Does antepartum perineal massage reduce intrapartum lacerations?

Journal of Family Practice, July, 2008 by John Dame, Jon Neher, Sarah Safranek

Evidence-based answer

Yes--to a point. Antepartum perineal massage reduces both the incidence of perineal trauma requiring suturing and the likelihood of episiotomy in women who have never given birth vaginaliy. It reduces the incidence of postpartum perineal pain in women who have given birth vaginally. Perineal massage doesn't reduce the frequency of first-or second-degree lacerations or third- and fourth-degree perineal trauma. (Strength of recommendation [SOR]: A, systematic review of randomized controlled trials [RCTs].)

Clinical commentary

Raise the subject, then let the patient decide

Perineal massage is relatively easy to describe and do, but its intimate nature can make physicians and patients alike feel uncomfortable, The benefit for primigravid women justifies asking appropriate patients at least an exploratory question or 2 during early and second-trimester visits.

A question such as, "How much do you know about the process of having a vaginal delivery?" often prompts inquiries about pain control, delivery techniques, episiotomy, and tears. These inquiries can provide an opportunity to discuss perineal massage as a safe, effective technique to reduce the chance of an episiotomy, need for suturing, and long-term postpartum pain. Letting the patient make up her own mind can give her more confidence as the big day approaches.

Timothy E. Huber, MD

Oroville, Calif

* Evidence summary

A systematic review evaluating whether antepartum perineal massage reduced perineal trauma included 3 RCTs with a total of 1941 primagravidas and 493 multigravidas. (1) Women were randomized to receive either instruction in perineal massage or no instruction.

Beginning at 34 weeks, women or their partners performed perineal massage for 4 minutes, 3 to 4 times a week, (2) or once a day for 10 minutes. (3,4) Massage was performed by inserting I or 2 fingers 3 to 5 cm into the vagina and sweeping downward and from side to side, using almond oil for lubrication.

Birth attendants were blinded to patients' assignments. All studies evaluated immediate postpartum outcomes; 1 study included a 3-month follow-up questionnaire. (3)

Massage reduces trauma, but less is more

Massage reduced perineal trauma requiring suturing by 10% among primigravid patients, compared with controls (relative risk [RR]=0.90; 95 % confidence interval [CI], 0.84-0.96; number needed to treat [NNT]=14). Subgroup analysis revealed an inverse relationship between reduced trauma and frequency of massage: Primagravidas who massaged fewer than 1.5 times a week showed a 17% reduction (RR=0.83; 95% CI, 0.75-0.92; NNT=9), compared with an 8% reduction for women who massaged 1.5 to 3.4 times a week (RR=0.92; 95% CI, 0.85-1.00; NNT=22) and a statistically insignificant 7% reduction for the group that massaged more than 3.5 times a week (RR=0.93; 95% CI, 0.86-1.02).

Perineal massage reduced the incidence of episiotomy by 15% among primigravidas compared with controls (RR=0.85; 95% CI, 0.74-0.97; NNT=20); the largest reduction occurred in primagravidas who massaged as often as 1.5 times per week (RR=0.72; 95% CI, 0.57-0.91).This effect was not seen in primagravidas who massaged more often. Multigravid patients didn't experience a statistically significant reduction in episiotomy.

Perineal massage didn't affect the overall incidence of first-and second-degree perineal lacerations (first-degree laceration: RR=0.95; 95% CI, 0.78-1.16; second-degree laceration: RR=0.98; 95% CI, 0.84-1.15), nor the incidence of third-or fourth-degree lacerations (RR=0.81; 95% CI, 0.56-1.15). No difference was noted in the incidence of instrument delivery (RR=0.94; 95% CI, 0.81-1.08).

Massage means less pain for multigravidas

Massage reduced postpartum perineal pain in multigravidas, according to a questionnaire administered at 3 months in 1 study, to which 376 of 493 women (76%) responded (RR=0.45; 95% CI, 0.02-0.87; NNT=13). (3) A subgroup of women who massaged more often than 3.5 times a week had a larger reduction in pain (RR=0.51; 95% CI, 0.33-0.79; NNT=11). At 3 months, massage produced no difference in rates of dyspareunia, sexual satisfaction, or incontinence of urine or feces when compared with standard care.

Recommendations

We found no expert or advocacy group guidelines on this topic.

FAST TRACK

Antepartum perineal massage reduces both the incidence of perineal trauma requiring suturing and the likelihood of episiotomy in primigravidas

FAST TRACK

Although perineal massage is easy to describe and do, its intimate nature may make physicians and patients alike uncomfortable

References

(1.) Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2006;(1):CD005123.

(2.) Shipman MK, Boniface DR, Tefft ME, et al. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. BJOG. 1997;104:787-791.

(3.) 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.