Perineal Repair: Improving Knowledge, Confidence, and Skills

07 March 2023

Evidence shows that 85% of women experience a perineal injury. With this in mind, it is imperative that obstetric practitioners have the skills to master perineal repair.

Perineal Repair: Improving Knowledge, Confidence, and Skills

Perineal Repair: Improving Knowledge, Confidence, and Skills

Pregnancy and childbirth are very important events in a woman’s life. Most women feel some anxiety about childbirth, including the pain of labor and the possibility of perineal injury during delivery.

Evidence shows that “85% of women experience a perineal injury, and at least one-third of these experience spontaneous perineal laceration.”3 With this in mind, it is imperative that obstetric practitioners are provided with ongoing education to maintain skills to master perineal repair.

As with all safe patient care, perineal repair skills should not be taught during the childbirth process. “The working ergonomics during postpartum perineal repair poses challenges with regard to educating and training midwives and obstetricians."

"Complicated tears, limited visual overview, and patient discomfort during the procedure are stress factors for the learning situation. The trainee is often used as an assistant, and this can have a negative impact for the training. For the teacher the limited space and overview can be a challenging place to teach.”4

“Several regulatory bodies and national organizations have begun to require simulation of obstetrician-gynecologists, and the newer generation of physicians has experienced simulation throughout their training…In recent years, more and more evidence has emerged showing improvements in participant confidence, skills, behaviors, and, finally, patient outcomes following simulation program implementation.”2 

Since requirement changes were implemented, multiple studies have found “the introduction of an educational program in perineal assessment and repair is effective in improving knowledge, confidence and skills of participants.”1

Litigation related to inadequate perineal repair is growing. A UK based study found that “Obstetric anal sphincter injuries have significant resource implications for healthcare providers owing to the ongoing follow-up and can trigger negligence claims. The total value of OASI-related negligence claims in England's National Health Service (NHS) was an estimated £31.2 million between 2000 and 2010."

"These claims referred specifically to failure to perform or extend an episiotomy, failure to diagnose the true extent and grade of the injury, inadequacy of repair and failure to perform a repair.”5 These findings prompted the NHS to compile an Obstetric Anal Sphincter Injury (OASI) care bundle to be implemented nationally through all its facilities.

In addition to technical skills, the OASI care bundle includes appropriate communication with the patient beginning no later than 32 weeks of pregnancy. The project’s four components are summarized here:

Overall, the literature supports both initial and ongoing practice of perineal repair in order to maintain skills for all practitioners. Simulation has been proven to be an effective means of teaching these skills in a safe environment for learners. Further support of this notion was completed in a 2021 comprehensive literature review on perineal repair. The study concluded:

  • “Structured hands-on skills training that includes multimodal learning is effective for teaching perineal repair skills.
  • More opportunities to practice perineal assessment and repair skills leads to increased levels of confidence.
  • One-day workshop is as effective as a two-day workshop to teach perineal wound assessment and repair skills.
  • Knowledge and skills are retained from this type of education up to six months post the intervention.”



1 Diaz MP, Effectiveness of structured education and training in perineal wound assessment and repair for midwives and midwifery students: A review of the literature.
2 DILLON, S. Simulation in Obstetrics and Gynecology: A Review of the Past, Present, and Future. Obstetrics and gynecology clinics of North America, [s. l.], v. 48, n. 4, p. 689–703, 2021. DOI 10.1016/j.ogc.2021.07.003. 
3 Bączek G, Rzońca E, Sys D, Rychlewicz S, Durka A, Rzońca P, Bień A. Spontaneous Perineal Trauma during Non-Operative Childbirth—Retrospective Analysis of Perineal Laceration Risk Factors. International Journal of Environmental Research and Public Health. 2022; 19(13):7653. 
4 Optimizing teaching and training in postpartum repairs.
5 The OASI care bundle quality improvement project: lessons learned and future direction