Perineal Massage
June 2000; Volume 2; 44-45
By Adriane Fugh-Berman, MD, and Anthony Scialli, MD
Midwives commonly recommend perineal massage to reduce injury to the perineum during birth. Several studies have examined the technique and although findings are not consistent, the technique may benefit nulliparous women.
Clinical Trials
Three randomized trials of perineal massage were identified and are reviewed here. In a randomized, single-blind prospective study in the United Kingdom, 861 nulliparous women with singleton pregnancies were assigned to massage or no-massage groups.1 Both groups were asked to perform pelvic floor exercises, which were explained by a midwife and in a leaflet; a series of four exercises was performed four times every hour. Women in the massage group received a bottle of sweet almond oil as well as written and verbal instructions on performing perineal massage. Either the pregnant woman or her partner could perform the massage. The woman could be in a semi-sitting position, squatting against a wall, or standing with one foot elevated, and was supposed to concentrate on relaxing the pelvic muscles during the massage. The person performing the massage was to lubricate a thumb or two fingers with the almond oil and then insert the digit(s) about two inches into the vagina. Using a sweeping rhythmic motion with downward pressure, the thumb or fingers were moved from 3 o’clock to 9 o’clock and back again applying steady pressure posteriorly (enough to feel tingling but not so much as to be painful). The skin of the perineum could also be massaged between the thumb and fingers. Women were asked to perform perineal massage three to four times a week for four minutes, beginning six weeks before their estimated due date. Both groups were asked to keep daily diaries and to complete self-administered questionnaires after delivery.
Despite randomization, maternal age was significantly higher in the massage group (28.9 years) than in the no-massage group (28.1 years). Since infant birth weight was significantly associated with maternal age, both of these were included as variables in the analyses. In this study, 66.3% of participants returned prenatal diaries and 97.9% completed the postnatal questionnaire. In addition, 32.9% of the women assigned to the massage group complied in full, 52.1% partially complied, and 15% performed no massage. The rate of second- or third-degree tears or episiotomy was 75.1% in the massage group and 69.0% in the control group (not a significant difference). Although reduction in tears was not significant for women under 30, there was a significant reduction in tears (12.1%) for women over 30. There was a significant reduction in instrumental delivery only in the over-30 group (12.9% vs. 3.6% in women under 30).
Another single-blind, randomized controlled trial included both nulliparous and multiparous women in five teaching hospitals in Quebec, Canada.2 The researcher randomly assigned 1,034 women without a previous vaginal birth and 493 with more than one previous vaginal birth to either a massage or no-massage group; all women were between 30-35 weeks gestation. Massage was performed 5-10 min/d, starting at 34-35 weeks gestation and continuing until delivery. Compliance was good. Sixty-six percent of women without a previous vaginal birth performed the massage more than four times a week for more than three weeks; more than 85% performed massage on at least a third of the assigned days.
Among all participants, the incidence of intact perineum was 19.3% in the massage group and 12.3% in the control group. Perineal massage had no effect on the risk of third- and fourth-degree perineal lacerations. For women without a previous vaginal birth, there was a statistically significant higher rate of intact perineum: 24.3% in the massage group vs. 15.1% in the no-massage group. There was a significant trend for higher rate of intact perineum among women who performed perineal massage most often (20% in those who practiced perineal massage less than a third of the recommended time; 23% in those who practiced it one-third to two-thirds of the recommended time; and 27.5% in those who performed massage more than two-thirds of the assigned massage days). Perineal outcome was not significantly different among women with at least one previous vaginal birth.
The effect of perineal massage on perineal pain, sexual function, and urinary and fecal incontinence three months after delivery was examined in the same cohort in a separate publication.3 Among participants without a previous vaginal birth, there were no differences between the massage and control groups in terms of perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, gas, or stool three months postpartum. Among women with a previous vaginal birth, significantly more women assigned to massage were free of perineal pain (93.6% vs. 85.8%). The frequencies of dyspareunia and incontinence of urine, gas, or stool were similar in the two groups. The investigators note that there is not a good rational explanation for the finding of reduced pain among women with a previous vaginal birth in the massage group as massage did not increase the rate of intact perineum in this group.
Although these researchers did not find a beneficial effect on perineal function three months postpartum, they do point out that the study should lay to rest any concerns that perineal massage is harmful (some have expressed concerns that it might decrease perineal strength and permanently enlarge the vaginal entrance). If this were true, one would expect an increased rate of urinary incontinence and decreased sexual stimulation during intercourse for the women or their partners. There were no differences between the groups in the frequency of urinary or anal incontinence or in the level of sexual satisfaction of the women or their partners.
Conclusion
Perineal massage appears to be a safe, self- or partner-administered therapy that may have beneficial effects in terms of maintaining an intact perineum in nulliparous women, especially those over 30. Although there does not appear to be a beneficial effect on dyspareunia or incontinence of urine, gas, or stool three months postpartum, neither does there appear to be any adverse effect.
References
1. Shipman MK, et al. Antenatal perineal massage and subsequent perineal outcomes: A randomised controlled trial. Br J Obstet Gynecol 1997;104:787-791.
2. Labrecque M, et al. Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. Am J Obstet Gynecol 1999;180:593-600.
3. Labrecque M, et al. Randomized trial of perineal massage during pregnancy: Perineal symptoms three months after delivery. Am J Obstet Gynecol 2000;182:76-80.
Funding of Reviewed Studies
Reference 1: not stated. Reference 2: Medical Research Council of Canada and the Fonds de Recherche en Santé du Québec; Rougier Inc. provided massage oil; Wyeth-Ayerst Canada supported investigators workshops. Reference 3: Medical Research Council of Canada and the Fonds de Recherche en Santé du Québec; Rougier Inc. provided massage oil; Wyeth-Ayerst Canada and Organon supported investigators workshops.
June 2000; Volume 2; 44-45
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