EVIDENCE-BASED ANSWER
Yes—to a point. Antepartum perineal massage reduces both the incidence of perineal trauma requiring suturing and the likelihood of episiotomy in women who have never given birth vaginally. It reduces the incidence of postpartum perineal pain in women who have given birth vaginally. Perineal massage doesn’t reduce the frequency of first- or second-degree lacerations or third- and fourth-degree perineal trauma. (Strength of recommendation [SOR]: A, systematic review of randomized controlled trials [RCTs].)
Clinical commentary
Raise the subject, then let the patient decide
Timothy E. Huber, MD
Oroville, Calif
Perineal massage is relatively easy to describe and do, but its intimate nature can make physicians and patients alike feel uncomfortable. The benefit for primigravid women justifies asking appropriate patients at least an exploratory question or 2 during early and second-trimester visits.
A question such as, “How much do you know about the process of having a vaginal delivery?” often prompts inquiries about pain control, delivery techniques, episiotomy, and tears. These inquiries can provide an opportunity to discuss perineal massage as a safe, effective technique to reduce the chance of an episiotomy, need for suturing, and long-term postpartum pain. Letting the patient make up her own mind can give her more confidence as the big day approaches.
Evidence summary
A systematic review evaluating whether antepartum perineal massage reduced perineal trauma included 3 RCTs with a total of 1941 primagravidas and 493 multigravidas.1 Women were randomized to receive either instruction in perineal massage or no instruction.
Beginning at 34 weeks, women or their partners performed perineal massage for 4 minutes, 3 to 4 times a week,2 or once a day for 10 minutes.3,4 Massage was performed by inserting 1 or 2 fingers 3 to 5 cm into the vagina and sweeping downward and from side to side, using almond oil for lubrication.
Birth attendants were blinded to patients’ assignments. All studies evaluated immediate postpartum outcomes; 1 study included a 3-month follow-up questionnaire.3
Massage reduces trauma, but less is more
Massage reduced perineal trauma requiring suturing by 10% among primigravid patients, compared with controls (relative risk [RR]=0.90; 95% confidence interval [CI], 0.84-0.96; number needed to treat [NNT]=14). Subgroup analysis revealed an inverse relationship between reduced trauma and frequency of massage: Primagravidas who massaged fewer than 1.5 times a week showed a 17% reduction (RR=0.83; 95% CI, 0.75-0.92; NNT=9), compared with an 8% reduction for women who massaged 1.5 to 3.4 times a week (RR=0.92; 95% CI, 0.85-1.00; NNT=22) and a statistically insignificant 7% reduction for the group that massaged more than 3.5 times a week (RR=0.93; 95% CI, 0.86-1.02).