Authors: (including presenting author): :
Chan KY, Ho WM, Wong LW, Fong WS, Choy SY, Lui YM, Lee PY, Shiu WY, Leung SK, Wan OM
Affiliation: :
Department of Obstetrics and Gynecology, United Christian Hospital
Keyword 1: :
Perineal Protection
Keyword 3: :
Episiotomy Rates
Introduction: :
Routine episiotomy has been associated with increased maternal morbidity, including higher risks of perineal trauma, postpartum pain, and dyspareunia, as well as delayed recovery. The departmental episiotomy rate reached 39.02% in 2022, showing an upward trend that deviated from international evidence-based recommendations. The National Institute for Health and Care Excellence (NICE) guideline NG235 on Intrapartum care explicitly advocates a restrictive policy for episiotomy, recommending it only in specific indications such as fetal distress requiring urgent delivery, instrumental vaginal birth (forceps or vacuum), shoulder dystocia, or high risk of severe perineal tears (e.g., obstetric anal sphincter injury, OASI). In response, a NICE-guided quality improvement initiative incorporating perineal protection training was strategically planned to align clinical practice with these evidence-based guidelines and reduce unnecessary interventions.
Objectives: :
The project aimed to reduce episiotomy rates through midwife and student midwife education on perineal protection techniques and guideline adherence. In early 2023, the clinical alignment team conducted intensive specialized workshops covering detailed anatomy, hands-on/hands-off techniques, perineal massage methods, and warm compresses application, significantly enhancing staff competence and confidence in "try intact" vaginal deliveries while improving clinical outcomes.
Methodology: :
Workshops utilized evidence from cross-sectional studies and systematic reviews, including perineal massage with lubricant and warm pads applied at 45–59°C during crowning. A standardized "Information Sheet of Episiotomy" captured staff details, obstetric factors, and NICE-based indications (fetal distress, extended tear risk, large-for-gestational-age fetus, previous OASI). Regular audits and feedback sessions ensured more than 90% staff satisfaction with training and enabled targeted reinforcement for guideline alignment across all midwives.
Result & Outcome: :
Episiotomy rates declined substantially from 39.02% in 2022 to 30.35% in 2024 and further to 29.18% in 2025, elevating the unit from second highest to second lowest among eight public hospitals, without increased severe perineal trauma. High workshop satisfaction (>90%) and significantly boosted staff confidence drove sustained behavioral change. This experience demonstrates that NICE-aligned perineal protection training, combined with structured feedback and proactive engagement, effectively reduces episiotomy use, optimizes evidence-based maternal outcomes, and establishes a sustainable quality improvement model for obstetric practice.
