Clinical Question

Does digital perineal massage in the antenatal period reduce birth trauma or long-term morbidity?

Evidence-Based Answer

Antenatal digital perineal massage in the final month of pregnancy is safe and well tolerated. Women who have not had a previous vaginal delivery and perform digital perineal massage in the final month of pregnancy experience less perineal birth trauma, mostly through fewer episiotomies, than those who have not performed massage. Women who have had a previous vaginal delivery do not experience a reduction in birth trauma, but they report less pain at three months postpartum. No difference is noted in assisted vaginal deliveries, sexual satisfaction, or urinary incontinence. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Vaginal deliveries commonly result in some degree of genital tract trauma. This is most likely for women who have not had a previous vaginal delivery. Women with perineal trauma are more likely to report short-term pain and discomfort postpartum, as well as dyspareunia, than women who deliver with an intact perineum. Therefore, various interventions have been evaluated to reduce perineal trauma.^1,2 This review looked specifically at perineal massage during the final four weeks of pregnancy.

The review was comprised of four studies with a total of 2,497 participants. Only one study included women with previous vaginal deliveries (493 patients). Primary outcomes included perineal trauma that required suturing, episiotomy, and perineal tears grouped into first-degree, second-degree, and third- or fourth-degree trauma. Secondary outcomes included patient satisfaction with perineal massage, postpartum perineal pain, postpartum dyspareunia, and postpartum incontinence.

Women who performed perineal massage showed a reduction in perineal trauma requiring suturing (relative risk [RR] = 0.91; 95% confidence interval [CI], 0.86 to 0.96; number needed to treat = 15). However, this was statistically significant only in women who had not previously delivered vaginally (RR = 0.90; 95% CI, 0.84 to 0.96). Subgroup analysis showed an inverse relationship between the number of times per week that women performed massage and the degree of reduction of tears requiring suturing. Participants who performed massage up to 1.5 times per week on average had a 16% reduction; 1.5 to 3.4 times per week, an 8% reduction; and more than 3.5 times per week, no statistically significant reduction.

Perineal massage decreased the likelihood of having an episiotomy (RR = 0.84; 95% CI, 0.74 to 0.95; number needed to treat = 21). This was significant only for women without a previous vaginal delivery. Subgroup analysis showed that only those who performed massage up to 1.5 times per week on average had a statistically significant reduction in the incidence of episiotomy, whereas the women who used massage more frequently did not have a statistically significant reduction. Of note, no difference was found in the incidence of first- or second-degree tears, or third- or fourth-degree perineal trauma. Thus, the decreased incidence of episiotomy drove the overall reduction in perineal trauma.

No differences were noted in length of the second stage of labor, the overall proportion of instrumental deliveries, dyspareunia at three months postpartum, postpartum sexual satisfaction, or urinary and fecal incontinence. Ongoing postpartum perineal pain was reported in one study, and no difference between groups was seen overall at three months. Subgroup analysis showed that women who performed massage the most frequently were less likely to report pain (RR = 0.51; 95% CI, 0.33 to 0.79). Additionally, women with a previous vaginal delivery (n = 376) reported a lower incidence of pain at three months postpartum (RR = 0.45; 95% CI, 0.24 to 0.87). Patient satisfaction with perineal massage was not reported in any of the four studies included in this review. However, a 1994 article reported that women found perineal massage acceptable. Most reported they would practice it again and would recommend it to another pregnant woman.³

Although this review found evidence of decreased perineal trauma among women who performed perineal massage in the final month of pregnancy, the lack of a dose response suggests either a narrow therapeutic window or that another factor is involved in the decrease in trauma. There is evidence that perineal massage can decrease the incidence of postpartum pain at three months, at least among women who have a history of vaginal delivery. Perineal massage is not recommended in any pregnancy guidelines. However, it is safe and appears to be acceptable to women. The evidence for perineal massage is not strong enough to recommend it universally, but family physicians can suggest it for women who are interested in methods that might reduce perineal birth trauma or postpartum pain. Information about how a woman can perform massage is available at http://www.webmd.com/baby/tc/childbirth-perineal-massage-before-labor-topic-overview.