Perineal Massage To Prevent Perineal Trauma During Pregnancy

Journal of Family Practice, July, 1999 by Sarah Sa'adah

Labrecque M, Eason E, Marcoux S, et al. Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. Am J Obstet Gynecol 1999; 180:593-600.

Clinical question Can perineal massage during pregnancy prevent perineal trauma at birth?

Background There is clear evidence supporting the restrictive use of episiotomy to minimize perineal trauma during delivery, but data documenting the benefits of other interventions are sparse.[1] Perineal massage during pregnancy has been advocated to increase elasticity and reduce the risk of perineal trauma from episiotomy or spontaneous tears.

Population studied Participants included a total of 1527 pregnant women who had a previous vaginal delivery (n = 493) and who had not (n = 1034) from 5 hospitals in Quebec, Canada. Women at high risk of cesarean delivery were excluded.

Study design and validity This was a randomized single-blind controlled study of 10 minutes of perineal massage dally beginning in the 34th or 35th week of pregnancy compared with usual obstetric care. The study was well designed and had adequate power to detect significant differences in outcomes. Randomization was stratified by history of previous vaginal birth, specialty of attending physician, and hospital. Physicians were encouraged to limit use of episiotomies. All participants were provided with information on episiotomies and perineal trauma, and the study nurse also taught women in the experimental group perineal massage. This massage consisted of introducing 1 or 2 fingers 3 to 4 cm deep into the vagina and applying and maintaining pressure, first downward for 2 minutes and then for 2 minutes to each side of the vaginal entrance. Women were given a bottle of sweet almond oil to use for lubrication.

Participants in the massage group were instructed to keep dally diaries recording whether massage was done, and a postpartum questionnaire was given to determine the frequency of massage. The 2 instruments were used to calculate the degree of compliance. Using a standardized form, physicians provided information on the state of the perineum immediately after the delivery. All participants completed a postpartum questionnaire assessing their experience with perineal massage, feelings of control, and satisfaction with the delivery. Analysis was by intention to treat.

Outcomes measured The primary outcome measure was delivery with an intact perineum (no laceration or unsutured first-degree tear). Secondary outcomes were rate of episiotomy and severity of perineal tears. Additional outcomes included satisfaction with the delivery experience and sense of control.

Results Among women without a previous vaginal birth, 24.3% from the perineal massage group and 15.1% from the control group were delivered vaginally with an intact perineum, for an absolute difference of 9.2% (95% confidence interval, 3.8%-14.6%; P = .001; number needed to treat = 11). There was no difference in this group in the proportion of deliveries with episiotomy, and there was no significant difference in the number of third- and fourth-degree perineal lacerations. The incidence of delivery with an intact perineum increased with greater frequency of massage for women without a previous vaginal birth. There was no statistically significant difference between treatment and control groups in the proportion of women with previous vaginal delivery who had intact perineums. No difference was found between groups in the risk of sutured tears, satisfaction with the birth experience, or sense of control. Women who practiced third trimester perineal massage found this to be a highly acceptable practice, and more than 85% said they would recommend perineal massage to another pregnant woman.

Recommendations for clinical practice This large study provides data suggesting that the practice of third trimester perineal massage can increase the likelihood that women without a previous vaginal birth will deliver with an intact perineum. Unfortunately, there was no clinically significant reduction in the episiotomy rate or the incidence of third- and fourth-degree tears, which account for most of the morbidity associated with perineal birth trauma. Although most studies have lacked the power to demonstrate the efficacy of this technique, another large trial[2] has also demonstrated beneficial effects of perineal massage in nulliparous women, after controlling for birth weight and maternal age. On the basis of the available data, pregnant women without a previous vaginal delivery should be offered information about the potential benefits of third trimester perineal massage.

REFERENCES

[1.] Renfrew MJ, Hannah W, Albers L, Floyd E. Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature. Birth 1998; 25:143-60.

[2.] Shipman MK, Boniface DR, Tefft ME, McCloghry F. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. Br J Obstet Gynaecol 1997; 104:787-91.