Insight

Rethinking OASI Care Bundles for Inclusivity

Despite sustained clinical research, Obstetric anal sphincter injuries (OASI) remain among the most serious complications of vaginal birth. For many women and birthing people, the consequences extend far beyond the delivery room, with many experiencing long-term issues like faecal incontinence and chronic perineal pain.

As a result, the OASI care bundle has become a crucial element of perineal trauma prevention and management in the UK. Through the standardisation of key elements of care, maternity teams have been somewhat able to reduce the rates of severe perineal trauma and improve recognition and repair.

However, as discussed in a recent article in the British Journal of Midwifery, it may be time to further optimise the bundle. The OASI care bundle has improved outcomes overall, but it raises an important question: are those improvements being experienced equally across all patient groups?

Examining OASI through the lens of inclusive maternity care, it becomes clear that implementation matters just as much as evidence. An intervention can be effective overall and yet still fail women and birthing people who face language barriers, cultural stigma or structural disadvantage.

What the OASI care bundle gets right

The OASI care bundle, developed by the Royal College of Obstetricians and Gynaecologists and partners, provides an evidence‑based framework for OASI prevention and early recognition. While local variations exist, they typically bring together risk assessment, perineal protection techniques, guidance on mediolateral episiotomy, systematic post‑birth examination and stronger documentation, training and audit.

Observed together, these components have reduced unwarranted variation and given teams a shared standard of care. Not to mention, the bundles as a whole have helped to raise greater awareness of OASI among midwives, obstetricians and trainees, and contributed to better detection and timely repair.

Now we must consider how we need to evolve the bundle to ensure every woman and birthing person has an equal opportunity to benefit from it, regardless of language, ethnicity or background.

Who is being missed and why?

Emerging evidence suggests that OASI does not affect all groups equally. In the UK, OASI occurs in around 3 in 100 women having a vaginal birth, rising to around 6 in 100 women having their first vaginal birth. Recent research has also identified an association between non-English preferred language and severe perineal trauma.

The article suggests that language and communication are likely central components of this picture. In busy labour wards, crucial conversations about perineal protection, controlled pushing or consent for episiotomy and rectal examination can easily be compressed into a few hurried phrases, especially when interpreter support is limited. For women and birthing people who are not fluent in English, that can mean less opportunity to ask questions, express concerns or fully understand what is happening. When communication is constrained, it becomes harder to build trust, support informed choices and apply the OASI care bundle consistently.

Cultural stigma and structural barriers also play a role. In many communities, modesty norms and taboos around bowel function, sexual health and intimate examinations can make it difficult to talk openly about perineal trauma, incontinence or pelvic floor exercises. Misinformation and myths about “natural” birth may lead some to view recommended preventive measures with suspicion, particularly if messages from professionals are inconsistent. 

At the same time, practical challenges – from transport and childcare to digital exclusion – can limit access to antenatal education and postnatal follow‑up. Without addressing these factors, the OASI care bundle risks working best for those who already feel confident, informed and well served by the system, while others remain at greater risk of missed or under‑treated injuries.

Conclusion

Taken together, these insights suggest that the next phase of OASI improvement is less about adding new elements to the care bundle and more about making sure that every element is delivered in a way that is inclusive, understandable and equitable. That includes investing in culturally sensitive, multilingual information; strengthening interpreter pathways; building health literacy into routine contacts; and looking again at how we detect OASI, so that the quality of assessment does not depend on who happens to be on shift.

Tools such as Maternity by Kimal’s ONIRY can play a valuable part in this journey. By supporting more consistent, confident detection, they offer a way to reduce variation and give every woman and birthing person the same chance of timely diagnosis and repair, wherever they give birth.

To learn more about how ONIRY can support OASI detection in your service, visit the:

ONIRY product page