF PERINEAL REPAIR |
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Module Provider: Health & Social Care
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Short Name: PRIN+PRACPR
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Level: HE3
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Module Co-ordinator: WILSON AE Dr (HSC)
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Number of credits: 20
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Number of ECTS credits: 10
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| Module Availability |
| Semester 1 |
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| Assessment Pattern |
Portfolio of evidence to include:
Part A.
1. A learning contract formulated with instructor/supervisor in clinical practice
2. Clinical summative competency assessment through an OSCE undertaken by instructing midwife. Students will be expected to recognize, assess and implement perineal repair in the delivery suite, demonstrating cognitive, interpersonal and psychomotor skills, necessary for the competent repair of the perineum. Achievement of competency/proficiency at minimum of level 4. For midwives aiming towards instructing, supervising and assessing colleagues in the delivery suite/community level 6 will need to be achieved. 40% 40%
Part B.
1. A reflective case study to demonstrate a critical evaluation of the care and management provided to one woman who has sustained perineal trauma which has necessitated repair/non-repair. Words 2000
The student must demonstrate:
• rationale for reflective model used in essay
• an integration of the theoretical aspects of the module which have influenced women’s choice, and joint clinical decision making
• evidence of appropriate reading and research to support reflection
• recommendations for future best practice
2. Completion of wound healing workbook
3. 3 Reading logs. 1 log must relate to the long term problems associated with perineal trauma 60%
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| Module Overview |
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| Prerequisites/Co-requisites |
Qualified midwife, ideally currently working or rotating into the delivery suite
Level 2 study if currently undertaking BSc (Hons) Professional Practice.
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| Module Aims |
| This self-directed work-based module is aimed for the midwife practising primarily in the delivery suite, either as a core midwife or on rotation. It is practice focused enabling the midwife to develop a minimum competence/proficiency at level 4 in the knowledge and skill of recognising and assessing perineal trauma, with the implementation of perineal repair independently. Expert practitioners are encouraged to develop their skills in the instruction, supervision and assessment of colleagues and students using an objective structured examination (OSCE) for the assessment of their competency undertaking perineal repair. The midwife will also be encouraged to take responsibility for the evaluation and audit of their own practice in perineal repair, monitoring subsequent healing where possible. |
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| Learning Outcomes |
By the end of the module the student should be able to:
Subject knowledge and understanding
• reflect on the historical perspective and current trends in perineal trauma management.
• relate the anatomy and physiology of the pelvic floor and anorectum, to the prevention, recognition and assessment of perineal trauma and repair in midwifery practice.
• develop a focused understanding of the women's physical and psychosocial experiences related to perineal trauma, repair and healing.
• evaluate qualitative research surrounding women’s sexuality and body image considering feminist issues within midwifery practice.
• Identify women who may be at risk as a result of FGM .
• develop a critical understanding of how best practice is underpinned by significant research evidence during pregnancy, labour and the puerperium in relation to perineal trauma, repair, wound healing and women’s short and long term physical and psychological wellbeing.
• relate to the national intrapartuum NICE (2007) guidelines EU Midwifery Directives and local policies, considering how these influence midwifery practice, client and professional informed choice and decision making in perineal repair.
• develop an in depth understanding of the relationship between the medico legal aspects of perineal trauma and risk management.
• consider the importance of the multi-professional and multidisciplinary team and their contribution towards the care and management of perineal trauma.
• Identify with the ‘user’ valuing their experiences of perineal trauma and management
Cognitive skills
• critically evaluate the relevant research papers to underpin best practice in the prevention and recognition of perineal trauma, during pregnancy, intrapartum and postnatal care.
• critically evaluate the relevant research papers and proforma’s used in practice to underpin best practice in the recognition, assessment and subsequent management of the four degrees of perineal trauma.
• critically evaluate the relevant research papers to ensure appropriate materials and methods are selected when undertaking perineal repair of uncomplicated episiotomies and second degree tears by the midwife.
• critically evaluate the relevant research papers to integrate the evidence into clinical audit during postnatal care of the perineum.
• critically evaluate and reflect on own learning and how this is integrated into best practice.
• Key transferable skills
• facilitate a partnership in care where the woman is involved in the process of informed choices and decision making to maximise perineal integrity, and minimise trauma and repair morbidity.
• implement evidence based practice to support the principles of clinical governance and risk management
• facilitate a critical awareness and analysis of best practice, using the research evidence to discuss and debate contemporary and controversial issues amongst other members of the multi professional team in the workplace
• supervise and teach the skill of perineal repair to other midwives and students when reaching a maximum level of competence (expert level 6)
• Facilitate as appropriate, referral to other members of the multidisciplinary team ie: physiotherapy, uro-gynaecology and organisations such as Relate.
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| Module Content |
• Overview of the history of perineal trauma and repair
• anatomy and physiology of the pelvic floor and anorectum
• a critical evaluation of the role of the midwife in the prevention of perineal trauma
• current rationale for performing an episiotomy
• definitions and NICE (2007) classifications of trauma sustained to the pelvic floor that require repair
• recognition and accurate assessment of all degrees of perineal trauma using a recognised perineal trauma assessment proforma
• current recommendations for undertaking perineal repair, methods and materials for repair
• perineal repair 'hands on' workshops
• perineal infiltration, epidural top up prior to repair
• safety with regard to universal precautions
• principles of wound healing, postnatal care and audit of perineal healing
• sexuality, body image and FGM related to perineal management
• record keeping, risk management and clinical governance
• ‘Evidence for Best Practice’ guidelines /policies and EU Directives
• women's issues related to childbirth, perineal trauma, repair and subsequent morbidity, rethinking a new midwifery 'paradigm' for practice integrating feminism and gender sensitive issues
• Influence of social policy and organisational issues in care delivery – including training and competency in perineal repair
• medico-legal issues
• collaboration with physiotherapy, obstetric consultant uro-gynaecology, perineal trauma clinics and support organisations
• knowledge and change theory responsibility for acting as a change agent in continued professional development and lifelong learning
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| Methods of Teaching/Learning |
Overall 200 hours:
12 contact hours in classroom
50 hours practice based learning
138 hours self directed learning with learning contract and recognised release time from practice negotiated with manager
Key theoretical lectures and workshops
Work based learning
Reflection, research analysis and critique
Self directed learning
Visits to specialist clinics
Supervised practice
Due to the importance attached to observing and implementing perineal repair in clinical practice, and the need for formative and summative assessment in perineal repair, it is essential that the module provides a structure for supervised practice.
Each student will be responsible for their own learning using a learning contract, negotiated with an expert instructor/assessor holding the OSCE accreditation ideally.. The practice assessment of competency undertaking perineal repair will be undertaken at the bedside with an instructing midwife using an OSCE.
Where there is a short rotation into the delivery suite, negotiation needs to be made with student and delivery suite staff to ensure perineal repair can continue to be both observed and implemented to meet the required assessment criteria. *Allocation to the delivery suite needs to be planned well in advance of commencing the module. Observation of perineal trauma, assessment and repair is recommended as soon as practicable prior to module to enable the midwife to gain optimum experience prior to assessment.
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| Selected Texts/Journals |
Baston H. (2004) Perineal repair The Practising Midwife 7 (9) pp 12-15
Brownlee M. (1994) Synchronised suturing MIDIRS Midwifery Digest 4 (1). March.
Clement S, Reed B. (1999) To stitch or not to stitch? The Practising Midwife 2 (4) pp 20-28
Dolman, M. (1992) Incontinence and childbirth: understanding the link Professional Care of Mother and Child July/August pp 208 210
Draper, J.and Newell, R. (1996) A discussion of some of the literature relating to history, repair and consequences of perineal trauma. Midwifery 12 pp 140 145.
Ethicon (1998) Perinea] Repair Johnson and Johnson Company, Edinburgh, UK
Fitzpatrick M, Cassidy M. (2002) Experience with an obstetric perineal clinic European Journal of Obstetrics and Gynaecology 100 pp 199-203
Gordon, B and Mackrodt C. (1998) The Ipswich childbirth study:l. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured British Journal of Obstetrics and Gynaecology 105 pp 435 440
Gomme C, Yiannouzis K. (2001) Developing a tool to assess perineal trauma British Journal of Midwifery 9 (9) pp 538 544
Grant, A. Sleep J. & Spencer, D. (1989) Dyspareunia associated with the use of glycerol impregnated catgut to repair perineal trauma. Report of a 3 year follow up study. British journal of Obstetrics and Gynaecology 96 pp 741 3
Groom K, Paterson-Brown. (2002) Can we improve on the diagnosis of third degree tears? European Journal of Obstetrics and Gynacology and Reproductive Biology 101 pp19-21
Henderson C, Bick D, (Eds) (2005) Perineal Care: An International Issue Cromwell Press: Trowbridge, Wiltshire. *Highly recommended book to purchase for module ISBN No 1-85642-276-3
Kenyon S, (2004) How can we improve post birth perineal health? MIDIRS Midwifery Digest 14 (1) pp 7-12
Kettle C, Hill, R Jones P. (2002) Continuous versus interrupted perineal repair with standard of rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial The Lancet 359 pp 2217-2223 www.thelancet.com
Harris, M 1992 The impact on research findings in relieving postpartum perineal pain in a large district hospital Midwifery 8: 125 131
Hartley J 1999 Save the perineum The Practising Midwife 2 (l):14 15
Head, M. (1993) Dropping stitches Nursing Times 89 pp 33
Jackson K. (2000) The bottom line: care of the perineum must be improved British Journal of Midwifery 8 (10) pp 609 614
Kettle C, Johnson RB. (2001) Continuous versus interrupted sutures for perineal repair Cohirane Review In The Cochrane Library Issue 1 Oxford: Update Software Accessed 11.4.01
Kettle C, Hill R,Jones P. (2002) Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial The Lancet 359 pp 2217 2223 www,thelancet, com
Kirkman S. (2000) The midwife and pelvic floor dysfunction The Practising Midwife 3 (8) pp 20 22
Layton S. (2004) The effect of perineal trauma on women's health British Journal of Midwifery 12 (4) pp231-236
Lavin, J. (1996) Pelvic floor damage Modem Midwife May, pp 14 15
Lee B. (2002) Are you sitting comfortably? Issues around perineal repair RCM Midwives Journal 5 (9) pp 298 301
Lewis, L. (1996) Extending the midwives' role in perineal management Nursing Times 92 (1l) pp 39 41
Lundquist M, Olsson A Nissen E. (2000) Is it necessary to suture all lacerations after a vaginal delivery? Birth B27 (2) pp 79-85
Mackrodt, C Gordon, B Fern, E. (1998) The Ipswich Childbirth Study 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair British Journal of Obstetrics and Gynaecology Vol. 105 pp 441 445
Metcalf A, Tohill S, Williams, A 2002 A pragmatic tool for the measurement of perineal tears British Journal of Midwifery 10 (7):412 417
Metcalf A, (2004) Improving the assessment of perineal tears: the Peri-Rule British Journal of Midwifery 12 (10) pp 618-620
Metcalf A, Bick D, Tohill S, Williams A. (2006) A prospective cohort study of repair and non repair of second-degree perineal trauma: results and issues for future research Evidence Based Midwifery 4 (2) pp 60-4
NHS Executive (2001) Methods and materials used in perineal repair NHS Executive Guidelines http:llwww.rcog.org.uklguidelines/perineal.htmI
Odibo, L 1997 Suturing of perineal trauma: how well are we doing an audit British Journal of Midwifery 5 (11) : 690 692
Olah, K. (1994) Subcuticular perineal repair using a new, continuous technique British Journal of Midwifery February, 2 (2) pp 230-260
Poen, A. (1997) Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy British Journal of Obstetrics and Gynaecology 104 pp 563 566
Premkumar G. (2005) Perineal trauma: reducing associated postnatal maternal morbidity Midwives 8 (1) pp 30-32
Renfrew M, Hannah W, Albers L. (1998) Practices that minimise the trauma of the genital tract in childbirth: A systemaric review of the literature Birth 25 (3) pp 143 160
RCOG (2004) Methods and Materials used in perineal repair Guideline No. 23 www.rcog.org.uk
Salmon D. (2000) A feminist analysis of women's experiences of perineal trauma in the immediate postnatal delivery period MIDIRS Midwifery Digest 10 (2) pp 2119 25
Sampselle CM, Hines S. (1999) Spontaneous pushing during birth Relationship to perineal outcomes Journal of Nurse-Midwifery 44 (1) pp 36-39
Shipman, M Boniface, D. (1997) Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial British Journal of Obstetrics and Gynaecology 104 pp 787 791
Sultan A, Kamm M, Hudson C, (1994) Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair British Medical Journal 308 pp 887-891
Wilson A. (2009) A Quasi-Experimental study to evaluate the effectiveness of an educational programme in perineal repair for midwives and students. PhD Thesis. University of Surrey. Guildford.
• Perineal Repair Handbook provided with additional references.
Access to journals on line with Athens password, logged on with university.
Journals
Birth
British Journal of Midwifery
British Journal of Obstetrics and Gynaecology
British medical Journal
GUT
International Journal of Gynaecology and Obstetrics
JOGNN
Journal of Wound Care
Journal of Nurse-Midwifery
Journal of Midwifery and Women's Health
MIDIRS Midwifery Digest
Midwifery
The Lancet
The Practising Midwife
Web sites:
www.rcog.og.uk/quidelines
www.emap
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| Last Updated |
| 29TH JULY 2010 |
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