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What can be Done to Reduce Pelvic Floor Injury During Vaginal Birth?

Title: Effects of perineal massage at different stages on perineal and postpartum pelvic floor function in primiparous women: a systematic review and meta-analysis

This systematic review and meta-analysis examined the effects of perineal massage at different stages—either antenatally or during the second stage of labor—on preventing perineal injuries and improving postpartum pelvic floor function in primiparous women. The study analyzed 10 randomized controlled trials involving 1,057 women. It found that perineal massage during the second stage of labor significantly reduced perineal pain immediately postpartum. Antenatal perineal massage was associated with a reduction in fecal and flatus incontinence three months postpartum, although it did not significantly impact urinary incontinence. The findings suggest that incorporating perineal massage both antenatally and during labor can be beneficial in reducing perineal injuries and enhancing pelvic floor function postpartum.

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Variability in Perineal Trauma Management Among Spanish Midwives

Title: Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain

This observational cross-sectional study explored the practices of 305 midwives in Spain regarding the prevention and repair of obstetric perineal trauma, focusing particularly on the use of episiotomy. The study revealed significant variability in how midwives approached these practices. A notable finding was that 83% of midwives did not regularly use intrapartum perineal massage, a technique often recommended for reducing perineal trauma. Additionally, 61% of midwives used warm compresses on the perineum. When it came to episiotomies, 42.3% of midwives adopted a restrictive approach, performing them in fewer than 10% of cases, while 16.7% performed episiotomies in over 20% of cases. The study also found that midwives who attended home births, worked in teaching hospitals, or had recently completed their training were more likely to use episiotomy restrictively. These findings underscore the variability in perineal trauma prevention practices, particularly in the use of perineal massage and episiotomy, among midwives in Spain.

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Understanding and Managing Obstetric Perineal Lacerations

Title: Perineal Lacerations

Obstetric perineal lacerations are common during vaginal childbirth and can range from minor first-degree tears to severe third- and fourth-degree injuries, including obstetric anal sphincter injuries (OASIS). While most minor lacerations heal without long-term complications, severe tears can lead to significant issues like pelvic floor dysfunction, incontinence, and sexual dysfunction. The risk of perineal lacerations is heightened by factors such as first-time childbirth, larger babies, and certain fetal positions. Although episiotomies, particularly midline ones, can increase the risk of severe lacerations, the use of mediolateral episiotomies may reduce this risk. Preventative measures, including perineal massage during late pregnancy, have been shown to decrease the severity of perineal trauma. Proper identification and repair of these lacerations during delivery are crucial to minimizing long-term complications, and follow-up care is essential for ensuring effective recovery.

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A systematic meta-analysis about the way perineal massage effects the health outcome on mother in baby in first-time deliveries

Title: Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

The authors of this study investigate the use of perineal massage at the different stages of labor.  Research involving women with first-time pregnancies were included in the study. Seventeen randomized controlled trials involving 3248 women were included in the review. 

The authors of the study concluded that better outcomes were shown when perineal massage begun during the second stage of labor (including an intact perineum and reduced second and third degree perineal tears). Perineal massage starting during the first stage of labor was shown to significantly shorten the duration of labor. The authors recommend that more high-quality studies that involves standardizing the procedure for perineal massage is needed.

Citation: Li Y, Wang C, Lu H, Cao L, Zhu X, Wang A, Sun R. Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis. Int J Nurs Stud. 2022 Nov 13;138:104390. doi: 10.1016/j.ijnurstu.2022.104390. Epub ahead of print. PMID: 36442355.

Meta-Analysis of 21 studies about Pelvic Floor Muscle Training to prevent perineal trauma

Title: PFMT relevant strategies to prevent perineal trauma: a systematic review and network meta-analysis

The authors of this study performed a review of all the published studies about the effectiveness of pelvic floor muscle training and the potential for perineal trauma. 21 clinical studies were included in the analysis. The combination of doing pelvic floor muscle training with perineal massage—or even pelvic floor muscle training on its own—showed superiority in keeping the perineum intact.

The authors of the study concluded that antenatal perineal massage, combined with pelvic floor exercises, and even pelvic floor muscle training on its own were effective strategies for the prevention of perineal trauma.

Citation: PFMT relevant strategies to prevent perineal trauma: a systematic review and network meta-analysis. Arch Gynecol Obstet. 2022 Sep 15. doi: 10.1007/s00404-022-06769-w.

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Effect of prenatal perineal massage on postpartum perineal injury and postpartum complications: A Meta-Analysis

Title: Effect of Prenatal Perineal Massage on Postpartum Perineal Injury and Postpartum Complications: A Meta-Analysis

The efficacy of perineal massage is controversial. The study aimed at comparing the effects of perineal massage on perineal injury and complications. PubMed, Embase, the Cochrane Library, and ISI Web of Science were searched for literature on the relationship between prenatal perineal massage and postpartum perineal injury and complications. Indicators included postpartum perineal tears, perineotomy, postpartum perineal pain, natural labor, and postpartum incontinence. 

A total of 6,487 subjects in 16 studies were included. This encompassed 3,211 woman who did perineal massage and 3,276 who did not. The analysis showed that there was no significant difference in 1- or 2-degree perineal tearing between the two groups. However, prenatal perineal massage was shown to significantly reduce the incidence of 3- and 4-degree perineal tears. Additionally, prenatal perineal massage reduced the risk of lateral perineal resection and the risk of postpartum pain at 3 months.  

The authors concluded that prenatal perineal massage can reduce the risk of perineal injury, the incidence of lateral perineal resection, and the incidence of long-term pain.

Citation: Effect of Prenatal Perineal Massage on Postpartum Perineal Injury and Postpartum Complications: A Meta-Analysis. Comput Math Methods Med. 2022 Jul 14;2022:3315638.

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Does perineal stretching with instruments increase the elasticity of the pelvic floor muscle?

Title: Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial

The authors in this study, from Brazil, compared the effects of instrument-assisted perineal stretching techniques when combined with perineal massage to the effects of the techniques when done without any devices on the extensibility and strength of the pelvic floor muscles (PFMs). 96 pregnant woman aged 18-40 years participated in the study. The woman were divided into four group each having its own short perineal stretching protocol. The pelvic floor muscle extensibility was assessed at the beginning and the end of the study. In addition, pelvic floor muscle strength was assessed too. The study showed that pregnant woman who received a combination of perineal massage and instrument-assisted perineal stretching had a greater increase in pelvic floor extensibility than either perineal massage or instrument-assisted perineal stretching alone.

The authors concluded that pregnant women could benefit from combining perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Citation: Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial. Phys Ther. 2022 Mar 1;102(3):pzab305. doi: 10.1093/ptj/pzab305.

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Studies with 3467 patients on the potential benefits of perineal massage

Title: Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials.

A majority of vaginal births are accompanied by perineal injuries. Perineal trauma can cause severe morbidity, especially resulting from third- and fourth- degree perineal tears. The researchers assumed that antenatal perineal massage helps reduce the occurrence of perineal trauma especially severe perineal tears and other postpartum complications.

The researchers used four different databases for the available trials from the beginning of the research to August 2019 that evaluate the incidence of perineal tears in perineal trauma patients, that is, pregnant women practicing antenatal perineal massage versus pregnant women who do not practice perineal massage.

In total, eleven studies with 3467 patients were evaluated and results showed that women who receive antenatal perineal massage had considerably much lower incidence of episiotomies and perineal tears; better wound healing and less perineal pain. Moreover, antenatal perineal massage was shown to reduce the duration of the second stage of labor and anal incontinence. In addition, newborn babies from patients who practiced antenatal perineal massage had better Apgar scores at 1 and 5 min after birth.

The study found that practicing antenatal perineal massage is linked to lower risk of perineal trauma and postpartum complications.

Citation: Int Urogynecol J. 2020 May 12. doi: 10.1007/s00192-020-04302-8

A review of 26 studies on reducing third- and fourth-degree tears

Title: Third- and fourth-degree tears: A review of the current evidence for prevention and management.

Published: 2020

Australian women have been found to have higher rates of third- and fourth- degree tears as compared to women from countries with the same economic status as Australia.

This research aims to thoroughly study and review previous literature and published articles to find the best ways to prevent and manage third- and fourth- degree perineal tears in Australian maternity clinics.

The researchers reviewed twenty-six studies in total. The most common risk factors found for third- and fourth- degree tears in these studies were the mother giving birth for the first time or has only given birth once before; mother’s ethnicity; large babies and interventions done during labor and at birth such as deliveries done with the aid of instruments.

Preventive practices with varying degrees of effectiveness included: antenatal perineal massage, maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for births with the aid of instruments.

The authors of the study conclude that third- and fourth- degree tears are linked with direct and long-term consequences for women and health care systems. They recommend evidence-based approaches to prevent women from sustaining severe perineal tears and ease the implications of those who do.

Link to the publication

Citation: Aust N Z J Obstet Gynaecol. 2020 Apr;60(2):175-182. doi: 10.1111/ajo.13127. Epub 2020 Feb 17.

Reducing perineal trauma in pregnant woman aged 35+ with perineal massage

Title: Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial.

The researchers of this study wanted to determine the effectiveness of educational prevention programs on perineal massage, pelvic floor muscle training (PFMT) and a pelvic floor dysfunction (PFD) in pregnant women above 35 years old to prevent perineal tear and episiotomy.

To do this, 400 pregnant women at the obstetrics outpatient clinic who were 4 weeks prior to their due date were divided/slit into two groups randomly. The first group which had 200 participants were asked to do perineal massage, pelvic floor muscle training and received an educational PFD prevention program. The second group, also composed of 200 participants receive only the PFD prevention program. The incidence of perineal tears were reported at the time of delivery as the primary outcome.

Women from the first group reported fewer perineal tears, episiotomies and postnatal pain. In addition, the grades of perineal tear in the first group were mostly first and second degree as compared with the second group. Moreover, there was a lesser need for analgesia during the hospital stay in the first group.

The authors concluded that practicing antenatal perineal massage and PFMT in addition to health education is beneficial to decrease perineal complications.

Citation: Int Urogynecol J 2020 Mar;31(3):613-619.

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