Prenatal perineal massage: preventing lacerations during delivery

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

Background

The efficacy of perineal massage is controversial. The study was aimed at comparing the effects of perineal massage on perineal injury and complications.

Methods

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 until April 2022. Indicators included postpartum perineal tears, perineotomy, postpartum perineal pain, natural labour, and postpartum incontinence. Finally, RevMan5.4 software was used to analyze the extracted data.

Results

A total of 6487 subjects in 16 studies were included, with 3211 who received perineal massage and 3276 did not. There was no significant difference in 1-2 degree perineal tearing between the intervention group and the control group (RR = 0.96, 95% CI [0.90, 1.03], P = 0.30), and there was no heterogeneity between studies (P = 0.62, I² = 0%), indicating publication bias. Compared with the control group, prenatal perineal massage significantly reduced the incidence of 3-4 degree perineal tears (RR = 0.56, 95% CI [0.47, 0.67], P < 0.00001), and there was no heterogeneity between studies (P = 0.16, I² = 30%), indicating publication bias. Compared with the control group, prenatal perineal massage reduced the risk of lateral perineal resection (RR = 0.87, 95% CI [0.80, 0.95], P = 0.001), and there was no heterogeneity between studies (P = 0.14, I² = 31%), and there was no publication bias. Compared with the control group, prenatal perineal massage reduced the risk of postpartum pain at 3 months (RR = 0.64, 95% CI [0.51, 0.81], P = 0.0002). There was no significant heterogeneity among studies (P = 0.23, I² = 31%).

Conclusion

Compared with no prenatal perineal massage, prenatal perineal massage can reduce the risk of perineal injury, the incidence of lateral perineal resection, and the incidence of long-term pain.

Prevalence of Perineal Tear Peripartum after Two Antepartum Perineal Massage Techniques: A Non-Randomised Controlled Trial

Perineal massage increases elasticity of myofascial perineal tissue and decreases the burning and perineal pain during labour, thus optimising child birth, although an application protocol has not been standardised yet. The objective of this study is to determine the efficiency of massage in perineal tear prevention and identification of possible differences in massage application. Total of 90 pregnant participants were divided into three groups: perineal massage and EPI-NO^® device group, applied by an expert physiotherapist, self-massage group, where women were instructed to apply perineal massage in domestic household, and a control group, which received ordinary obstetric attention. Results: The results showed significant differences among the control group and the two perineal massage groups in perineal postpartum pain. Correlations in perineal postpartum pain, labour duration and the baby's weight were not statistically significant. Lithotomy posture was significantly less prevalent in the massage group than in the other two; this variable is known to have a direct effect on episiotomy incidence and could act as a causal covariate of the different incidence of episiotomy in the groups. Perineal massage reduces postpartum perineal pain, prevalence and severity of perineal tear during delivery.

The Effects of the Pilates Method on Pelvic Floor Injuries during Pregnancy and Childbirth: A Quasi-Experimental Study

The perineal injuries suffered during childbirth have a great impact on the quality of life of the female population. Evidence suggests that the Pilates method is used by pregnant women to improve the physical and psychological outcomes of pregnancy. The aim of this study was to investigate the influence of the Pilates Method during pregnancy on the incidence and degree of intrapartum perineal trauma. A quasi-experimental study was carried out between November 2018 and December 2019 at different health centers in two health districts. Participants were 72 pregnant women attending the antenatal program, who were assigned to a Pilates group or a control group (48 and 24 pregnant women, respectively). The main outcome measurement was perineal trauma during childbirth. After participating in the Pilates program, the women in the experimental group were significantly less likely to suffer perineal trauma in spontaneous deliveries compared to the women in the control group. After evaluating these results, it is concluded that health center managers should promote the training of midwives in the prevention and treatment of pelvic floor injuries during pregnancy and should consider strategies to enhance adhesion and participation with respect to pelvic floor exercise programs throughout pregnancy by means of Apps and other digital media specifically aimed at this phase.

Effect of perineal massage on the rate of episiotomy and perineal tearing

OBJECTIVE

To examine the effects of perineal massage during active labor on the frequency of episiotomy and perineal tearing.

METHODS

A randomized controlled study was conducted at a center in Sivas, Turkey, between January 1, 2010, and May 31, 2011. Healthy pregnant women presenting for their first or second delivery at 37-42 weeks of pregnancy were enrolled during the first stage of labor. Participants were randomly assigned (1:1) to the massage group (10-minute perineal massage with glycerol four times during the first stage and once during the second stage of labor) or control group (routine care). The frequency of episiotomy and perineal tearing were compared between the groups. Participants and investigators were not masked to group assignment.

RESULTS

Both groups contained 142 participants. Episiotomy was performed among 44 (31.0%) women in the massage group and 99 (69.7%) in the control group (P = 0.001). Lacerations were recorded among 13 (4.2%) women in the massage group and 6 (4.2%) in the control group (P = 0.096).

CONCLUSION

Application of perineal massage during active labor decreased the frequency of episiotomy procedures. ClinicalTrials.gov:NCT02201615.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum.

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Hyaluronidase for reducing perineal trauma

BACKGROUND

Perineal hyaluronidase (HAase) injection was widely used to reduce the occurrence of perineal trauma, pain and need for episiotomy in the 1950s to 1960s. Reports suggested that the administration of HAase was a simple, low risk, low cost and effective way to decrease perineal trauma without adverse effects.

OBJECTIVES

The objective of this review was to assess the effectiveness and safety of perineal HAase injection for reducing spontaneous perineal trauma, episiotomy and perineal pain in vaginal deliveries.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2013), the International Clinical Trials Registry Platform (ICTRP) and the Networked Digital Library of Theses and Dissertations (both on 1 April 2013), and reference lists of retrieved studies. We also contacted relevant organisations.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials comparing perineal HAase injection with placebo injection or no intervention in vaginal deliveries.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy.

MAIN RESULTS

The search strategy identified six potentially eligible studies. Two studies were excluded. We included four randomised controlled trials that randomised a total of 599 women (data were available for 595 women).Two trials (283 women) compared the effects of perineal HAase injection during the second stage of labour with placebo injection and were at low risk of bias. Three trials (one three-armed trial was analysed twice) (373 women) compared the effects of perineal HAase injection during second stage of labour with no intervention and two out of the three trials were at high risk of bias. Data from four trials involving 599 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (average risk ratio (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95,Tau² = 0.08, I² = 82% compared with women in the control group, but there was no clear evidence of a reduction in the incidence of episiotomy (average RR 0.74, 95% CI 0.43 to 1.29, Tau² = 0.17, I² = 66%), first and second degree perineal lacerations (average RR 0.54, 95% CI 0.38 to 1.33, Tau² = 0.30 , I² = 85%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13). Data from two trials involving 283 women indicated that there was no clear evidence of a reduction in the incidence of perineal trauma (RR 0.90, 95% CI 0.77 to 1.06, Tau²=1.07, I² = 7%), episiotomy (RR 0.77, 95% CI 0.32 to 1.89, Tau² = 0.27, I² = 54%), first and second degree perineal lacerations (RR 1.08, 95% CI 0.83 to 1.40, Tau² = 1.11, I² = 10%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13) with perineal HAase injection. Data from three trials involving 373 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (RR 0.61, 95% CI 0.42 to 0.88, Tau² = 0.08, I² = 78%) compared with no intervention, but had no clear effect on in the incidence of episiotomy (RR 0.79, 95% CI 0.44 to 1.42, Tau² = 0.16, I² = 70%) and first and second degree perineal lacerations (RR 0.58, 95% CI 0.31 to 1.10, Tau² = 0.18, I² = 59%). No side effects were reported in the included trials.No included trials reported on perineal pain and other pre-specified secondary outcomes: perineal trauma requiring suturing; blood loss; dyspareunia; urinary incontinence; faecal incontinence; assisted delivery rate; women's satisfaction; Apgar score less than seven at five minutes and need for admission to special care baby unit.

AUTHORS' CONCLUSIONS

Perineal HAase injection during second stage of labour had a lower incidence of perineal trauma compared with control or no intervention, but there was no clear evidence of benefit compared with placebo injection. The difference in incidence of perineal trauma may probably be due to bias and confounding in the non-placebo controlled comparison, this result should be interpreted cautiously. The potential use of perineal HAase injection as a method to reduce perineal trauma were yet to be determined as there was no appropriate established dose for HAase, no evidence of follow up, and the number of high-quality trials and outcomes reported were too limited to draw conclusions on its effectiveness and safety. Further rigorous randomised controlled trials are required to evaluate the role of perineal HAase injection in vaginal deliveries.

Prenatal tactile stimulation attenuates drug-induced behavioral sensitization, modifies behavior, and alters brain architecture

Based on the findings of postnatal tactile stimulation (TS), a favorable experience in rats, the present study examined the influence of prenatal TS on juvenile behavior, adult amphetamine (AMPH) sensitization, and structural alteration in the prefrontal cortex (PFC) and the striatum. Female rats received TS through a baby hair brush throughout pregnancy, and the pups born were tested for open field locomotion, elevated plus maze (EPM), novel object recognition (NOR), and play fighting behaviors. Development and persistence of drug-induced behavioral sensitization in adults were tested by repeated AMPH administration and a challenge, respectively. Structural plasticity in the brain was assessed from the prefrontal cortical thickness and striatum size from serial coronal sections. The results indicate that TS females showed enhanced exploration in the open field. TS decreased the frequency of playful attacks whereas the response to face or evade an attack was not affected. Anxiety-like behavior and cognitive performance were not influenced by TS. AMPH administration resulted in gradual increase in locomotor activity (i.e., behavioral sensitization) that persisted at least for 2 weeks. However, both male and female TS rats exhibited attenuated AMPH sensitization compared to sex-matched controls. Furthermore, the drug-associated alteration in the prefrontal cortical thickness and striatum size observed in controls were prevented by TS experience. In summary, TS during prenatal development modified juvenile behavior, attenuated drug-induced behavioral sensitization in adulthood, and reorganized brain regions implicated in drug addiction.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2010) and the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the reports and extracted data.

MAIN RESULTS

We identified and included one trial (147 participants) that compared the effect of prophylactic antibiotic (single-dose, second generation cephalosporin, intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio 0.34, 95% confidence interval 0.12 to 0.96).

AUTHORS' CONCLUSIONS

Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Práticas obstétricas e resultados maternos e neonatais: análise fatorial de correspondência múltipla em dois centros de parto normal

OBJETIVO: Descrever as práticas obstétricas e os resultados maternos e neonatais de dois Centros de Parto Normal do Município de São Paulo, comparandose as unidades intra e extra-hospitalares. MÉTODOS: Estudo observacional, transversal e retrospectivo com dados secundários provenientes de 192 prontuários das instituições envolvidas. As variáveis de estudo foram as práticas selecionadas para o parto normal: a utilização de ocitocina, o tipo de rompimento das membranas amnióticas, a realização de episiotomia ou perineotomia e o tempo de permanência materna e neonatal. Foi elaborado um instrumento informatizado para coleta de dados com base nas variáveis de estudo. Os dados foram tratados através de análise estatística multivariada. RESULTADOS: O centro de parto normal intra-hospitalar utilizou com maior frequência às intervenções relacionadas à utilização de ocitocina, rompimento artificial de membranas amnióticas e tempo de permanência materna e neonatal superior às 48h, após o parto. O centro de parto normal extra-hospitalar apresentou maior frequência de parturientes com períneo íntegro após o parto, rompimento de membranas de maneira espontânea e tempo de permanência materna e neonatal inferior a 48 horas pós-parto. Os resultados maternos e neonatais não evidenciaram complicações relacionadas às práticas utilizadas. CONCLUSÃO: As práticas obstétricas pouco diferiram, comparando-se os dois tipos de Centros de Parto Normal; ambos seguem as recomendações da Organização Mundial de Saúde e aplicam as intervenções somente nos casos indicados.

A randomized comparison of suturing techniques for episiotomy and laceration repair after spontaneous vaginal birth

STUDY OBJECTIVE

To compare the continuous knotless technique of perineal repair with the interrupted method after spontaneous vaginal birth

DESIGN

A randomized controlled trial.

DESIGN CLASSIFICATION

Canadian Task Force Classification I.

SETTING

This study was undertaken in a university hospital with more than 2200 deliveries per year. The static population of this district includes a wide range of socioeconomic classes and is predominately white.

PATIENTS

From May 1 to November 19, 2003, 214 primiparous women with a second-degree perineal tear or episiotomy were randomly allocated to either the continuous knotless technique (CKT; n=107) or the interrupted technique (IT; n=107) suturing method.

INTERVENTIONS

The interrupted technique (IT) involves placing 3 layers of sutures whereas the continuous knotless technique (CKT) involves reapproximating vaginal trauma, perineal muscles, and skin with a loose, continuous, nonlocking technique.

MEASUREMENTS AND MAIN RESULTS

The primary outcomes of the study were perineal pain (evaluated by visual analogue scale) at 48 hours and day 10 and dyspareunia 3 months after delivery. Secondary outcomes included suture removal, wound dehiscence, analgesia use up to 48 hours, and satisfaction with repair established at 3 and 12 months after childbirth. At day 10, 19 women had dropped out of the study. Significantly fewer women reported pain at 10 days with the CKT than with the IT (32.3% vs 60.4%; p<.001). Analgesia use up to 48 hours postpartum was less in the CKT group than in the IT group (33.6% vs 54.2%; p<.05). No difference was found in superficial dyspareunia at 3 months for the CKT versus the IT group.

CONCLUSION

The use of a continuous knotless technique for perineal repair is associated with less short-term pain than techniques with interrupted sutures.

Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth

BACKGROUND

One to eight per cent of women suffer third-degree perineal tears (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection.

OBJECTIVES

To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side-effects in fourth-degree perineal tear during vaginal birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 July 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2005), MEDLINE (1966 to 15 July 2005), and LILACS (1982 to 15 July 2005).

SELECTION CRITERIA

Randomised controlled trials which reported data comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in fourth-degree perineal tear during vaginal birth.

DATA COLLECTION AND ANALYSIS

No trials were found that met the selection criteria.

MAIN RESULTS

No randomised controlled trials were identified.

AUTHORS' CONCLUSIONS

There are insufficient data to support a policy of routine prophylactic antibiotics in fourth-degree perineal tear during vaginal birth. A well-designed randomised controlled trial is needed.