Effects of antenatal perineal massage on perineal trauma

Effects of antenatal perineal massage on perineal trauma

Several research studies have been undertaken to determine the effects of antenatal perineal massage on perineal trauma (Beckmann & Garrett, 2006). In all these researches, several factors have been identified as relating to perineal outcome and this include age greater than twenty years, nulliparity, length of second stage if greater than one hour epidural anesthesia and some other specific factors like fetal distress (Johanson, 2000).

Body weight, accipitoposterior position and breech presentation are possible other factors that have been identified to cause perineal trauma. In their research, Eason, Labrecque, Wells & Feldman (2001) note that women who practice antenatal perineal massage during each week before birth are likely to have low incidences of perineal trauma, pain and lacerations as compared to those who do not. However, his sample was very small (only 20 participants) and thus was not limited to nulliparous population (Parahoo, 2006).

Perineal trauma following the normal vaginal birth can be associated with both long-term and short-term morbidity in significant levels (Wagner & Marsden, 2006). Antenatal perineal massage has been widely proposed as the best method for decreasing the effects and incidence of perineal trauma. Perineal massage should be started from after 34 weeks of pregnancy (Labrecque et al, 1999). The practice is best recommended during or after a shower because at this time, blood vessels at the perineum are fully dilated thus making the perineum softer and comfortable to massage.

Parahoo, (2006) notes that application of antenatal perineal trauma helps a lot in reducing both the perineal trauma during birth and the associated pain afterwards. Majority of women are keen to give birth without any perineal cuts, tears or stitches as they in most cases cause severe pain and discomforts later on which can impact adversely on their sexual functionalities. Administering perineal massage especially during the last month of pregnancy has been found to be an appropriate way of enabling the perineal tissue to expand with a lot of ease during child birth (Feldman, 2001).

Researches have shown that perineal massage undertaken either by the woman or her partner for at least twice a week reduces heavily the chances of developing perineal trauma and the subsequent perineal pain (Wagner & Marsden, 2006). This becomes clear especially on those women who have never given birth before. Antenatal perineal massage has the potentiality to significantly reduce the chances of perineal trauma and the associated perineal pain (Bodner et al, 2002). This method is generally well accepted by women. It is thus imperative that women all over the world are well informed of the benefits of applying perineal massage and also provided with the relevant information on how to apply it (Wagner & Marsden, 2006).

According to Labrecque et al (1999), appropriate antenatal perineal massage applied from approximately the 35th week of gestation reduces significantly the likelihood of perineal trauma that may need stitching. In addition women who do the massage are less likely to develop cases of perineal pain at three months after the birth.

Definition of terms

Perineum: this is the area of tissue that lies between the vagina and the anus. The perineum muscles connect with the muscles of the pelvic floor. The perineum is very important especially in women to (Labrecque et al, 1999). Tearing or stretching of the perineum during child birth can most likely remove support from the back wall of the vagina thereby making dropping down of the uterus more likely. Having a weak pelvic floor can also result in the incontinence of the bowels and the bladder. Further, trauma to the premium may lead to discomfort and a lot of pain when making love (Johanson, 2000).

Perineal massage: perineal massage is a form of therapy that is administered to prepare the perineum to stretch with a lot of ease during child birth. Perineal tissues need to stretch out during the birth process so as to allow the baby to pass out through the vagina easily (Johanson, 2000). Perineal massage is important in a number of ways:

It increases the elasticity of the perineum muscles. This helps in improving the rate of blood flow to the perineum and its capacity to stretch out more easily and with less pain during birth.

It reduces chances of tears in the perineum and also the chances of needing an episiotomy.

Helps reduce the degree of pain after birth.

Perineal trauma is a common occurrence that affects women during child birth and it is estimated that more than 85 percent of all women who deliver will sustain some degree of the trauma. Perineal trauma morbidity as relates to child birth constitutes a major global health challenge (Gomme, Sheridan & Bewley, 2004).

This potential morbidity which is mostly associated with vaginal birth is a major issue of concern for both women and midwifes. Severe perineal trauma can result in feacal inconsistency, dysparnea as well as perineal pain. In his book, Bodner et al, (2002) suggests that perineal trauma can cause serious psychological problems for women. This can make them fearful of future pregnancies, a thing that can eventually lead to feelings of isolation and loss of social identity.

More psychological effects of the trauma can as well impact adversely on women’s relationships with their partners and the linkages with their newborns (Beckmann & Garrett, 2006). Researches have indicated that perineal trauma contributes a lot to an increase in requests for caesarean sections. The reduction in routine episiotomy means that the majority of this trauma is spontaneous (Beckmann & Garrett, 2006). Considering all these factors, it emerges that any method proven to reduce the likelihood of sustaining the effects of perineal trauma has to be recommended. Preventing the effects of this trauma on women will be of great benefit to a large number of women.

A problem based learning case study, recently undertaken, highlighted a lady who gave birth in a stand alone birthing centre. Mr. Gorski achieved a normal vaginal delivery with an intact perineum. The author undertook an extensive literature search to establish what clinical care could be provided that would enable women to give birth without genital tract trauma. This essay reviews the literature on perineal massage and its effects upon the incidents and morbidity associated with perineal trauma

Researches on major databases on maternity and postnatal care reveal lots of articles on the subjects. The quantity of literature retrieved from these articles is very much relevant. Most of these literature is however very quantitative in nature and as such provide hard objective facts that can be statistically analyzed and interpreted. This research perspective is consistently in line with many of the questions that midwives have to answer in respect of this research topic. Most of the literature developed so far in many countries show that the need to reduce the effects of perineal trauma is an issue of world wide concern that requires concern efforts that transcend political boundaries (Parahoo, 2006).

It is in light of these that several stakeholders worldwide have stepped up advocacy for the use of perineal massage antenatally as a possible way of reducing perineal trauma associated with vaginal birth (Beckmann & Garrett, 2006). It is widely believed that perineal massage can increase the flexibility of the perineal muscle and thus decrease the degree of muscular resistance. This enables the perineum to stretch freely without tearing or developing lacerations. Perineal massage is a more recent and developing concept in the discipline of midwifery and as such as not taken roots deep. This practice is widely advocated by the National Institute for National Excellence (NICE). This institute has developed guidelines for advising women on how to go about it (Bodner et al, 2002).

Various organizations have advocated the use of antenatal perineal massage to decrease the incidents and rate of perineal trauma during vaginal birth to (Labrecque et al, 1999). NICE recommends that oil or any other recommended lubricant should be used to massage the perineal muscles for up to five times a week as from the 34th week of pregnancy. This, according to the institution’s research increases the likelihood of having an intact perineum after delivery especially in nulliparous women (Beckmann & Garrett, 2006).

Beckmann & Garrett carried out a systematic review on the effect of antenatal massage on the incidents of perineal trauma at birth. The purpose of a systematic review is to find answers to a particular issue or problem (Cronin, et al 2008), it is an approach used to summarize, appraise, and communicate the results of otherwise unmanageable quantities of research (Macinnes, 2010).All available research studies on a particular topic are identified, analysed and a conclusion reached. This type of review produces the ‘best available evidence’ on which practice can be based, (Polit & Hungler 1995).

The aim of the systematic review was to assess the effect of antenatal perinatal massage on the incidents of perineal trauma at birth. All published and unpublished randomised and quasi-randomised controlled trails evaluating any described method of antenatal perineal massage were considered for the review. Macinnes, (2010) describes how, a literature review should give an overview of all the current literature surrounding the topic of interest. All pregnant women who were planning a vaginal birth and had undertaken perineal massage for at least the last four weeks of pregnancy using any method of perineal massage or device.

Data collected and analysed by both authors independently who applied the selection criteria to the studies assessing study quality, study authors were contacted directly for additional information. Four trails were included in the study (2497 women) comparing digital perineal massage with control. Antenatal perineal massage was associated with an overall reduction in the incidents of trauma requiring suturing (four trais, 2480 women, and risk ratio 0.19. results also show that women carrying out massage were less likely to have an episiotomy; however these results are only significant for women without previous vaginal birth. Data sources included an Electronic search including the Cochrane Pregnancy and childbirth (2008), Medline, PubMed (1966 to June 2008), and Embase (1980) using their search strategy, researchers were also contacted directly.

No language or study type constraints were imposed allowing a recently published Japanese study to be included, however the Japanese study was the only study to be carried out within the past 10 years, and all other studies are more than ten years old. It is important to pay attention to the publication dates of the literature reviewed, (Parahoo2006), however more recent research of good quality, on the topic was limited. Midwives are seen to be guardians of the perineum and often regard an intact perineum after delivery with pride (Robertson , 2002). Walsh, 2007) describes how midwives use a variety of strategies, techniques and maneuvers before during and after delivery in an attempt to reduce perineal trauma, the optimum outcome for mother and midwife is an intact perineum.

Several empirical researches have shown that antenatal perineal massage can be very helpful in preventing perineal lacerations and episiotomy (Beckmann & Garrett, 2006). In 1999, there was an article in the American Journal of Ob/Gyn by Labrecque in which the effectiveness of perineal massage during pregnancy for preventing perineal trauma at birth was investigated. Women participants in the experimental groups were voluntarily requested to perform about a fifteen minute perineal massage daily from the thirty-fifth week of pregnancy until they delivered. The massage primarily involved introducing one or two fingers at up to about three to four centimeters into the vagina and applying and maintaining pressure — first downward for approximately two minutes and then for further two minutes onto each side of the vaginal entrance. The women were freely given a bottle of sweet almond oil to use as a lubricant in the exercise.

The result of this research study showed that among the women participants without a previous vaginal birth, about 25 percent of them from the perineal massage group and fifteen percent from the control group were delivered vaginally with an intact perineum, with about ten per cent absolute difference. This incidence intact perineum delivery increased with compliance in regular practice of the antenatal perineal massage (Beckmann & Garrett, 2006).

As for the women with a previous vaginal birth, about thirty five per cent and thirty two per cent in the massage and control groups, respectively, made deliveries with an intact perineum, for an absolute difference of about three percent (Beckmann & Garrett, 2006). There were no statistically significant differences between the groups in the frequency of sutured vulvae and vaginal tears, women’s sense of control and satisfaction with the delivery experience. The researchers in this experiment concluded that concluded that perineal massage is a very effective approach to increasing the chances of child delivery with an intact perineum for women with a virgin vaginal delivery, but not for women who have had a previous vaginal birth (Beckmann & Garrett, 2006).

More researches on this subject have indicated that slow and controlled vaginal delivery is the key to an intact perineum and reduced incidence of perineal lacerations and subsequent pain (Beckmann & Garrett, 2006). The baby, who is the primary subject of the midwife’s practice, must not suffer any form of fetal distress and as such, the mother and her partner must listen closely to the midwife or health care provider for advice on when and how to push and when to stop pushing. The other extra advantage of performing antenatal perineal massage may be to allow for the mother to give a normal vaginal birth without developing any episiotomy or laceration (Gomme, Sheridan & Bewley, 2004).

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