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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.
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Several studies have been undertaken to identify factors which may influence perineal outcome during child-birth. Variables which appeared to be related to perineal outcome, namely nulliparity, age greater than 20 years, length of second stage greater than one hour, epidural or pudendal anaesthesia, and specific indication for episiotomy (i.e. fetal distress and forceps delivery), have been identified in a previous study1. Birth position as a factor in perineal outcome has been considered by several researchers, but no clear association has been identified2–6. Birthweight, breech presentation, and occipitoposterior position also increase perineal trauma1,5–7.
Much has been written about the effectiveness of antenatal perineal massage in reducing perineal tears at delivery. Information advocating the use of antenatal perineal massage is widely disseminated by many groups involved in childbirth. The National Childbirth Trust advocates its use in its pregnancy book, as does the Active Birth Centre8. Some midwives and doctors also recommend the practice.
Of several studies concerned with antenatal perineal massage one examined the effects of two methods of teaching perineal massage and concluded that there was no difference between the instruction methods with respect to the practice of perineal massage. Episiotomy and laceration rates were also not affected by teaching method9. Another study randomly allocating 20 women to either a massage or no massage group concluded that women who practise perineal massage at least four times per week would have a lower incidence of episiotomies and lacerations that those who do not. The sample was very small and was not limited to a nulliparous population10. A later study compared 29 nulliparous women who practised perineal massage with a control group of 26. The study concluded that there was a statistically significant difference between the two groups and suggested that perineal massage might be one technique that would decrease the need for episiotomy. The sample was not randomised11. A more recent pilot study examined the feasibility of a randomised, controlled trial. Randomisation of 46 nulliparous women resulted in 91% compliance by those in the massage group and 100% by those in the no massage group and concluded that it was feasible to undertake a randomised, controlled trial to evaluate the efficacy of perineal massage in preventing perineal trauma12.
This study was carried out in response to an increasing interest in antenatal perineal massage by mothers and midwives in Watford. Although the practice was advocated by some midwives at the hospital there were others who needed research evidence before advocating its use.
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This single-blind, randomised, controlled trial took place at Watford General Hospital in Watford, Hertfordshire, England between June 1994 and December 1995. Approval for the study was given by the local ethics committee. There are approximately 3300 deliveries annually at Watford General and, on average, 1300 of these are primagravidas. Approximately 80% are vaginal deliveries with over half being delivered by midwives.
In order to achieve 80% power to identify a difference of 10% in perineal trauma in the massage group compared with no massage, at a significance level of 0.05, a study sample of 780 was required.
A computer based random number generator was used to allocate numbers 1–1200 at random to either the experimental or control condition (600 to each). These numbers were used to label envelopes containing materials appropriate to the allocated condition. The allocated condition of the envelopes was not apparent from either their weight or appearance and was not available to those conducting the study until the analysis stage. Subjects were assigned envelopes in the order in which they presented themselves to the research programme.
All nulliparous women were identified for possible inclusion in the study from hospital booking lists (n= 1687). Each woman was sent a letter asking her to see her community midwife at the clinic between 29 and 32 weeks of gestation to receive information about the study. Women living out of the area were asked to contact the trial research midwife directly for information. One hundred and sixty of the potential participants (9.5%) were excluded for any of the following reasons: multiple pregnancy, planned caesarean section, already performing perineal massage, premature delivery, medical conditions necessitating hospital admission, an allergy to nuts or nut products (massage oil supplied was sweet almond oil) or inability to speak and read English. Eight hundred and sixty-one (51.0%) consented to the study while the remaining 666 (39.5%) refused to participate. Reasons given for refusal were later confirmed in telephone interviews (Table 1).
Table 1. Main reasons given for refusal (one per person) (n= 666).
|No antenatal visit between 32-34 weeks||332 (49.8)|
|Lack of interest||123 (18.5)|
|Midwife forgot||64 (9.6)|
|Wished to dohot do perineal massagc||42 (6.3)|
|Mother forgot||19 (2.9)|
|Procedures unacceptable||17 (2.6)|
|Lack of time||12 (1.8)|
|Poor obstetric history||10 (1.5)|
There were no differences between the consents, exclusions and refusals with respect to social class. The consent rate showed a small but statistically significant difference between the Caucasian and the other ethnic groups. Of the Caucasian group 60.6% consented compared with 51.5% of the other groups (P= 0.038).
Table 2 shows the socio-demographic breakdown of the women who formed the study sample.
Table 2. Demographic characteristics of study sample (n= 861). Values are given as n (%), excluding missing data.
|Marital status|| |
| Married||626 (73.4)|
| Unmarried||227 (26.6)|
|Age in years|| |
| < 20||35 (4.1)|
| 20-29||474 (55.8)|
| 130||340 (40.1)|
|Social class|| |
| 1 & 2||435 (51.2)|
| 3-5||402 (47.3)|
| Armed Forces||12 (1.4)|
|Ethnic group Caucasian|| |
Women who consented to the study were randomly allocated to either the massage or no massage group. Both groups were asked to perform pelvic floor exercises, which consisted of a group of four exercises four times in succession approximately every waking hour. The women were given a leaflet describing the exercises, and the midwife explained how they should be performed. Those in the massage group also received written information and verbal instruction about performing perineal massage (Appendix 1). The massage technique described in previous studies was taught by the attending midwife10–11,13. Women were asked to perform perineal massage three to four times a week for 4 min, starting six weeks before their estimated due date. A bottle of sweet almond oil BPC was provided to act as a lubricant when inserting the fingers into the vagina.
Women in both groups were asked to complete record sheets recording daily practice and a self-administered questionnaire within a day or two after delivery. The questionnaire covered, among other things, aspects of massage and exercise practice. In order to try to minimise bias, women were asked not to discuss their participation in the study with attending staff in labour and midwives in the labour ward were asked not to ask women whether or not they were taking part. Random checks by the trial research midwife indicated that the midwives were blind to the group allocation.
For each participant the length of actual pushing time was calculated from delivery records and the type of analgesia, birth position and use of syntocinon were noted. Following delivery, information about type of delivery, delivery attendant and perineal status was recorded. Estimated blood loss and infant's birthweight were also recorded.
Perineal trauma rates for individual midwives involved in the deliveries of study participants were compared with rates for nonstudy deliveries over the same period. This information was used to check whether women received care from midwives with comparable skills and would allow adjustment of the results if necessary.
Participants who delivered out of the area, did not have live births or had caesarean or pool deliveries were excluded from the final analysis. All analysis presented is based on an intention to treat basis. The results were analysed by comparison of proportions and logistic modelling using the Statistical Package for the Social Sciences (SPSS). Appropriate odds ratios (OR), significance tests and 95% confidence intervals (CI) were obtained.
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The results of this study demonstrate an overall benefit for women in the massage group. There was a reduction in second and third degree tears and episiotomies of 6.1% and a reduction in instrumental deliveries of 6.3%. When adjusted for age and birthweight these differences reach statistical significance. Although there was a small but nonsignificant reduction in perineal trauma among those women having spontaneous deliveries, it may be that the reduction in perineal trauma is entirely dependent on the reduction in instrumental deliveries. A larger study is required to examine this issue.
The amount of benefit in terms of reductions in perineal trauma and instrumental deliveries was not as great over the entire age range as suggested by previous small scale studies. However, in women aged 30 years and over there was a significant reduction of 12.1% in perineal trauma and 12.3% in instrumental deliveries.
A possible explanation for the benefit of perineal massage on the reduction in instrumental deliveries and improved perineal trauma for older women is that there is less elasticity and suppleness in the tissues of these women. This would prevent the perineum from stretching as easily as in the younger nullipara. This is supported by the increased trauma rate with increased age.
A limitation of this study is that the sample was not large enough to look at differences in benefit due to the amount of massage actually carried out. An alternative to increasing the sample size would be to improve the completion rate of daily massage record sheets. In this study 66.3% were returned. Another possible limitation is the lack of information about the reliability of the assessments of perineal trauma.
Reduction in perineal trauma and instrumental delivery rate has obvious benefits for the mother. Reduction in perineal trauma reduces the pain and discomfort felt by women in the early postnatal period. This will encourage comfortable mobilisation, enjoyment of the newborn and possibly even breastfeeding. There may also be a reduction in the need for antibiotics.
There could also be benefits for the health service. The results of this study suggest that a small investment of time by midwives introducing massage antenatally could lead to fewer instrumental deliveries and a reduction in associated costs.
In comparison with national data the study sample has more social class one and two (51.2%) than in Great Britain as a whole (39.3%), and a higher number of women aged 30 years and over giving birth for the first time (40.1% compared with 30.6%)14. The study population was predominantly Caucasian, as in previous studies10–11, and further research is needed on different ethnic populations. The benefit of perineal massage in the wider population could be less than that demonstrated in this study.
This study indicates a significant benefit from perineal massage for primigravid women 30 years and above. The introduction of perineal massage into antenatal care alongside pelvic floor exercises should be considered.
The authors would like to thank North Thames Regional Health Authority, The Smith and Nephew Foundation and Hygeia Ltd, Cheshire, for funding; Ms R. McCandlish (NPEU Oxford), Ms J. Wadsworth (Statistician, St Mary's Hospital, London), Ms K. Taylor (Study Co-ordinator) for assistance in setting up the project and data collection; Ms J. Lazarus (Research Administrator); Ms K. Bell (Manager, Womens’ Services); Dr M. Williams for invaluable computer support; obstetric consultants in the unit; and most importantly Watford General Hospital midwives and mothers for their willing participation.