Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy

doi:10.1016/S0002-9378(99)70260-7

American Journal of Obstetrics and Gynecology

Volume 180, Issue 3, March 1999, Pages 593-600

https://doi.org/10.1016/S0002-9378(99)70260-7 Get rights and content

Abstract

Objective: The aim of the study was to evaluate the effectiveness of perineal massage during pregnancy for the prevention of perineal trauma at birth. Study Design: Pregnant women with (n = 493) and without (n = 1034) a previous vaginal birth from 5 hospitals in the province of Québec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental groups were requested to perform a 10-minute perineal massage daily from the 34th or 35th week of pregnancy until delivery. Results: Among participants without a previous vaginal birth, 24.3% (100/411) from the perineal massage group and 15.1% (63/417) from the control group were delivered vaginally with an intact perineum, for a 9.2% absolute difference (95% confidence interval 3.8%-14.6%). The incidence of delivery with an intact perineum increased with compliance with regular practice of perineal massage (χ² for trend 13.2, P = 0.0003). Among women with a previous vaginal birth, 34.9% (82/235) and 32.4% (78/241) in the massage and control groups, respectively, were delivered with an intact perineum, for an absolute difference of 2.5% (95% confidence interval –6.0% to 11.0%). There were no differences between the groups in the frequency of sutured vulvar and vaginal tears, women’s sense of control, and satisfaction with the delivery experience. Conclusion: Perineal massage is an effective approach to increasing the chance of delivery with an intact perineum for women with a first vaginal delivery but not for women with a previous vaginal birth. (Am J Obstet Gynecol 1999;180:593-600.)

Section snippets

Participants

The study sample consisted of pregnant women being delivered in 5 teaching hospitals in the province of Québec, Canada. The study was approved by the research ethics committees at all participating centers. From September 1994 through December 1995, 3304 women with and 3597 women without a previous vaginal birth were approached to participate at prenatal visits or at third-trimester ultrasonographic or blood testing (Fig 1).

. Perineal massage trial profile.

Women were excluded for the following

Results

A total of 1034 women without a previous vaginal birth and 493 with ≥1 previous vaginal birth were randomly assigned. Five were unavailable for follow-up (Fig 1). Baseline characteristics of women were similar in the experimental and control groups (Table I).

. Baseline characteristics of women according to study group

Characteristics	Women without previous vaginal birth		Women with previous vaginal birth
Characteristics	Massage (n = 519)	Control (n = 515)	Massage (n = 246)	Control (n = 247)
Age (y, mean ± SD)	28.0 ± 4.9

Comment

Our study showed that perineal massage is effective in increasing the likelihood that women having their first vaginal birth will be delivered with an intact perineum. Furthermore, we observed a dose-response effect; increasingly regular practice of perineal massage was associated with an increasing likelihood of maintaining an intact perineum. The effect of perineal massage is explained mainly by a reduction in sutured first-degree tears and episiotomy. Although most of the postpartum

Acknowledgements

We thank the nurse coordinators at the participating centers for their invaluable contributions: Marie-Thèrese Trudel (Hôpital du Saint-Sacrement, and Pavillon Saint-François d’Assise, Centre Hospitalier Universitaire de Québec, Québec City); Jacinthe Vanier, Francine Pinsonneault, and Johanne Raymond (Centre Hospitalier Pierre-Boucher, Longueuil); Linda Poirier (Royal Victoria Hospital, Montréal); and Pauline Barette (Sir Mortimer Davis Jewish General Hospital, Montréal). We are also indebted

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Cited by (81)

The prevention of perineal trauma during vaginal birth
2024, American Journal of Obstetrics and Gynecology
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity.
Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged.
Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review
2023, Journal of Gynecology Obstetrics and Human Reproduction
Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries.
The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI).
PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze.
Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures.
APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained.
APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.
The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis
2023, European Journal of Obstetrics and Gynecology and Reproductive Biology
To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients.
A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials.
Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I² = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I² = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention.
The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.
Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial
2017, Midwifery
Citation Excerpt :
Primiparous women have the highest rate of perineal trauma and previous research has demonstrated that perineal massage is effective in these women (Gorbea Chavez et al., 2004; Morkved et al., 2003; Hughes et al., 2001). Previous studies have demonstrated that perineal massage (Shipman et al., 1991; Labrecque et al., 1999) and pelvic floor exercises (Dumoulin et al., 2004; Reilly et al., 2002; Shipman et al., 1997) are beneficial for perineum but the combination of both has not been tried. A structured training programme for the pelvic floor muscles is associated with fewer women pushing in the second stage of labour for longer than 60 minutes (Du et al., 2015; Salvesen and Morkved, 2004).
perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida.
the aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma.
a single-blind quasi-randomized controlled trial with two groups: standard care and intervention.
a tertiary, metropolitan hospital in Seville, Spain.
women (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives.
outcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001).
a training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma.
the pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only.
the programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma.
Randomised controlled trial using smartphone website vs leaflet to support antenatal perineal massage practice for pregnant women
2016, Women and Birth
In Japan, the rate of pregnant women who practice antenatal perineal massage was only 15.1%.
The aim of this study was to develop and evaluate a smartphone website and a leaflet to support antenatal perineal massage practice for primiparous women.
In a randomised control trial, 161 primiparous women were randomly assigned to a smartphone website group (n = 81) or a leaflet group (n = 80). Data analysis were by per protocol analysis and intention to treat analysis.
Of the 161 women participants, 47 in the smartphone website group and 49 in the leaflet group completed all questionnaires. Primary outcome was continuance rate (three times a week over a three week period) of antenatal perineal massage practice. The rates by a per protocol analysis were 51.1% in the smartphone website group and 51.0% in the leaflet group, respectively. There was no significant difference between the groups. Moreover, the rates by an intention to treat analysis were 29.6% in the smartphone website group and 31.3% in the leaflet group, respectively. There was also no significant difference between the groups.
There were no significant differences in the evaluation of perineal massage, childbirth self-efficacy, satisfaction with efforts towards childbirth, and perineal outcomes following childbirth which were measured as secondary outcomes between the groups.
There was no significant difference in continuance rate of antenatal perineal massage practice between those using a smartphone website and those with a leaflet, however, the rate was better than no instructions.
Effect of perineal massage on the rate of episiotomy and perineal tearing
2015, International Journal of Gynecology and Obstetrics
Citation Excerpt :
The necessary sample size was calculated by power analysis. Previous studies indicate that the rate of intact perinea can be increased by 10% by applying prenatal perineal massage [3,18]. In 2009, the frequency of episiotomy procedures at Sivas State Hospital was 63% among all pregnant women and 99% among primiparous women.
To examine the effects of perineal massage during active labor on the frequency of episiotomy and perineal tearing.
A randomized controlled study was conducted at a center in Sivas, Turkey, between January 1, 2010, and May 31, 2011. Healthy pregnant women presenting for their first or second delivery at 37–42 weeks of pregnancy were enrolled during the first stage of labor. Participants were randomly assigned (1:1) to the massage group (10-minute perineal massage with glycerol four times during the first stage and once during the second stage of labor) or control group (routine care). The frequency of episiotomy and perineal tearing were compared between the groups. Participants and investigators were not masked to group assignment.
Both groups contained 142 participants. Episiotomy was performed among 44 (31.0%) women in the massage group and 99 (69.7%) in the control group (P = 0.001). Lacerations were recorded among 13 (4.2%) women in the massage group and 6 (4.2%) in the control group (P = 0.096).
Application of perineal massage during active labor decreased the frequency of episiotomy procedures.
ClinicalTrials.gov: NCT02201615

View all citing articles on Scopus

^☆: Supported by grants from the Medical Research Council of Canada and the Fonds de Recherche en Santé du Québec and conducted in Québec City, Montréal, and Longueuil, Québec, Canada. Dr Labrecque holds a Research Fellowship from the Medical Research Council of Canada. Dr Marcoux holds a National Health Research Scholarship from Health Canada. Rougier Inc provided massage oil and Wyeth-Ayerst Canada Inc supported investigator workshops.

^☆☆: Reprint requests: Michel Labrecque, MD, 1296 rue Green, Sainte-Foy, Québec, Canada G1W 3M3.

^★: 0002-9378/99 $8.00 + 0 6/1/95481

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Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy☆,☆☆,★

Abstract

Section snippets

Participants

Results

Comment

Acknowledgements

J Nurse Midwifery

J Nurse Midwifery

J Nurse Midwifery

Am J Obstet Gynecol

J Nurse Midwifery

J Nurse Midwifery

Is routine episiotomy necessary?

BMJ

West Berkshire perineal management trial

BMJ

West Berkshire perineal management trial: three-year follow-up

BMJ

Routine vs selective episiotomy: a randomised controlled trial

Lancet

Episiotomy, elective or selective: a report of a random allocation trial

J Obstet Gynecol