Originally published in Massage & Bodywork magazine, December/January 2001.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

Childbirth, although a perfectly natural physiological process, can be very painful and physically traumatic for the mother. New and improved alternative approaches to labor pain have afforded many women some relief during that part of the process, but there remains a major problematic area - lacerations in the perineum area (between the vagina and rectum), with resultant postpartum pain and possible permanent damage. For years, physicians have performed episiotomies (surgical cutting of the perineal tissue) to enlarge the birth canal with the intention of decreasing damage and easing the birth. But recent research has revealed that episiotomies are not only ineffective, but also can be harmful to the mother. Antenatal perineal massage, usually performed by the mother or her partner during the latter part of pregnancy, is emerging as a safe and proven alternative, reducing perineal tears and decreasing pain, both during birth and after delivery.


The Case Against Episiotomy
Perineal trauma, a common occurrence during delivery, affects as many as 85 percent of women giving birth.1 While spontaneous lacerations can contribute to genital tract trauma, with instrumental and first vaginal deliveries increasing the risk2, episiotomy is considered the most prevalent cause of this problem, producing "trauma similar to a spontaneous second-degree perineal tear."3 Several studies have proven other ill effects of episiotomy, such as sphincter muscle damage and more blood loss than with a caesarean section.4 Doctors at Harvard Medical School, in a retrospective study of more than 600 mothers, determined that, "Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence," with episiotomy tripling the risk for postpartum anal incontinence in comparison to spontaneous lacerations.5 Spontaneous tearing, when it does occur, is more likely to be superficial, not involving muscle tissue, and less likely to cause postpartum pain, infection (which can lead to death) and painful intercourse.6

Although these recent studies have indicated severe risks to the mother when episiotomy is performed, the average rate for its use in the United States is more than 50 percent, with some hospitals reporting 90 percent.7 Not only is this procedure potentially dangerous, but it also increases medical costs and recovery time, and can have a negative affect on the mother's satisfaction with the entire birth experience. Researchers are now calling for an end to this routine practice, reserving the procedure for high-risk cases such as fetal distress. In reply to the Harvard study, physicians at Georgetown University Medical Center had this to say: "As medical knowledge advances, it is conceivable episiotomy may one day join such extinct operations as blood letting, high forceps delivery...(and other procedures)...which are now considered crude and barbaric, but were once widely practiced, in the books of medical antiquity."8

While eliminating this archaic practice as routine may solve the problem of unnecessary harm, it leaves the task of finding a better solution. Even with the restriction of episiotomy use, women are still at risk of perineal trauma, with as many as 50 percent sustaining lacerations which require multilayer suturing.9 For years, midwives have advocated the use of perineal massage as an alternative to increase elasticity and prevent perineal trauma, and now with the increasing criticism of indiscriminate episiotomy, the medical field is taking a serious look.


The Case for Perineal Massage
Early perineal massage studies during the mid-80s and early '90s lacked strength because of small sample sizes, methodological problems and variations in compliance by subjects, although a few indicated positive results in decreasing episiotomy and perineal tears. In 1994, Canadian researchers, Labrecque et al published a pilot to establish feasibility of a larger randomized, controlled study on the use of antenatal perineal massage. The pilot was too small to be statistically significant, with the study team reporting no positive results. Using the pilot to establish necessary criteria for a larger study, the team determined the sample size needed, and strategies for compliance, recruitment and a lowered episiotomy rate. They found the women in the study to be very accepting of perineal massage. Even those who did not benefit indicated they would use it in their next pregnancy and recommend it to others. Researchers also noted that perineal massage provided psychological benefit by giving the women an opportunity to take an active role in preparing for the birth process.10

In 1997, before completion of Labrecque's larger, second trial, a major project was published by Shipman et al in the British Journal of Obstetrics and Gynecology. Results of this single-blind, randomized, controlled study of 861 nulliparous (never delivered a child) women indicated statistical significance for the benefits of perineal massage. Adjusting for mother's age and infant's birthweight, the team noted a 6.1 percent reduction of second- or third-degree tears or episiotomies, and a reduction of 6.3 percent in instrumental deliveries in the massage group.11

Both the massage and control subjects were requested to perform pelvic floor exercises throughout the day, from 29 to 32 weeks gestation up to the day of delivery. The massage group was given verbal and printed instruction on perineal massage, to be administered three to four times weekly, for four minutes, beginning six weeks before their due date. Sweet almond oil was provided to each massage subject as a lubricant. Participants were requested to keep a record sheet of their daily practice and to fill out a questionnaire after delivery. Only 32.9 percent of the massage group complied fully with the massage protocol, with 52.1 percent complying partially. Nineteen women in the control group (no massage) reported practicing the perineal technique. Despite the lack of full compliance, the massage group evidenced overall benefit.12

When researchers analyzed results by age, it was found that women aged 30 and over had "a significant reduction of 12.1 percent in perineal trauma and 12.3 percent in instrumental deliveries." The team noted the increased benefit to this age group may be related to the gradual decline of elasticity and suppleness of the tissues as age increases, restricting the stretching capacity of the perineum. Highlighting limitations of the study, authors said the sample size "was not large enough to look at differences in benefit due to the amount of massage actually carried out," as reflected in the 66 percent return rate of daily massage record sheets. Either a larger sample size or a method of improving completion rate were suggested to examine this aspect.13

In conclusion, researchers commented on the overall benefit to the mother of perineal massage, noting that in addition to reduced medical costs and less instrumental deliveries, "reduction in perineal trauma reduces the pain and discomfort felt by women in the early postnatal period. This will encourage comfortable mobilisation (sic), enjoyment of the newborn and possibly even breastfeeding. There may also be a reduction in the need for antibiotics."14

Labrecque and his colleagues published the results of their second, larger perineal massage project in 1999, with even more impressive findings than the Shipman study. Objectives of the single-blind, randomized trial were expanded to include effect of massage on: delivery with an intact perineum, rate of episiotomy, severity of perineal lacerations, and occurrence of vulvovaginal tearing. In addition, the team "assessed whether perineal massage increased women's sense of control during labor and delivery and their satisfaction with the experience." Of the 1,524 women in the study, 493 were multiparous (having one or more previous vaginal births), in contrast to Shipman's group of exclusively nulliparous mothers. Instruction of the perineal technique was provided to the massage group by a nurse, with the control group receiving only routine obstetric care.15

Massage participants were asked to practice the technique daily for approximately 10 minutes, beginning at 34 to 35 weeks gestation, and were provided sweet almond oil for lubrication. The technique consisted of applying and maintaining downward pressure with one or two fingers in the vagina (3-4 cm deep) for two minutes, then for two minutes each to either side of the opening. To encourage compliance, massage subjects were contacted by a nurse after the first and third weeks. Ninety percent of nulliparous subjects and 85 percent of multiparous subjects returned their daily diary. On assessment, 66 percent of nulliparous women practiced the technique four or more times per week for three weeks with 85 percent participating on at least one-third of the days assigned. Those with previous vaginal births had a slightly lower compliance rate. In addition to medical data obtained from the physician, information concerning the mother's feelings of control, attitude toward the massage and satisfaction with the birth was gathered through a self-administered questionnaire completed within days after delivery.16

Results showed "perineal massage is an effective approach to increasing the chance of delivery with an intact perineum for women with a first vaginal delivery," 61 percent higher than in the control group. However, for those with a previous vaginal birth, there was no statistical significance in outcome. The study team reported a dose-response effect of massage, with increased practice being associated with increased likelihood of keeping the perineum intact. For first vaginal deliveries, episiotomy rates decreased in the massage group, but the difference between the two groups in regard to third- and fourth-degree lacerations was not statistically significant. There was no difference between the two groups in mothers' feelings of control and satisfaction with the birth, but researchers noted that factors of intrapartum care, rather than perineal massage, were likely the major influence in the womens' self-assessment of their experience. However, as in the previous pilot study, women in the massage group (80 percent nulliparous and 77 percent multiparous) indicated they would use the technique in a subsequent pregnancy and recommend it to other pregnant women.17



Postpartum Results
A follow-up study published earlier this year by Labrecque focused on the effect of perineal massage on perineal symptoms three months after delivery. Using the same protocol as the previous study but with a smaller subject population, the team addressed several postpartum concerns: pain, dyspareunia (painful intercourse), sexual satisfaction and anal incontinence. They noted that patients and medical staff had expressed concerns regarding the post-delivery integrity of the perineal area with regard to possible decreased strength and permanent enlargement. Results indicated there were no statistically significant differences between the control group and massage group in any of the above stated concerns. In conclusion, authors stated, "The benefits of prenatal perineal massage in preserving the integrity of the perineum at birth do not translate into better perineal function at three months postpartum. Nevertheless, the concerns that perineal massage might impair sexual function and increase the likelihood of urinary incontinence can be safely laid to rest."18

Women in the United States are once again taking an active role in deciding how their child will be born, reclaiming their natural ability to accomplish this right of passage into motherhood. The mothers involved in these studies have expressed whole-hearted support of perineal massage. Despite the case against episiotomy, there are still physicians clinging to routine use of an outdated and harmful surgical procedure which should be reserved for situations of distress. Studies such as those from Labrecque and Shipman have opened the door to change, providing scientific proof of the effectiveness of yet another gentle alternative to the medicalization of childbirth.

Shirley Vanderbilt is a staff writer for Massage & Bodywork magazine.

References
1. Schwanke, Jane. "Vaginal Massage Can Reduce Some Childbirth Pain and Procedures." WebMD Medical News http://my.webmd.com/content/article/1728.54268 (9 Sept. 2000).
2. Renfrew, M., Hannah, W., Albers, L. and Floyd, E., "Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature," Birth 25, 3 (Sept. 1988): 143.
3. Labrecque, M., Eason, E., Marcouz, S., Lemieux, F., Pinault, J., Feldman, P. and Laperriere, L., "Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy," American Journal of Obstetrics and Gynecology 180, 3 (March 1999): 593.
4. Oyelese, K.O., Porter, A. and Wai, C. "Is episiotomy ethically acceptable?" bmj.com . http://www.bmj.com/cgi/eletters/320/7227/86#EL1 (9 Sept. 2000).
5. Signorello, L., Harlow, B., Chekos, A. and Repke, J. "Midline episiotomy and anal incontinence: retrospective cohort study." bmj.com. http://www.bmj.com/cgi/content/abstract/320/7227/86 (8 Jan. 2000).
6. Douglas, Ann. "Perineal massage eases the pain of childbirth." CNN.com. http://www.cnn.com/2000/HEALTH/women/04/18/episiotomy.health.wmd/ (9 Sept. 2000).
7. McKeown, L. A. "Common Procedure During Delivery Linked to Lasting Rectal Injuries: Widespread Use of Episiotomy Called into Question." Web MD Health. http://my.webmd.com/content/article/1728.53980 (9 Sept. 2000).
8. Oyelese.
9. Labrecque, 593.
10. Labrecque, M., Marcoux., S., Pinault, J.J., Laroche, C. and Martin, S., "Prevention of perineal trauma by perineal massage during pregnancy: a pilot study," Birth 21, 1 (March 1994): 21-24.
11. Shipman, M. K., Boniface, D. R., Tefft, M. E. and McCloghry, F., "Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial," British Journal of Obstetrics and Gynaecology 104, 7 (July 1997): 787, 790.
12. Ibid., 788-790.
13. Ibid., 790.
14. Ibid.
15. Labrecque, American Journal of Obstetrics and Gynecology, 593, 595.
16. Ibid., 594-595.
17. Ibid., 596-599.
18. Labrecque, M., Eason, E. and Marcoux, S., "Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery," American Journal of Obstetrics and Gynecology 182, 1 (Jan. 2000): 76-80.