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Meta analysis of 18 studies show that  Antenatal Perineal Massage can protect the perineum from injury

Title: Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review

Childbirth may cause perineal damage like tears or an episiotomy. This review from Poland examined Antenatal Perineal Massage (APM), a practice that aims to minimize such injuries.

The study involved thorough examination of 18 articles from an initial 711, using databases like PubMed and Web of Science. 

This systematic review aimed to evaluate the impact of APM on perinatal perineal injuries and subsequent complications in postpartum women, such as pelvic pain, dyspareunia, urinary incontinence (UI), and fecal and gas incontinence (FI).

Results showed that APM, typically starting from the 34th week of pregnancy, helped reduce perineal injuries and decreased postpartum complications like pelvic discomfort and incontinence. However, approaches to APM varied across studies, affecting result consistency.

In conclusion, APM seems beneficial in protecting the perineum during childbirth and reduces postpartum complications. Standardizing APM practice could lead to more consistent results.

Citation: Milka W, Paradowska W, Kołomańska-Bogucka D, Mazur-Bialy AI. Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review. J Gynecol Obstet Hum Reprod. 2023 Jul 4;52(8):102627. 

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848 women study show that perineal massage and warm compresses are an effective strategy to protect the perineum during childbirth

Title: Enhancing Perineal Integrity During Labor Through Massage and Warm Compresses: A Promising Approach

The study aimed to evaluate the effect of perineal massage and warm compresses on the integrity of the perineum during the second stage of labor. A total of 848 women, who were 18 years or older and between 37 to 41 weeks pregnant, participated in this single-center, prospective, randomized controlled trial. The participants were randomly assigned to two groups: 424 women in the perineal massage and warm compresses group, and 424 in the control group.

The study found that the technique of perineal massage and warm compresses significantly increased the incidence of an intact perineum and reduced the incidence of second-degree tears, episiotomies, and obstetric anal sphincter injuries. The study concluded that this technique is feasible, inexpensive, and reproducible, and should be taught to midwives and made available as an option for women during labor.

Citation: Rodrigues S, Silva P, Rocha F, Monterroso L, Silva JN, de Sousa NQ, Escuriet R. Perineal massage and warm compresses - Randomised controlled trial for reduce perineal trauma during labor.

Midwifery. 2023 Jun 15;124:103763.

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Meta-analysis of fifty studies show perineal massage is associated with a lower risk of perineal lacerations: A study from Brazil

Title: The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis

This researchers from Brazil conducted a meta-analysis a total of fifty studies with a total of 17,221 participants. Their objective was to investigate the effectiveness of intervention to prevent the occurrence of perineal trauma in a woman during labour.

The researchers found no intervention done during childbirth to be effective for the prevention of perineal trauma when compared to no intervention. However, they found there was a lower risk of perineal tearing when doing various techniques during pregnancy, especially perineal massage compared to no intervention at all.

Citation: Eur J Obstet Gynecol Reprod Biol . 2023 Feb 17;283:100-111

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A study of 108 women in Nigeria demonstrate the value of perineal massage

Title: Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial.

This study’s objective is to assess the effectiveness of antennal perineal massage (APM) in decreasing perineal injuries and post-partum morbidities. 108 first-time mothers from Nigeria were included in the study. These women were divided into two groups with one group who received APM and the other group who did not receive APM. The study found that women who received APM had better chances of evading perineal injuries after childbirth. The need for episiotomy was also lower in this group. In addition, the incidence of flatus incontinence was also significantly less in this group. It was noted, though, that the occurrence of premature rupture of membranes, preterm labor, and birth asphyxia were similar in both groups.

Citation: J Obstet Gynaecol Res. 2018 Jul;44(7):1252-1258. doi: 10.1111/jog.13640
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A literature review from Brazil about reducing perineal trauma during labor

Title: Scientific evidence on perineal trauma during labor: Integrative review.

The researchers from Brazil evaluated the evidence for management and preservation of the perineum during vaginal delivery. The reviewed ten research studies from various journal and medical databases and identified four categories: antenatal perineal care, perineal massage during the second stage of labor until the baby was vaginally delivered, manual perineal support during the expulsive stage of labor, and perineal hyaluronidase injection. The authors of the study concluded that perineal massage by expecting mothers or their partners during the last part of pregnancy is recommended for perineal protection. It is recommended that the perineal massage is done with perineal massage oil and other lubricants.

Citation: Eur J Obstet Gynecol Reprod Biol. 2018 Apr;223:18-25. doi: 10.1016/j.ejogrb.2018.01.036.
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The effectiveness and evidence of ante-natal perineal massage: A study from Spain

Title: Update on the effectiveness and evidence of ante-natal perineal massage

This publication from Spain discusses the need for strategies to reduce perineal trauma caused during vaginal delivery, especially the use of prenatal perineal massage, a proposed technique to increase the elasticity of the perineum, and consequently reduce damage to the pelvic floor. They conducted a literature review to discover the effectiveness findings and the scientific evidence that supports the use of perineal massage in the weeks before labor. Multiple databases were used including The Medline, Cochrane, Tripdatabase and Cuiden. The databases consulted covered the six years running up to the study in both Spanish and English-language publications. Ten studies with different levels of evidence were found and used in their analysis. All the studies favored the use of perineal massage.

The authors concluded that although further research is needed, according to current evidence using a prenatal perineal massage during late pregnancy can reduce perineal trauma during childbirth, especially in first-time pregnancies, as well as reduce postpartum pain in women who have not previously had a baby.

Citation: Update on the effectiveness and evidence of ante-natal perineal massage]. An Sist Sanit Navar. 2021 Dec 27;44(3):437-444. Spanish. doi: 10.23938/ASSN.0976. 

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How to prevent and repair obstetric tears

Title: Obstetric Lacerations: Prevention and Repair

The authors reviewed obstetric lacerations that are a common complication of vaginal delivery. These lacerations may cause chronic pain and urinary and fecal incontinence. The claim that perineal massage in the third trimester can reduce lacerations in women who are pregnant for the first time. Additionally, perineal support, perineal massage and warm compresses during the second stage of labor can reduce injury to the anal sphincter.

Citation: Am Fam Physician. 2021 Jun 15;103(12):745-752.

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41-article review of non-pharmacological techniques in pregnancy and childbirth

Title: Non-pharmacological therapies applied in pregnancy and labor: an integrative review

The authors of this study reviewed the literature available of non-pharmacological therapies during pregnancy and labor. The did this by searching any literature published since 2008 in English, Spanish, and Portuguese databases. Overall, 41 articles were analyzed. They divided the articles into 10 categories: massage, perineal massage, hot bath, supportive care, childbirth preparation group, breathing techniques, pelvic floor exercises, transcutaneous electrostimulation, Swiss ball and spontaneous pushing. Six articles showed that when these techniques were used the mother experienced less pain in labor. All the article showed a positive outcome for different variables of labor, such as reduction of time, anxiety and pelvic floor laceration rates.

Citation: Rev Esc Enferm USP 2021 Apr 16;55:e03681. doi: 10.1590/S1980-220X2019019703681. eCollection 2021.

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Effects of perineal preparation techniques on tissue extensibility and muscle strength: a pilot study.

Perineal preparation techniques for childbirth have been used to decrease the risk of perineal trauma during labor and delivery. This study aims to assess the effects of stretching the perineum using instruments as compared to perineal massage on the extensibility and strength of Pelvic Floor Muscles as no prior research regarding this has been made.

Women who have not yet given birth were divided into two groups—one group with women who would receive instrument-assisted stretching (IStr) and another group of women who would receive perineal massage (PnM). This was done twice weekly beginning at the 34^th week of gestation with both groups participated in eight sessions. The group with IStr used EPI-NO® for 15minutes while the PnM group received 10 minutes of perineal massage. Each woman was evaluated by a physiotherapist who was unaware of the group they belonged to, after the fourth and eighth session. And the results from both groups were compared.

Both groups showed an increase in PFM extensibility and muscle strength, with no difference between groups.

The study found that instrument-assisted stretching and perineal massage both increase PFM extensibility and do not alter the muscle strength of PFMs in pregnant women.

Citation: Int Urogynecol J. 2019 Jun;30(6):951-957 
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Title: Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines.

These are the guidelines that were developed in accordance with the methods prescribed by the French Health Authority (HAS). The paper analyzed all interventions during pregnancy and childbirth that might stop obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms. Perineal massage during pregnancy must be encouraged among women who want it. 

Citation: J Gynecol Obstet Hum Reprod. 2019 Sep;48(7):455-460. doi: 10.1016/j.jogoh.2018.12.002.
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Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth.

Women may experience short or long-term morbidity as a result of perineal trauma during childbirth. Episiotomy and severe perineal tear rates vary widely around the world. Episiotomy rates in New Zealand, as well as a trial of midwife-led care in Ireland, were found to be significantly lower than in many other nations in 2011. A study was conducted to determine how midwives in these nations and contexts attain such low rates.

The participants of the study were midwives with experience in preserving the perineum intact (PPI) from two maternity units in Ireland and a variety of birth settings in New Zealand. The study included a total of twenty-one consenting midwives, seven from Ireland and 14 from New Zealand.

The data was gathered using face-to-face, semi-structured interviews. Interviews were taped and transcribed. Data was then analyzed and organized into major themes. 'Sources of knowledge for PPI,' 'Associated factors,' 'Decision-making on episiotomy,' and 'Preparations for PPI' were identified as four themes in the study. In developing their own expertise for PPI, participants drew largely on a variety of sources of information.

Physical aspects of the perineum were found to be important contributors in the development of PPI. In most cases, episiotomy was only done when there were evidence of fetal distress. Perineal massage during pregnancy was found to be beneficial.

The results of this study adds to the evidence on this topic by providing useful insight into the perspectives and skills of midwives with experience in PPI at delivery.

Citation: Midwifery. 2017 Dec;55:83-89. 

[Awareness of the methods of primary and secondary childbirth trauma prevention among parturients].

This research primarily aims to assess new moms' awareness of the primary prevention of pelvic floor problems after childbirth. In addition, it also aims to identify information sources, actually preventing delivery trauma, and attitudes toward pelvic floor muscle training.

The study was conducted in the Department of Gynecology and Obstetrics, University Hospital and Medical Faculty in Pilsen, Charles University. It included 202 women who had a vaginal delivery at our center from June to December 2015. These women anonymously answered a six-question survey.

The study found that 83% of the respondents were aware of the possibilities of primary prevention of childbirth. First time mothers were more aware of this information. The Internet was the most common source of information while only 5% received information from their doctor. Despite the fact that most women are aware of the importance of postpartum trauma prevention, only about half of those polled actually practiced it.

Perineal massage was the most popular approach, vaginal dilatation balloons were used less frequently, and alternative procedures were employed by only 4% of women. 79 percent of women had done pelvic floor muscle exercises before giving birth, and 90 percent desired to exercise after delivery.

Mothers have a good understanding of primary and secondary prevention of pelvic floor disorders. However, the information provided by clinicians is insufficient. Despite widespread awareness, antepartum preventive techniques are not widely practiced. The survey clearly demonstrates the level of awareness and reality regarding primary and secondary prevention of pelvic floor problems.

Citation: Ceska Gynekol. 2017 Fall;82(4):327-332.

Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial.

After birth, perineal trauma is common and can be caused by tears, episiotomy, or both. Perineal massage has been demonstrated to help first-time mothers avoid episiotomies. Pelvic floor exercises, on the other hand, may have an impact by shortening the first and second stages of labor. The purpose of this study was to see how pelvic floor training in birth programs affected perineal trauma.

The study was conducted in a tertiary, metropolitan hospital in Seville, Spain on women assigned into two groups: standard care and intervention.

Four hundred sixty-six women who were 32 weeks pregnant, pregnant with one baby, and expecting a normal birth were randomly assigned to one of two groups. From 32 weeks of pregnancy until delivery, women in the experimental groups were required to follow a pelvic floor training program that included daily perineal massage and pelvic floor exercises. Standard care was provided to the control group. Midwives collected these women in a labor ward.

The perineal/pelvic floor intervention resulted in a reduction in episiotomy and a higher likelihood of having an intact perineum in women who were assigned to this group. Third and fourth degree tears were similarly less common. Women in the intervention group also experienced reduced postpartum perineal pain and required less postnatal analgesia.

The study found that preventing episiotomies and rips in first-time mothers may be as simple as doing pelvic floor exercises and perineal massage. To reduce perineal trauma, this regimen might be advised to these women.

When compared to women who only got standard care, the pelvic floor program was associated with much lower rates of episiotomies and severe perineal damage, as well as a significantly greater intact perineum. The program is a safe and effective intervention that should be offered to all pregnant women starting at the 32nd week to prevent perineal damage.

Citation: Midwifery. 2017 Jul;50:72-77. doi: 10.1016/j.midw.2017.03.015. Epub 2017 Mar 27.

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