I M P L E M E N TAT I O N R E P O R T

Management of perineal pain among postpartum women

in an obstetric and gynecological hospital in China:
a best practice implementation project
Yu Zhang 1,3  Li Huang 1  Yan Ding 1  Yajing Shi 1  Jiaying Chen 1  Alexa McArthur 2
1
Obstetric and Gynecological Hospital of Fudan University, Shanghai, People’s Republic of China, 2The Joanna Briggs Institute, The Faculty of
Health and Medical Sciences, University of Adelaide, Adelaide, Australia, and 3Fudan University Centre for Evidence-based Nursing: a Joanna Briggs
Institute Centre of Excellence, Fudan University, Shanghai, People’s Republic of China

EXECUTIVE SUMMARY

Background: Perineal pain is a serious condition that may negatively impact a significant number of postpartum
women. Healthcare professionals, including midwives and nurses, are available to support women 24 hours a day
during this period in hospital and are in an ideal position to assist in the management of perineal pain for postpartum
women.
Objectives: The aim of this evidence implementation project was to improve management of perineal pain among
postpartum women in Ward 21 of the Obstetric and Gynecological Hospital, Fudan University.
Methods: This evidence implementation project utilized the Joanna Briggs Institute Practical Application of Clinical
Evidence System, and Getting Research into Practice audit and feedback tools. Six best practice recommendations
were used for the audit cycle. A total of 18 nurses, three midwives and 30 female patients participated in the project.
A baseline audit was conducted, followed by the implementation of strategies targeted to address the identified
barriers. A follow-up audit was then conducted to evaluate change in practice.
Results: Improvements in practice were observed for all six criteria. Significant improvements were found for the
following: staff education increased compliance by 76% (from 24% to 100%). Education regarding antenatal perineal
massage technique increased by 97% (from 3% to 100%). Compliance rates for use of ice packs increased by 63%
(from 17 to 80%). Compliance rates for daily perineal pain assessment conducted for three days following childbirth
increased by 100%, and analgesia administration rates increased by 27% (from 1% to 40%). Compliance rates for
women’s acceptance of postnatal perineal care education increased by 70% (from 30 to 100%).
Conclusion: The current clinical audit project has made a significant improvement in establishing evidence-based
practice of management of perineal pain among postpartum women in the gynecologic and obstetric hospital in
Shanghai. It has been effective in increasing staff compliance and reducing the perineal pain among postpartum
women.
Keywords Education; management; perineal massage; perineal pain; postpartum women; prevention
JBI Database System Rev Implement Rep 2017; 15(1):165–177.

Background persistent health problems experienced by women

erineal trauma is a common condition during
P vaginal birth.1 Although postnatal care is rou-
tinely provided for all women and their infants,
several important indicators and a number of recent
studies raise concerns about its quality and effective-
ness.2 These have highlighted widespread and
Correspondence: Yu Zhang, xiaoyu19830402@163.com
There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2016-003232
after childbirth, many of which are unreported by
women and not identified by healthcare profes-
sionals. Common health problems include physical
morbidity such as back pain, breast feeding prob-
lems, perineal pain, stress incontinence and mental
health problems, such as postnatal depression.2
Pain as a result of perineal trauma can negatively
affect women in the postpartum period.3 Pain, healing
time and ongoing morbidity are increasingly propor-
tionate to the degree of trauma.4 Over 85% of women
having a vaginal birth sustain some form of perineal

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 165

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT
trauma5 and 60–70% require suturing, which is
equivalent to approximately 400,000 women a year
in the United Kingdom (UK) in 1997.5,6 There are
wide variations in rates of episiotomy: 8% in the
Netherlands, 9% in East European countries,
13% in the UK7 and 25% in the USA.8-10 Sutured
spontaneous tears are reported in about a third of
women in the USA10 and the UK,11 but this is prob-
ably an underestimate because of inconsistencies in
both reporting and classification of perineal trauma.
The incidence of anal sphincter tears varies between
0.5% in the UK and 7% in Canada.12
Perineal trauma affects women’s physical,
psychological and social wellbeing in the immediate
postnatal period and may also have a long-term
impact. It can also disrupt breastfeeding, family life
and sexual relations. In the UK, about 23–42% of
women continue to have pain and discomfort at 10–
12 days postpartum, 7–10% of women continue to
have long-term pain (during three to 18 months after
delivery),6,13 23% of women experience superficial
dyspareunia, 3–10% of women report fecal incon-
tinence;14,15 and up to 24% women have urinary
problems at three months postnatally.5,6 Varying
levels of these conditions depend on the severity of
perineal trauma and the effectiveness of treatment.
There are many reported strategies for decreasing
perineal pain. Once or twice weekly perineal massage
in the antenatal period may increase the flexibility of
perineal muscles and skin, reducing the incidence and
degree of perineal tears and use of episiotomy.1 Evi-
dence suggests that women should be informed that
epidural analgesia is associated with increased instru-
mental delivery, which is associated with increased
rates of perineal trauma.16 Evidence from a systematic
review supported the effectiveness of local cooling
treatments (ice packs, cold gel pads and ice baths)
applied to the perineum following childbirth to
relieve pain. Ice packs provided improved pain relief
24–72 hours after birth compared with no treat-
ment.17 Perineal assessment, including signs and
symptoms of infection, inadequate repair, wound
breakdown or non-healing should also be eval-
uated.18 Women should be advised of the importance
of perineal hygiene, including frequent changing of
sanitary pads and performing hand hygiene.19
Perineal pain is a most common problem during
the postpartum period. Pain may result from peri-
neal trauma due to bruising, spontaneous tears,
surgical incisions (episiotomies) or in association
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Y. Zhang et al.
with operative births (ventouse or forceps assisted
births).20 Various treatments have been used for
pain relief. Perineal trauma may increase the risk
of infection and is a potentially significant source of
pain, which can negatively impact a woman’s post-
partum recovery. A variety of nursing interventions
aimed at relieving perineal pain are largely based on
localized cooling. Unfortunately, some interventions
may not follow best practice for providing adequate
pain relief or preventing perineal postpartum infec-
tion. Within our hospital setting, and in regional
China, perineal pain is a common issue, especially in
the three to five days following birth. Healthcare
professionals need to be aware that perineal pain is a
considerable problem and requires assessment and
effective management in the postpartum period.
The current project was conducted in the Red
House Obstetric and Gynecological (OB&GY) Hos-
pital affiliated with Fudan University in China. Red
House OB&GY Hospital was established in 1884 in
Shangai, China. The Red House OB&GY Hospital is
one of the largest tertiary designed hospitals dedi-
cated to providing high-quality patient care, nursing
and medical education and research for women’s
health in China. The hospital has 820 beds,
500 nurses and 45,000 annual inpatient admissions.
There are two birthing rooms and 12 maternity
wards in the hospital. The project was conducted
in one of the maternity wards and one of the mid-
wivery clinics. The ward has 56 beds, 18 nurses and
three midwives and admits women both in the
antenatal and postnatal period. The midwifery
clinics provide antenatal care to pregnant women,
including education regarding birth, methods for
pain relief, abnormal conditions and breastfeeding
education. All pregnant women have the opportu-
nity to attend this clinic during their pregnancy.
Evidence-based postpartum perineal care has
not been adequately provided within this hospital
setting. Information and education for pregnant
women about antenatal perineal massage tech-
niques, and how to manage perineal pain following
birth have not been routinely provided. Therefore,
this evidence implementation project has focused on
the promotion and management of perineal pain
among postnatal women.
Aims and objectives
The aim of this evidence implementation project was
to make a contribution toward promoting evidence-
ß 2017 THE JOANNA BRIGGS INSTITUTE 166
IMPLEMENTATION REPORT
based best practice for postpartum women in man-
aging perineal care, thereby reducing the rates of
perineal pain.
The specific objectives were as follows:
 To increase nursing staff knowledge and skills
of management of perineal care for women
following birth, and education for when they
are discharged home.
 To formalize local practice in the discharge plan-
ning for postpartum women.
 To improve compliance with evidence-based
criteria regarding discharge planning for post-
partum women.
 To reduce the rates of perineal pain.
Methods
The current evidence implementation project uti-
lized the Joanna Briggs Institute (JBI) Practical
Application of Clinical Evidence System (PACES)
and Getting Research into Practice (GRiP) audit and
feedback online tool. These tools facilitate a process
of change using an audit, feedback and re-audit
cycle. This project was divided into three phases:
 Establishing a team for the project and under-
taking a baseline audit based on criteria informed
by the evidence.
 Reflecting on the results of the baseline audit and
designing and implementing strategies to address
non-compliance found in the baseline audit
informed by the JBI GRiP framework.
 Conducting a follow-up audit to assess the out-
comes of the interventions implemented to
improve practice and identify future practice
issues to be addressed in subsequent audits.
The audit was conducted from July 1 to October
30, 2015 and was undertaken as part of the JBI
Evidence Based Clinical Fellowship program.
Ethical consideration
The project was registered as a quality improvement
activity within the hospital, and therefore ethical
approval was not required.
Phase 1: Team establishment and baseline audit
 The audit team was led by YZ (project lead), who
was responsible for project team training,
strategy design, process control and promotion,
data organization and management. The project
lead was also responsible for communication
with other healthcare staff and assisting with
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Y. Zhang et al.
the implementation of quality improvement
strategies.
 YD (Associate Chief Nurse) supervised the nurs-
ing staff and assisted with data collection.
 LH (Registered Nurse [RN]) focused on nursing,
patient and caregiver education and assisted with
the survey tool design.
 YS (RN) and JC (RN) assisted with data
collection.
Audit criteria
An evidence summary was developed on the basis of
a structured search of the literature and selected
evidence-based care databases. The evidence sum-
mary identified high-quality evidence on which some
of the recommendations for practice were based.21
The recommendations presented within the evidence
summary are outlined below:
 Antenatal perineal massage, from 35 weeks once
or twice a week, is recommended and may reduce
the rate of perineal pain, trauma or the need for
an episiotomy (Grade B).
 Women should be provided with an opportunity
to discuss perineal massage and provided
with information on how to perform massage
(Grade B).
 Ice packs or cold gel packs may be recommended
to reduce perineal pain after childbirth (Grade B).
 Both oral and rectal analgesia have been shown
to be effective in decreasing perineal pain, but the
acceptance of using rectal analgesia by some
women may impact its use (Grade B).
 Women should be advised of the importance of
perineal hygiene, including frequent changing of
sanitary pads, washing hands before and after
doing this, and daily bathing or showering to
keep their perineum clean (Grade A).
The above evidence and recommendations were
used to develop a list of audit criteria which are
available in the JBI PACES software program.
Table 1 shows the evidence informed audit criteria
used in the project (in both baseline and follow-up
audit) together with a description of the sample
and approach to measuring compliance with best
practice for each audit criterion.
Baseline audit
A baseline audit using the JBI PACES program
was conducted using data collection flow sheets
developed specifically for the project. During the
ß 2017 THE JOANNA BRIGGS INSTITUTE 167
IMPLEMENTATION REPORT Y. Zhang et al.

Table 1: Audit criteria, sample and approach to measuring compliance with best practice

Method used to measure %

Audit criterion
1. Nursing staff received education
regarding patient education for peri- (Cycle 1: July 1–7)
neal care
2. Pregnant women received edu-
cation regarding antenatal perineal
massage technique
3. Ice packs are implemented in the
first 24–72 hours after childbirth
4. Daily perineal pain assessment/
observation is conducted for three
days after childbirth
5. Analgesia was administered for
perineal pain
6. Women received education about
postnatal perineal care
Sample compliance with best practice
18 nurses per cycle To calculate the number of nurses
who received educational training,
(Cycle 2: October 1–30) and to test their knowledge
30 pregnant women per Interview with women to determine
cycle whether she has received structured
(Cycle 1: July 6–17) education
(Cycle 2: October 1–30)
30 postpartum women Review patient’s records
per cycle
(Cycle 1: July 6–17)
(Cycle2: October 1–30)
30 postpartum women Review patient’s records
per cycle
(Cycle 1: July 6–17)
(Cycle 2: October 1–30)
30 postpartum women Review patient’s records
per cycle
(Cycle 1: July 6–17)
(Cycle 2: October 1–30)
30 postpartum women Interview with women to determine
per cycle whether she has received a struc-
(Cycle 1: July 6–17) tured education
(Cycle 2: October 1–30)

first week of July, 18 nurses and three midwives
undertook a test regarding previous education
they had received for postpartum perineal care. A
knowledge survey on perineal pain management,
including a 23-item questionnaire, was developed
by team members to assist in understanding wom-
en’s knowledge related to perineal pain manage-
ment. The knowledge questionnaire was based on
the 23 knowledge points that must be mastered by
the six standard design. The answer for each item
was true or false, with a correct answer scoring 1,
and 0 for an incorrect answer, with a total score out
of 23. In addition to the criteria for the clinical audit,
a separate questionnaire was conducted to ascertain
the nurses’ and midwives’ level of knowledge.
Midwife/nurse training was held in the second week
of July. Thirty postnatal women were tested regard-
ing the education they had received from healthcare
staff for perineal care. All data were collected by two
teams from July 1 to July 17, 2015.
Phase 2: Design and implementation of
strategies to improve practice (getting research
into practice)
The implementation period was conducted over
10 weeks from July 20 to September 27, 2015.
Based on the analysis of the pre-implementation
audit results, the project team discussed the barriers
of implementation for each criterion and ways
to resolve them, and searched for available
resources to assist in overcoming the barriers. The
results for GRiP are reported in Phase 2 of the
results section.
Phase 3: Follow-up audit post implementation
of change strategy
The post implementation audit used the same evi-
dence-based audit criteria as in the baseline audit
and was conducted from September 28 to October
30, 2015. Data collection was performed by the
same two teams as in the baseline audit.

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 168

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT Y. Zhang et al.

Figure 1: Compliance with best practice audit criteria in baseline audit (%)

Results demonstrated that the pain decreased with each day

Phase 1: Baseline audit
The results of the baseline audit (Figure 1) indicated
that staff receiving education regarding perineal care
was low, with an average compliance rate of 24%.
Women’s knowledge regarding perineal care was the
highest, at 30%. Related implemented ice packs
and analgesia were 17% and 13%, respectively.
Education regarding perineal massage technique in
late pregnancy and daily perineal pain assessment
were lowest, 3% and 0%, respectively. The fre-
quency of each criterion is recorded in Table 2,
and compliance rates shown in Figure 1.
Regarding knowledge questionnaire of nurse,
staff knowledge of perineal pain management, the
average score was 10.4 (total score out of 23), with a
correct rate of 45.2%. In relation to the assessment
of perineal pain, out of a sample of 30 women,
13 women had mild pain, while the remaining
17 experienced moderate pain. No severe pain
was reported. The average pain score for the first
three days were 3.76, 2.53 and 2.03, which
following birth. Moderate pain rate was recorded
among 56.6% of women. The average pain score
was 2.78 points following three days after birth. This
was recorded in the following Tables 3 and 4.
Phase 2: Strategies for getting research into
practice
The project team identified five barriers to compli-
ance with best practice, and strategies for addressing
these barriers were implemented. This is also sum-
marized in Table 5.
Barrier 1: Nurse/midwives lacked the knowledge
and skills regarding prevention and management
of perineal pain.
Strategies:
 Staff education materials and group training
regarding prevention and care of perineal pain
were developed, and three education sessions
regarding prevention and care of perineal pain
were delivered to the staff.

Table 2: Results of the six criteria in baseline cycle

Frequency
Criteria Y N Total
1. Nursing staff received education regarding patient education for perineal 5 16 21
care
2. Pregnant women received education regarding antenatal perineal 1 29 30
massage technique
3. Ice packs are implemented in the first 24–72 h after childbirth 5 25 30
4. Daily perineal pain assessment/observation is conducted for three days 0 30 30
after childbirth
5. Analgesia was administered for perineal pain 4 26 30
6. Women received education about postnatal perineal care 9 21 30

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 169

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT Y. Zhang et al.

Table 3: Perineal pain assessment regarding the prevention and care to reduce perineal pain.
degree of pain in baseline and follow-up cycle Postpartum women were then invited to demon-
strate this new knowledge and skills for the staff
Perineal pain degree member to ensure that they had understood. A
patient information leaflet was developed to
Total Mild Moderate Severe assist women with self-monitoring and care
Baseline cycle 30 13 17 0 on discharge.
(43.3%) (56.6%) (0%) Resources:
Follow-up 30 26 4 0  Three leaflets were developed regarding the
cycle (86.7%) (13.3%) (0%) effect of perineal pain, how to alleviate perineal
pain, and self-care management. These leaflets
were provided to all nursing staff which were
then distributed to the women.
Resources: Outcomes:
 Multimedia courseware about management of  Women’s perineal pain knowledge increased
perineal pain among postpartum women was from 27% to 100% prior to discharge. All preg-
developed and provided to all midwifery/ nant women at this hospital and all postpartum
nursing staff. women at our wards had the opportunity to
 Written materials (a 10-page booklet including attend this clinic during their pregnancy.
the effect of perineal pain and how to alleviate
perineal pain) were provided to all nursing staff. Barrier 3: Nursing staff perceived an increase in
 Three training sessions were conducted. Each workload when providing women with prevention
training in a special meeting room for one hour. strategies, and management of perineal pain.
Outcomes: Strategies:
 All staff (nurses and midwives) attended the  Every criterion was integrated into clinical
training and were provided with information nursing practice, and all staff were required to
regarding the management of perineal pain implement them, with an aim of optimizing
among postpartum women. workflow regarding prevention and care of
 At the conclusion of the education program, a perineal pain.
written exam (with 23 items) about education, Resources:
knowledge and skills was undertaken by all staff,  Three leaflets were developed regarding the effect
with an average correct rate from 45.2% ascend of perineal pain, how to alleviate perineal pain,
to 97%. and self-care management. These leaflets were
provided to all nursing staff.
Barrier 2: Women lacked knowledge and therefore  Two extra nursing staff were allocated to
motivation regarding prevention and care of the maternity ward by the director of the
perineal pain. nursing department, to assist with this process.
Strategies: Documentation was simplified through the
 Following the staff education session, nursing use of a table format, making data entry a
staff educated women about the importance of simpler process.

Table 4: Perineal pain assessment score in baseline and follow-up cycle

Total perineal pain score Average perineal pain score

First day Second day Third day First day Second day Third day 3 days
Baseline cycle 113 76 61 3.76 2.53 2.03 2.78
Follow-up cycle 90 63 43 3.00 2.10 1.43 2.18

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 170

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT
Table 5: GRiP matrix
Barrier
Nurses and midwives
lacked the knowledge and
skills regarding preven-
tion and care of perineal
pain
Women lacked motiv-
ation and skills for pre-
vention and care of
perineal pain
Increased workload of
nurses for providing pre-
vention and care of peri-
neal pain to women
Lack of effective tools to
evaluate and optimize
workflow of prevention
and care of perineal pain
Antenatal perineal mas-
sage, due to the
traditional culture, is not
commonly practiced or
accepted, as many women
were uncomfortable with
performing perineal mas-
sage
Outcomes:
 Nurses were able to complete the perineal pain
assessment procedures, following all items of the
worksheet (Appendix I).
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Strategy Resources
One team training. Multimedia material.
To provide three edu- One 10-page written
cation sessions regarding materials (effect of
prevention and care of perineal pain, how to
perineal pain. alleviate perineal pain).
Training session.
The trained nurses and Three types of leaflets
midwives gave patient (effect of perineal pain,
education about the how to alleviate peri-
importance of prevention neal pain).
and care of perineal pain. All trained nurses.
Skills of prevention and
care of perineal pain have
been demonstrated.
Optimize workflow of Three types of leaflets
prevention and care of (effect of perineal pain,
perineal pain. how to alleviate peri-
Provide leaflets to help neal pain and self-
nurses to implement pre- care).
vention and care of peri- Two extra nursing
neal pain. staff were added to the
ward by the Director
of Nursing.
All documents were in
a table format, making
data entry a simpler
process.
Design simple and feas- - Leaflets
ible method for the evalu- - Training session
ation of perineal pain. - Perineal pain scale
Staff training on the use
of perineal pain scale.
Highlight importance of - Practice demon-
antenatal perineal mas- stration
sage through education - Leaflets
for pregnant women by - All trained midwives
the midwives.
Barrier 4: Lack of effective tools to evaluate and
optimize workflow of prevention and care of
perineal pain.
ß 2017 THE JOANNA BRIGGS INSTITUTE
Y. Zhang et al.
Outcomes
All nurses attended the
training and were pro-
vided with leaflets.
The correct rate of
trained nurse was 97%
in test after training.
Women’s perineal pain
knowledge increased
from 26.7 to 100%
prior to discharge.
Nurses completed peri-
neal pain assessment
procedures following
all items of worksheet.
Updated an operation
preparation checklist.
Developed a pain
assessment and man-
agement chart.
The rate of acceptance
among pregnant
women regarding ante-
natal perineal massage
was approximately
50% with included
women.
171
IMPLEMENTATION REPORT
Strategies:
 A simple and feasible method for evaluating
perineal pain using the numerical rating scale
(NRS) was designed, and staff training on the
use of the perineal pain scale was provided.
Resources:
 Leaflets were developed and made available to
all nursing staff, and three training sessions
were conducted.
 A perineal pain scale (Appendix II) was accessible
to all nursing staff on their employee’s card,
therefore ensuring it was very easy to use.
Outcomes:
 Updated operation preparation checklist.
 Development of a pain assessment and manage-
ment chart.
Barrier 5: Antenatal perineal massage, due to the
traditional culture, is not commonly practiced or
accepted as many people are uncomfortable with
performing perineal massage.
Strategies:
 Through education provided to pregnant women
by the midwives, the importance of antenatal
perineal massage was highlighted.
Resources:
 Midwifery staff provided women with infor-
mation and a perineal massage demonstration,
using a model and a patient leaflet.
 They then asked the pregnant women regarding
their knowledge, to test the women’s skill level.
 Leaflets were distributed in many locations, such
as outside the entrance to the ward area, in the
midwifery clinic, and in the nurse’s work station.
 This involved all trained midwives at the mid-
wifery clinics. All pregnant women have the
opportunity to attend this clinic during their
pregnancy.
Outcomes:
 The rate of acceptance among pregnant
women regarding antenatal perineal massage
was approximately 50% of the included women.
Phase 3: Follow-up audit
In the follow-up audit cycle, there were improve-
ments in compliance for each audit criterion; 100%
compliance for criteria 1, 2, 4 and 6; 80% for
criterion 3, and 40% for criterion 5. Compliance
rates clearly improved when compared with the
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Y. Zhang et al.
first audit cycle. The frequency of each criterion
for the follow-up audit is recorded in Table 6, and
compliance rates in Figure 2.
In the follow-up audit cycle, the average score
of staff knowledge regarding perineal pain manage-
ment was 22.3 (total score out of 23), with correct
answers reaching 97%. Among the 30 postpartum
women, 26 women had mild pain, and 4 of them
experienced moderate pain. No severe pain was
reported by the women. The average pain score over
the first three days was 3.00, 2.10 and 1.43. A
reduction in daily pain scores was reported in the
follow-up cycle when compared with the baseline,
and moderate pain was also significantly lower than
in the baseline cycle. Moderate pain was experienced
by 13.3% of women, with an average pain score
of 2.18 points in the three days following childbirth.
This is reported in Tables 3 and 4.
Discussion
The current implementation project achieved an
improvement in compliance with best practice in
the prevention of perineal pain among postpartum
women. All criteria compliance rates significantly
improved in the follow-up audit cycle, ranging from
27% to 100% compared with the baseline cycle.
Many factors contributed to this improvement.
Support from the hospital administrator, supervision
of the head nurse, education for both nursing staff
and women, and reorganization of nursing care
routines were all facilitators. This audit project
provided nurses with a systematic method to imple-
ment evidence in clinical practice. Educational
approaches for both postpartum women and nursing
staff were promoted through this project.
With criterion 1, the staff education compliance
rates increased by 76% (from 24% to 100%).
During the baseline period, only four nurses
and one midwife had received education regarding
perineal care. Therefore, team training and follow-
up education were provided for all nurses to partici-
pate in three training sessions. Each nurse received at
least two regular training sessions. After the training,
all nurses were assessed, with an average score of
97%. This implementation project highlighted
that by providing education, which in turn improved
the nursing skills, postpartum perineal pain was
reduced, with the pain score decreasing by 21.6%
(from 2.78% to 2.18%).
ß 2017 THE JOANNA BRIGGS INSTITUTE 172
IMPLEMENTATION REPORT Y. Zhang et al.

Table 6: Results of the six criteria in follow-up cycle

Frequency
Criteria Y N Total
1. Nursing staff received education regarding patient education for perineal care 21 0 21
2. Pregnant women received education regarding antenatal perineal massage 30 0 30
technique
3. Ice packs are implemented in the first 24–72 h after childbirth 24 6 30
4. Daily perineal pain assessment is conducted for three days after childbirth 30 0 30
5. Analgesia was administered for perineal pain 12 18 30
6. Women received education about postnatal perineal care 30 0 30

The compliance rate for receiving education
regarding perineal massage technique increased
by 97% (from 3% to 100%). Many women
interviewed in the baseline audit knew some of
the benefits of perineal massage, without any other
knowledge or skills. Therefore, in the follow-up
audit cycle, midwives carried out face-to-face
education with outpatient pregnant women, distrib-
uting leaflets and using model technology demon-
strations. Weekly text messages were sent to remind
pregnant women, encouraging them to conduct
perineal massage. Many women accepted education
but were not willing to implement antenatal perineal
massage, as they did not feel comfortable in
performing it. This could possibly be due to personal
privacy issues or seen as conflicting with Chinese
culture. Only 15 out of 30 women implemented
antenatal perineal massage. In the future, these
criteria should be further revised and promoted to
pregnant women to increase the acceptance of
perineal massage.
On the fourth criterion, daily perineal pain assess-
ment being conducted for three days after childbirth
showed the largest improvement, increasing by
100%. Prior to the commencement of this project,
the hospital had no pain assessment standards and
effective tools in use. The NRS was introduced and
provided improved compliance, responsiveness and
ease of use.22 Though it was time-consuming, daily
assessment was very important for perineal pain
prevention and reduction. A short and easy-to-
implement tool, and a daily worksheet were inte-
grated into the nurses’ routine care plan. Senior
nursing staff supervised the nursing staff to ensure
daily compliance with the criterion. Following staff
education, they then provided education to postpar-
tum women and distributed leaflets to women. After
several amendments, the pain assessment tool was

Figure 2: Compliance with best practice audit criteria in the follow-up cycle compared to baseline cycle (%)

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 173

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT
utilized within the hospital system and was inte-
grated into usual care.
Postpartum women and nursing staff had
knowledge of the third, fifth and sixth criteria,
so the implementation of these was easier. Criterion
3 compliance rate with use of ice packs increased
by 63% (from 17% to 80%). The reason for 20%
of non-implementation could be accounted for the
fact that some women did not require an ice pack due
to low levels of pain experienced. Criterion 5 focused
on administered analgesia, with compliance rates
increasing by 27% (from 13% to 40%). Women
were aware that they could use analgesics, but only
12 of them required analgesics for relief of perineal
pain. The sixth criterion regarding compliance for
women’s acceptance of postnatal perineal care edu-
cation increased by 70% (from 30% to 100%).
Through the distribution of leaflets, explanation
and skill demonstration by trained nurses, this
became part of the routine education and standard
practice. Prior to discharge, postpartum women
completed a questionnaire to investigate their level
of knowledge.
Throughout the project, the most important
barrier identified was related to implementing
evidence into clinical practice, which was a new
concept for many staff. The audit team developed
a comprehensive worksheet, which contained
perineal pain assessment, education, skills support,
monitoring and documentation for each shift.
With the support of senior staff, the worksheet
was integrated into the routine puerperal nursing
care plan. The audit results have demonstrated
that the worksheet has been an effective tool
for integrating evidence into practice and also pro-
moting nurses’ compliance. However, it has also
increased staff workload, and the nursing worksheet
could possibly be simplified for subsequent audits.
Conclusion
The current implementation project has made a
significant improvement in establishing evidence-
based practice for the management of perineal pain
among postpartum women in an obstetric and gyne-
cologic hospital in Shanghai. Through this audit
project, several strategies including nurse training,
educational brochures for women, perineal pain
measurement instrument, and worksheets have been
developed to promote evidence into practice. It has
been very useful in improving nurses’ compliance
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Y. Zhang et al.
with evidence-based strategies to improve perineal
care, and the reduction of perineal pain among
postpartum women. Further auditing will be necess-
ary to continue improving clinical outcomes and
nursing quality and to ensure the sustainability of
the project.
Acknowledgements
Thank you to the Joanna Briggs Institute for organ-
izing the Evidence-Based Clinical Fellowship pro-
gram, and all the JBI staff for providing training
and facilitation.
Thank you to Dr Yifan Xue and Alexa McArthur,
Research Fellows of the Joanna Briggs Institute, for
their mentoring support.
Thank you to Professor Yan Hu, the Dean of the
School of Nursing, Fudan University, for her support
with the project and the fellowship program.
Thank you to our Nursing Director, Yan Ding,
for providing this opportunity and policy support.
References
1. Beckmann MM, Stock OM. Antenatal perineal massage for
reducing perineal trauma. Cochrane Database Syst Rev
(4):2013:CD005123.
2. National Institute for Health and Care Excellence. Postnatal
care. NICE clinical guideline 37. 2014; Available from: gui-
dance.nice.org.uk/cg37. [Cited June 18, 2015].
3. Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal
techniques during the second stage of labour for reducing
perineal trauma. Cochrane Database Syst Rev 2011;(12):
CD006672.
4. Geranmayeh M, Rezaei Habibabadi Z, Fallahkish B, Farahani
M, Khakbazan Z, Mehran A. Reducing perineal trauma
through perineal massage with vaseline in second stage
of labor. Arch Gynecol Obstet 2012;285(1):77–81.
5. McCandlish R, Bowler U, van Asten H, Berridge G, Winter C,
Sames L, et al. A randomised controlled trial of care of the
perineum during second stage of normal labour. Br J
ObstetGynaecol 1998;105(12):1262–72.
6. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I,
et al. West Berkshire perineal management trial. BMJ
1984;298(6445):587–690.
7. Department of Health. Statistical bulletin, NHS Maternity
Statistics, England: 2001–2002 London: Department of
Health; 2003.
8. DeFrances CJ, Hall MJ. 2002 National Hospital Discharge
Survey. Adv Data 2004;(342):1–29.
9. Wagner M. Pursuing the birth machine: the search for
appropriate technology Camperdown: ACE Graphics;
1994; 165–174.
ß 2017 THE JOANNA BRIGGS INSTITUTE 174
IMPLEMENTATION REPORT
10. Graves EJ, Kozak LJ. National hospital discharge survey:
annual summary, 1996. Vital Health Stat 13 (140):1999:1–46.
11. Audit Commission. First class delivery: improving maternity
services in England and Wales London: Audit Commission
Publications; 1997.
12. Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair
of obstetric anal sphincter rupture using the overlap tech-
nique. Br J ObstetGynaecol 1999;106(4):318–23.
13. Glazener CMA, Abdalla M, Stroud P, Naji S, Templeton A,
Russell IT. Postnatal maternal morbidity: extent, causes,
prevention and treatment. Br J ObstetGynaecol 1995;
102(4): 282–7.
14. Sleep J, Grant A. Pelvic floor exercises in postnatal care. Br J
Midwifery 1987;3(4):158–64.
15. Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter
disruption during vaginal delivery. N Engl J Med 1993;
329(26):1905–11.
16. Klein MC. Does epidural analgesia increase rate of cesarean
section? Can Fam Physician 2006;52(4):419–21.
17. East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Local
cooling for relieving pain from perineal trauma sustained
during childbirth. Cochrane Database Syst Rev 2012;
(5):CD006304.
JBI Database of Systematic Reviews and Implementation Reports
©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
Y. Zhang et al.
18. Demott K, Bick D, Norman R, Ritchie G, Turnbull N, Adams
C, et al. Clinical guidelines and evidence review for
post natal care: routine post natal care of recently deliv-
ered women and their babies. National Collaborating
Centre for Primary Care and Royal College of General
Practitioners; July 2006 .
19. Quijanoer CE, Abalos E. Conservative management of symp-
tomatic and/or complicated haemorrhoids in pregnancy
and the puerperium. Cochrane Database Syst Rev 2005;
(3):CD004077.
20. Chou D, Abalos E, Gyte GM, Gülmezoglu AM. Paracetamol/
acetaminophen (single administration) for perineal pain in
the early postpartum period. Cochrane Database Syst Rev
2013;1(3):1399–400.
21. Xue Y. Evidence Summary. Management of perineal pain.
The Joanna Briggs Institute Database of EBP. JBI@Ovid
2015:JBI12960.
22. Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW,
Loge JH, et al. European Palliative Care Research Collaborative
(EPCRC). Studies comparing Numerical Rating Scales, Verbal
Rating Scales, and Visual Analogue Scales for assessment of
pain intensity in adults: a systematic literature review. J Pain
Symptom Manage 2011; 41(6):1073–93.
ß 2017 THE JOANNA BRIGGS INSTITUTE 175
IMPLEMENTATION REPORT Y. Zhang et al.

Appendix I: Perineal care management work sheet

Day Assessment Education Skills support Method used Result

Day 1 Perineal pain degree: & Ice packs are & Ice packs are imple- &Ice packs
Mild & implemented mented &Analgesia
Moderate & &pain assessment &Pain assessment &Perineal
Severe & &Analgesia was &Postnatal perineal Care
Perineal pain score administered care
&postnatal perineal
care
Day 2 Perineal pain degree: &Ice packs are & Ice packs are imple- &Ice packs
Mild & implemented mented &Analgesia
Moderate & &pain assessment &pain assessment &Perineal
Severe & &Analgesia was &postnatal perineal Care
Perineal pain score administered care
&postnatal perineal
care
Day 3 Perineal pain degree: &Ice packs are & Ice packs are imple- &Ice packs &Collect
Mild & implemented mented &Analgesia patient
Moderate & &Pain assessment &Pain assessment &Perineal information
Severe & &Analgesia was &Postnatal perineal Care
Perineal pain score administered care
&Postnatal perineal
care

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 176

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.

IMPLEMENTATION REPORT Y. Zhang et al.

Appendix II: Perineal pain instrument

JBI Database of Systematic Reviews and Implementation Reports ß 2017 THE JOANNA BRIGGS INSTITUTE 177

©2017 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.