Red Flags for Episiotomy in a Midwife-Led Birth: Using Co-Production with Midwives to Capture Clinical Experience.

BACKGROUND:One of four key points in the Obstetric Anal Sphincter Injury Care Bundle, first piloted in the UK in 2016, was the directive to perform episiotomy when clinically indicated. Midwives are the primary health care professional for straightforward births in the UK and there is very little published literature that relates to their practice in this area.AIM:The aim of the study was to explore experienced midwives' decision-making processes in their assessments for episiotomy during birth.METHODS:43 midwives self-identifying as confident in performing episiotomy were sampled across 8 NHS Trusts in England and Wales. Data collection was via online focus groups and 1:1 interviews. Primary thematic analysis was undertaken by the research team. Preliminary themes were used to structure a co-production analysis workshop where eight experienced midwives undertook a secondary analysis of the data resulting in four overall themes.FINDINGS:Four themes were identified, 'Optimising Perineal Function', 'Red Flags to Stimulate Decision-Making', 'The Midwives' Episiotomy' and 'Infiltration as a Catalyst for Birth'.DISCUSSION:Midwives use a number of visual, auditory and touch cues to inform their assessments for episiotomy during birth.CONCLUSION:This study provides valuable insight into the cues that guide experienced midwives' decision-making in relation to episiotomy and contributes evidence related to performing episiotomy when clinically indicated in spontaneous vaginal birth.