Prevention of perineal trauma by perineal massage during pregnancy: a pilot study

The prevention of perineal trauma during vaginal birth

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.

Knowledge, attitude and acceptability regarding antenatal perineal massage in Thai pregnant women

INTRODUCTION AND HYPOTHESIS

Antenatal perineal massage for obstetric anal sphincter injury prevention is not routinely performed in Thailand. Due to the cultural conservatism in the country, attitudes and acceptability need to be evaluated before procedure implementation. This research was conducted to evaluate knowledge, attitudes, and acceptability of antenatal perineal massage and identify associated factors for acceptability in antenatal perineal massage among Thai pregnant women.

METHODS

A cross-sectional study was conducted in the antenatal clinic at King Chulalongkorn Memorial Hospital, Bangkok, Thailand between July 2021 and June 2022. Thai women with singleton pregnancies at 22 weeks or more of gestation without an indication for cesarean section were enrolled. Knowledge, attitudes, and acceptability of antenatal perineal massage were assessed using a self-administered questionnaire. In-depth interviews with pregnant women who were not interested in antenatal perineal massage were also completed.

RESULTS

A total of 144 pregnant women were enrolled with 119 participants (83%) having an accepting attitude about antenatal perineal massage. Results on knowledge included 22 (15%) participants aware of this practice, 46 participants (31.9%) knew it should be practiced after GA 34 weeks, 52 participants (36.1%) knew the massage should be maintained for 5-10 min, and 37 participants (25.7%) knew it should be performed daily. Factors associated with acceptability of antenatal perineal massage were prior interest in perineal massage and trust in the benefit of the perineal massage in facilitating vaginal delivery. Reasons for disagreeing in antenatal perineal massage included never hearing of perineal massage, concern about pregnancy complications, fear of pain, believing it to be a useless procedure, and previous successful vaginal delivery.

CONCLUSIONS

We found high acceptability for antenatal perineal massage. This program should be routinely explained and offered to Thai pregnant women to prevent severe perineal trauma and postpartum complications.

The effect of antenatal pelvic floor muscle exercises on labour and birth outcomes: a systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The current data on the effectiveness of antenatal pelvic floor muscle exercises (PFME) on childbirth outcomes are limited. Therefore, in this study the effect of antenatal PFMEs on labour and birth outcomes was assessed by undertaking a meta-analysis.

METHODS

Databases were systematically searched from 1988 until June 2019. Randomised controlled trials (RCTs) and quasi-experimental studies were included. The methodological quality of studies was assessed using Cochrane Collaboration tools. The outcomes of interest were: duration of first and second stage of labour, episiotomy and perineal outcomes, mode of birth (spontaneous vaginal birth, instrumental birth and caesarean section) and fetal presentation. The mean difference (MD) and risk ratio RR) with the corresponding 95% confidence intervals (CIs) were calculated to assess the association between PFME and the childbirth outcomes.

RESULTS

A total of 16 articles were included (n = 2,829 women). PFME shortened the duration of the second stage of labour (MD: -20.90, 95%, CI: -31.82 to -9.97, I²: 0%, p = 0.0002) and for primigravid women (MD: -21.02, 95% CI: -32.10 to -9.94, I²: 0%, p = 0.0002). PFME also reduced severe perineal lacerations (RR 0.57, 95% CI: 0.38 to 0.84, I²: 30%, p = 0.005). No significant difference was seen in normal vaginal birth, caesarean section, instrumental birth and episiotomy rate. Most of the studies carried a moderate to high risk of bias.

CONCLUSION

Antenatal PFME may be effective at shortening the second stage of labour and reducing severe perineal trauma. These findings need to be interpreted considering the included studies' risk of bias. More high-quality RCTs are needed.

Systematic review of pelvic floor interventions during pregnancy

BACKGROUND

Pelvic floor interventions during pregnancy could reduce the impact of pregnancy and delivery on the pelvic floor.

OBJECTIVE

To determine the effects of pelvic floor interventions during pregnancy on childbirth-related and pelvic floor parameters.

SEARCH STRATEGY

PubMed, Embase, and LILACS were searched for reports published during between 1990 and 2016 in English, Spanish, or Portuguese. The search terms were "pregnancy," "pelvic floor muscle training," and related terms.

SELECTION CRITERIA

Randomized controlled trials with healthy pregnant women were included.

DATA COLLECTION AND ANALYSIS

Baseline and outcome data (childbirth-related parameters, pelvic floor symptoms) were compared for three interventions: EPI-NO (Tecsana, Munich, Germany) perineal dilator, pelvic floor muscle training, and perineal massage.

MAIN RESULTS

A total of 22 trials were included. Two of three papers assessing EPI-NO showed no benefit. The largest study investigating pelvic floor muscle training reported a significant reduction in the duration of the second stage of labor (P<0.01), and this intervention also reduced the incidence of urinary incontinence (evaluated in 10 trials). Two of six trials investigating perineal massage reported that a lower rate of perineal pain was associated with this intervention.

CONCLUSION

Pelvic floor muscle training and perineal massage improved childbirth-related parameters and pelvic floor symptoms, whereas EPI-NO showed no benefit.

Antenatal perineal massage for reducing perineal trauma

BACKGROUND

Perineal trauma following vaginal birth can be associated with significant short-term and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma.

OBJECTIVES

To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012), EMBASE (1980 to October 2012) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating any described method of antenatal digital perineal massage undertaken for at least the last four weeks of pregnancy.

DATA COLLECTION AND ANALYSIS

Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information.

MAIN RESULTS

We included four trials (2497 women) comparing digital perineal massage with control. All were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)) and women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only. No differences were seen in the incidence of first- or second-degree perineal tears or third-/fourth-degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage.

AUTHORS' CONCLUSIONS

Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.

Textbook Recommendations for Preventing and Treating Perineal Injury at Vaginal Delivery

OBJECTIVE

To assess general obstetrics textbooks regarding the quality and quantity of information about perineal injury at vaginal delivery.

METHODS

An obstetrics and gynecology resident, a perinatologist, and a urogynecologist evaluated 7 obstetrics textbooks by using a standardized abstraction form that delineated descriptions of anatomy and physiology, episiotomy use, and perineal trauma prevention and repair.

RESULTS

Two textbooks briefly described anal sphincter anatomy, but none provided a detailed discussion of the relative contribution of anatomic components to continence. Four textbooks discussed the evidence for and against midline or mediolateral episiotomy, and 6 advised against routine episiotomy. Six textbooks described grading lacerations, but only one described detailed repair techniques for all grades. Two textbooks discussed techniques to reduce perineal trauma at the time of delivery. Only one textbook discussed the need to reapproximate the normal anal sphincter anatomy during perineal repair.

CONCLUSION

Although most textbooks accurately reflect current literature regarding routine episiotomy, there is limited discussion of advantages and disadvantages of various types of episiotomy and little offered regarding prevention and repair of perineal trauma at delivery.

LEVEL OF EVIDENCE

III.

Antenatal perineal massage for reducing perineal trauma

BACKGROUND

Perineal trauma following vaginal birth can be associated with significant short- and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma.

OBJECTIVES

To assess the effect of antenatal perineal massage on the incidence of perineal trauma at birth and subsequent morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2005), PubMed (1966 to January 2005), EMBASE (1980 to January 2005) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials evaluating any described method of antenatal perineal massage undertaken for at least the last four weeks of pregnancy.

DATA COLLECTION AND ANALYSIS

Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information.

MAIN RESULTS

Three trials (2434 women) comparing digital perineal massage with control were included. All were of good quality. Antenatal perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (three trials, 2417 women, relative risk (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat (NNT) 16 (10 to 39)). This reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.90 (95% CI 0.84 to 0.96), NNT 14 (9 to 35)). Women who practised perineal massage were less likely to have an episiotomy (three trials, 2417 women, RR 0.85 (95% CI 0.75 to 0.97), NNT 23 (13 to 111)). Again this reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.85 (95% CI 0.74 to 0.97), NNT 20 (11 to 110)). No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.68 (95% CI 0.50 to 0.91) NNT 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage.

AUTHORS' CONCLUSIONS

Antenatal perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.

Women's views on the practice of prenatal perineal massage

OBJECTIVE

To determine how women who practised perineal massage during pregnancy assessed the technique.

DESIGN

Observational study within one arm of a randomised controlled trial.

SETTING

Five secondary and tertiary care hospitals in the Province of Quebec, Canada.

PARTICIPANTS

Among 763 women randomised to the massage arm of a clinical trial of perineal massage during pregnancy, 684 (90%) who completed a questionnaire after delivery.

MAIN OUTCOME MEASURES

A 20-item questionnaire completed a few days after birth. The first 18 questions elicited opinions using a 6-point Likert scale. Based on a factor analysis, 17 of these questions were classified into four categories: acceptability of perineal massage (8 items); preparation for birth (4 items); relationship with the partner (2 items); and effect of massage on delivery (3 items). Scores of each scale varied between 1 (highly negative assessment) to 6 (highly positive assessment). The last two questions asked whether women would perform the massage in their next pregnancy and whether they would recommend perineal massage to another pregnant woman. In addition, 262 also provided comments about their experience in the daily diary provided to record compliance during the trial.

RESULTS

On average, perineal massage was felt to be quite acceptable [mean (standard deviation) 4.09 (0.93)]. Pain and technical problems reported during the first week or two of massage tended to disappear after a few weeks. Women's assessment of the effect of massage on preparation for birth [4.34 (1.08)] and on delivery [4.18 (1.37)] was positive. Women's views about the effect on their relationship with their partner were either positive or negative [3.54 (1.74)] and were proportional to the partner's participation with the massage. Most women said they would massage again if they were to have another pregnancy (79%; 95% CI, 76%-82%) and would recommend it to another pregnant woman (87%; 95% CI 84%-90%).

CONCLUSION

Overall, women's assessment of prenatal perineal massage is positive.

Prenatal perineal massage: preventing lacerations during delivery

OBJECTIVE

To investigate the associations between perineal lacerations and 13 variables associated with the incidence of perineal lacerations. Of particular interest was the variable of prenatal preparation of the perineum.

DESIGN

This retrospective descriptive study used a convenience sample of 368 women whose delivery was attended by at least one of two midwives practicing in the Northwest between 1979 and 1995.

SETTING AND PARTICIPANTS

All births in the study occurred in a home-based midwifery practice in the Northwest. The sample was primarily white and included 307 multiparous and 61 primiparous women.

MAIN OUTCOME MEASURES

The initial chi squares indicated that five of the 13 factors investigated were significantly associated with the degree of laceration: parity, maternal age, maternal position at delivery, length of second stage of labor, and prenatal perineal massage. However, further analyses showed that when parity was controlled, the only factors independently associated with the seriousness of lacerations were parity and prenatal perineal massage.

CONCLUSION

This study supports the conclusion that teaching perineal massage to primiparous women and multiparae who had episiotomies with their previous births is a useful intervention. It suggests that further study may help clarify the optimum frequency, timing, and technique of massage.

Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery

OBJECTIVE

The aim of this study was to evaluate the effect of perineal massage performed during pregnancy on perineal symptoms 3 months after delivery.

STUDY DESIGN

Pregnant women from 5 hospitals in the province of Quebec, 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 group were taught the perineal massage technique and were asked to perform a 10-minute perineal massage daily from the 34th through 35th weeks of pregnancy until delivery. Participants completed a self-administered questionnaire on perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, flatus, and stool at the time of enrollment and 3 months after delivery.

RESULTS

Among participants without a previous vaginal birth there were no differences between the massage (n = 283) and the control (n = 289) groups with respect to perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, gas, or stool 3 months post partum. Among women with a previous vaginal birth more women in the massage group (n = 187) than in the control group (n = 190) were free of perineal pain (93.6% vs 85.8%; P =.01) but the frequencies of dyspareunia and incontinence of urine, gas, or stool were similar in the 2 groups.

CONCLUSIONS

Perineal massage during pregnancy neither impairs nor substantially protects perineal function at 3 months post partum.

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

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 (chi2 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.

Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial

OBJECTIVE

To study the effects of antenatal perineal massage on subsequent perineal outcomes at delivery.

DESIGN

A randomised, single-blind prospective study.

SETTING

Department of Obstetrics and Gynaecology, Watford General Hospital.

PARTICIPANTS

Eight hundred and sixty-one nulliparous women with singleton pregnancy and fulfilling criteria for entry to the trial between June 1994 and October 1995.

RESULTS

Comparison of the group assigned to massage with the group assigned to no massage showed a reduction of 6.1% in second or third degree tears or episiotomies. This corresponded to tear rates of 75.1% in the no-massage group and 69.0% in the massage group (P = 0.073). There was a corresponding reduction in instrumental deliveries from 40.9% to 34.6% (P = 0.094). After adjustment for mother's age and infant's birthweight these reductions achieved statistical significance (P = 0.024 and P = 0.034, respectively). Analysis by mother's age showed a much larger benefit due to massage in those aged 30 and over and a smaller benefit in those under 30.

CONCLUSION

Antenatal perineal massage appears to have some benefit in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above.