Midwifery
incontinence, and postpartum perineal pain among women giving birth
Systematic review and meta-analysis
Antenatal perineal massage
decreases risk of perineal trauma
during birth
10.1136/eb-2013-101451
Marie Hastings-Tolsma
Division of Women, Children & Family Health, University of Colorado
Denver, College of Nursing, Aurora, Colorado, USA
Correspondence to: Professor Marie Hastings-Tolsma, Division of
Women, Children & Family Health, University of Colorado Denver,
College of Nursing, 13120 East 19th Avenue, PO Box 6511, Room 4315,
Aurora, CO 80045, USA; Marie.Hastings-Tolsma@ucdenver.edu
Commentary on: Beckmann MM, Stock OM. Antenatal perineal
massage for reducing perineal trauma. Cochrane Database Syst
Rev 2013;(4):CD005123
Implications for practice and research
Pregnant women who have not yet experienced vaginal birth should
be informed about the benets of antenatal perineal massage.
Conditions where antenatal perineal massage may benet women who
have already experienced vaginal birth, needs further exploration.
The additive value and acceptability of intrapartum perineal massage,
including its effect on immediate postpartum pain, dyspareunia and
incontinence, should be assessed.
Context
Upwards of 70% of women experience perineal trauma during child-
birth.1 Concern over such trauma is signicant for pregnant women, par-
ticularly for those from ethnic minorities, where cultural differences have
been found to increase worry about possible intervention, pain and dis-
comfort associated with birth.2 Anecdotal reports have long suggested
that performing perineal massage during pregnancy and labour is of
benet in reducing perineal trauma when done. Perineal massage
involves digitally stretching perineal tissues by inserting lubricated
ngers 1.5 inches into the lower portion of the vagina and slowly massa-
ging downward in a U-shaped movement. The value of the massage to
reduce more severe perineal lacerations during labour has been demon-
strated.3 There has been similar suggestion that digital perineal massage
during pregnancy is benecial in reducing the risk of laceration and/or
the need for episiotomy.4 Despite these beliefs, there has not been
adequate research to determine the value of prenatal digital perineal
massage in reducing perineal trauma associated with vaginal birth.
Methods
Beckmann and Stock conducted a Cochrane systematic review aimed at
assessing the effect of digital antenatal perineal massage on perineal
trauma at birth and subsequent morbidity. The primary outcomes
included a type of perineal laceration, need for suturing and incidence of
episiotomy. Secondary outcomes included length of the second stage of
labour, instrumental delivery, patient satisfaction, urinary and faecal
vaginally plus various neonatal outcomes. Four randomised and
quasi-randomised controlled trials from three countries involving 2497
women who had used any method of antenatal digital perineal massage
for at least the last 4 weeks of pregnancy were examined.
Findings
Though there is some risk of blinding and reporting bias, the results
support antenatal digital perineal massage in late pregnancy. A reduction
in lacerations that require suturing (RR=0.91, 95% CI 0.86 to 0.96) and a
decrease in the likelihood of episiotomy (RR=0.84, 95% CI 0.74 to 0.95)
were observed, but only for women without prior vaginal birth.
Conversely, for women with prior vaginal birth, there was a signicant
decrease in the incidence of pain at 3 months postpartum (RR=0.45, 95%
CI 0.24 to 0.87). There were no differences in instrumental deliveries,
sexual satisfaction or incontinence for women practicing antenatal peri-
neal massage.
Commentary
This study supports the practice of digital perineal massage by women
who have not had a prior vaginal birth, when done on average as few as
1.5 times/week in the last weeks of pregnancy. However, more frequent
massage makes it less likely for on-going perineal pain postpartum for
women who have had prior vaginal birth. Surprisingly, the results did
not favour conducting perineal massage with greater frequency on those
women who have not yet given birth vaginally where, theoretically, a
perineal massage should promote improved tissue distensibility and
reduce potential trauma. Other factors relating to the effectiveness of
antenatal perineal massage in the prevention or reduction of perineal
trauma are, no doubt, in need of examination and may provide useful
data in understanding this unanticipated result. Variation in the outcome
measures and a lack of clarity regarding pregnancy and childbirth-related
factors (eg, perineal massage during labour, birth weight, maternal
habitus, maternal expectation and motivation, models of care place of
birth) are important aspects to consider.
This review used good-quality data and provides useful information
for health professionals and patients to consider when attempting the
reduction of perineal trauma in childbirth. The ndings support the need
for additional research while underscoring the potential utility of an
intervention for select pregnant women. While there remain unanswered
questions about the utility of antenatal perineal massage for all women,
there are no known adverse effects of antenatal perineal massage and, in
the absence of such evidence, there is little reason to preclude patient
instruction on its potential benet.
Competing interests None.
References
1. Smith LA, Price N, Simonite V, et al. Incidence of and risk factors for perineal
trauma: a prospective observational study. BMC Pregnancy Childbirth 2013;13:59.
2. Redshaw M, Heikkil K. Ethnic differences in womens worries about labour and
birth. Ethn Health 2011;16:21323.
3. Aasheim V, Nilsen ABV, Lukasse M, et al. Perineal techniques during the second
stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011;(12):
CD006672.
4. American College of Nurse Midwives. Perineal massage in pregnancy. Share with
patients. J Midwifery Womens Health 2005;50:634.
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