In this episode we are continuing our series on protecting the perineum by talking about the evidence on whether prenatal perineal massage during labor (more specifically, during the pushing phase) is effective at preventing severe perineal tears. We’ll also discuss the importance of critically analyzing research, and poor quality meta-analyses can have a negative impact by spreading inaccurate information! Head’s up… if you haven’t listened to EBB Episode 206 yet, I recommend listening to that episode first, since it covers introductory information about perineal tears.
Content warning: Discussion of perineal tears during childbirth, severe tears, obstetric violence, and episiotomy.
Check out Episode 206 of the EBB Podcast to learn about perineal tears and avoiding episiotomy, Episode 210 to learn about warm compresses and hands on vs. hands off techniques, and Episode 216 to learn about perineal massage during pregnancy.
Go to our YouTube channel to see video versions of all our podcasts! (including PowerPoint presentations when used)
Visit https://evidencebasedbirth.com/childbirth-class/ to learn more about the Evidence Based Birth Childbirth Class.
Take a continuing education class on this topic (and earn a contact hour) by joining the EBB Professional Membership here: https://evidencebasedbirth.com/become-pro-member/
- Aquino, C. I., Guida, M., Saccone, G., et al. (2020). “Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials.” J Maternal Fetal Neonatal Medicine 33(6): 1051-1063. https://pubmed.ncbi.nlm.nih.gov/30107756/
- Aasheim, V., Nilsen, A. B. V., Reinar, L. M., et al. (2017). “Perineal techniques during the second stage of labour for reducing perineal trauma.” Cochrane Database of Sys Rev Issue 12. Art. No.: CD006672 https://pubmed.ncbi.nlm.nih.gov/28608597/
- Stamp, G., Kruzins, G., Crowther, C. (2001). “Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. BMJ 322:1277-1280. https://pubmed.ncbi.nlm.nih.gov/11375230/
- Albers, L. L., Sedler, K. D., Bedrick, E. J., et al. et al. (2005). “Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial.” J Midwifery Womens Health 50: 365-372. https://pubmed.ncbi.nlm.nih.gov/16154062/
- Attarha, M. V., Akbary, N., Heydary, T., et al. (2009). “Effect of perineal massage during second phase of labor on episiotomy and laceration rates among nulliparous women.” Hayat 15(2): 15-22. Published in Farsi. https://hayat.tums.ac.ir/browse.php?a_id=117&sid=1&slc_lang=en
- Geranmayeh, M., et al. (2012). “Reducing perineal trauma through perineal massage with vaseline in second stage of labor.” Arch Gynecol Obstet 285(1): 77-81.
- Sohrabi, M. I., Shirinkam, R. (2012) “The effectiveness of physical therapy techniques in the second stage of labor on perineal trauma in nulliparous women referring to the teaching hospital of Emam khomeini- Khalkhal. J Urinia Nursing and Midwifery Faculty 10(3): 1-8. http://unmf.umsu.ac.ir/browse.php?a_id=946&sid=1&slc_lang=en
Rebecca Dekker: Hi, everyone. On today’s podcast. We’re going to talk about the evidence on perineal massage during the pushing phase and whether it’s effective at preventing perineal tears during childbirth.
Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD. I’m the founder of Evidence Based Birth®. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
Hi, everyone. And welcome to today’s episode of the Evidence Based Birth® podcast. My name is Dr. Rebecca Dekker. Pronouns, she, her. And I will be your teacher for today’s episode. Today I’m so excited to bring to you some evidence-based information about perineal tears and some research on a method that is sometimes used to prevent perineal tears and is perineal massage during the pushing phase of labor.
Before we get started, I want to let you know upfront that we will be talking about some topics, including tears of the vagina, severe tears from the vagina to the rectum, obstetric violence, and traumatic childbirth, and episiotomies. So today’s episode is the fourth in a series that we’re doing this year called protecting the perineum.
In the first episode, which was episode 206 of the EBB podcast, I talked with you about what are perineal tears? what are the factors that increase your risk of having a perineal tear during childbirth? What are the health consequences of experiencing a tear? And why it’s so important to avoid an episiotomy?
And in the second episode, which is episode 210, I talked about warm compresses, the hands-on technique, and the hands-off technique for preventing tears. And the third episode, which was episode 216, I talked about the practice of perineal massage during pregnancy. And I revealed how some of the research on that topic is highly flawed and perhaps even fraudulent. So we don’t have good evidence supporting that practice.
If you haven’t listened to those episodes already, I’d encourage you to go back and listen, especially to episode 206, because each episode builds on the one before. Also, you might be listening to this on a podcast app, but I also wanted to let you know that there is a video of this episode on our YouTube channel. The videos tend to come out the afternoon after our morning release. So if you’re more of a visual learner, I encourage you to visit and subscribe to the EBB YouTube channel. I will be sharing a few PowerPoint slides when I go through a couple of the studies.
Finally, before we get started, I want to quickly define the perineum. The perineum is a diamond-shaped area that’s between the thighs. And in birthing people, it’s going to be the area that is between the synthesis pubis or the front of the pelvis and the rectum. So when we’re talking about protecting the perineum, we’re talking about protecting that tissue from tears or from being cut. And in particular, we’re talking about protecting the tissue that makes up the space between the vagina and the rectum.
Perineal tears, or tears of the perineum that can happen during childbirth can be it as first, second, third, or fourth degree. A first degree is the least severe. And a fourth degree is the most severe. The most important thing we want to do is lower the risk of experiencing a severe tear, sometimes called severe perineal trauma. These are third or fourth-degree tears, and they’re also called OAC tears or OASI. These tears can have severe health consequences.
In episode 206, I talked about the factors that can decrease or increase your risk of having a severe tear and the importance of avoiding an episiotomy. So a lot of the time when we’re looking at practices, like we’re going to do in this episode, we’re looking to see if they’re effective for helping you avoid severe perineal trauma, as well as whether or not they’re effective for helping you avoid episiotomy.
We also look at the effectiveness of having an intact perineum, which means you are able to leave the birth without having any knee stitches. So are you ready to dive into the evidence with me? Let’s get started. So perineal massage during labor is a practice that is done with the intent of stretching out your perineum so that your baby’s head can pass through the birth canal without causing any tears.
Now, clinicians are divided on whether or not it’s beneficial. In research studies, perineal massage during labor is usually done in the second stage or the pushing phase of labor. And it’s usually performed by the clinician introducing their middle and index fingers into the vagina to gently stretch the perineum from side to side, using a water-soluble lubricant. In one research study, they called it ironing the perineum.
However, in real-world settings, it might not always be done this way. Perineal massage can be gentle, or it can be much more vigorous, or rough, or painful. And the use of lubricants vary. In research studies, they almost always use a water-soluble lubricant. Whereas in hospital settings, they might use some kind of oil. I’ve even seen this is really gross and scary, but I’ve heard many stories of clinicians using baby shampoo. Like Johnson’s and Johnson’s baby shampoo to make their gloves slippery as they do the massage. And that is very awful for the microbiome of your vagina.
As someone who’s giving birth, what you might experience with perineal massage is while you’re pushing your care provider is sitting at the bottom of your bed in between your legs. Again, this is assuming you’re giving birth in bed in a semi-sitting or kind of semi-laying back position, which is sadly very common in many hospital settings. So the care provider will put gloves on their hands and a gown on. They’ll put some kind of lubricant on two fingers. And they put the two fingers in your vagina and push down. Then to the side. And then they push in a sweeping manner, from the right side of your vagina, down to the bottom, then to the left side, then back to the bottom, and repeat. So kind of making like a U shape around the vagina.
If you don’t have a doctor or midwife in the room yet, a nurse might perform the massage while they’re waiting for a doctor or midwife to arrive. And as I said, usually in research studies, they’re very particular about making sure the massage is gentle, but I hear reports from doulas and labor nurses around the world that sometimes this is done in extremely rough, aggressive manner, even sometimes. And we’ll talk more about that later on.
So one of the first things I do when I’m looking at the research on a subject is I look to see if there are any meta-analyses. Meta-analyses are usually great because they do all the hard work of searching to find all of the studies in a particular issue. And they evaluate the studies and then they combine the data into a meta-study known as a meta-analysis.
There was one published by Aquino et al in the journal of maternal-fetal and neonatal medicine in 2020. And the authors claim that this is the largest most comprehensive meta-analysis on this topic. Overall, they looked at nine randomized control trials that had more than 3,300 participants. They are specifically low looking for research studies where people were assigned to receive the perineal massage during labor versus no massage.
And they were primarily interested, their primary outcome was whether the perineal massage reduced severe perineal trauma. And they only found five randomized control trials on that topic. In most of the trials that they included, the massage was done by a midwife during the pushing time or between pushes. And it was usually performed, as I mentioned earlier, by introducing the middle and index fingers and gently stretching the perineum from side to side with the water-soluble lubricant.
In a couple of studies, the perineal massage was started during the late first stage before people were completely dilated, but most of the time it was done in the second stage during the pushing phase. To give you a heads up episiotomy rates in most of these studies were high. So it’s not really clear if this evidence is going to be able to be applied to settings where episiotomies are low.
I’ve talked about this in previous episodes, but ideally, the episiotomy rate would be less than 1%. And the best clinicians that I know maybe only cut one or two episiotomies in their entire career of 30 or 40 years. So having episiotomy rates of 20 to 30 to even 80% are incredibly high. Although you can see rates as high as 25% in some U.S. hospitals. It’s not as common today. In some countries rates, though, of episiotomies are extremely high. And it has nothing to do with the quality of tissue and whether or not it can stretch. It has everything to do with the training of the obstetricians in those communities.
So Aquino et al said that when they combined the data, they found that participants assigned to massage during labor had a 50% lower rate of severe perineal trauma. They did some analyses looking at if this was your first baby or people had given birth before. And they found that perineal massage was most effective when used with people giving birth for the first time and during the second stage of labor. They said, “Given the benefit and lack of harm, we believe perineal massage and late labor, in particular, in the second stage in nulliparous women could become routine.”
So that seems pretty straightforward. Massage is beneficial. It may lower the rate by 50%. And by that, I mean if the rate of severe tears was 3%, maybe it could lower it down to 1.5%. You’re reducing it by half. That’s what a 50% risk reduction means. However, if you listen to the last episode in this series in episode 2016, I talked about perineal massaging during pregnancy and how the meta-analyses on that topic were misleading. Because if you looked at the individual studies, some of the more highly flawed and maybe even fraudulent, so was like already my suspicion alert, my sus alert was really high for these studies.
So I already knew I was probably going to have to pull the individual studies. And that’s what we’re going to talk about. We’re going to find out was Aquino et al really giving us the true story, or is there more to the picture. Before I went to look at each of those studies individually, there was another meta-analysis published in 2017 by Aasheim et al. This was a Cochran review. And they also found that perineal massage during the second stage reduced severe tears by half. And they called it moderate-quality evidence.
They also found that the rate of intact perineum with massage, and they called that low-quality evidence. So now I’m going to show you some PowerPoint slides. So we can kind of look at the individual studies together. There were five studies that the meta-analysis authors claimed, when you combine them, you see results. So let’s look at those five.
Okay. So there were only five randomized controlled trials included in these meta-analyses that reported on the primary outcome of whether or not perineal massage during labor can reduce the risk of having a severe tear. We’ve got one by Stamp et al, published in 2001, in the British Medical Journal, Albers et al published in 2005 by the Journal of Midwifery and Women’s health Attarha et al, published in 2009 in a Journal from Iran that is published in Farsi, which is a different written language, a study by Geranmayeh et al, published in 2012 and the Archives of Gynecology and Obstetrics, and a study by Sohrabi et al published in 2012 in the Journal of Iranian Nursing and Midwifery Faculty, which is another journal that is published in Iran in the written language of Farsi.
Now, the Cochran view is said that the study by Guran Maya, the one by aha, and so all were at high risk for bias. The stamp and Albert’s studies were higher quality while the other three were at higher risk for bias. So let’s look at them in chronological order, but we’ll start with the two that were seemed to be of higher quality. So stamp at all, published in 2001 was the largest randomized control trial ever published on this topic.
And it took place at three large hospitals in Australia between 1995 and 1998. There were about 1300 participants. They were being cared for midwives. About half of them were giving birth to their first baby. And half of them had given birth before. They were randomly assigned to receive perineal massage during the second stage of labor or to receive the midwife’s usual practice.
The perineal massage, if performed, happened during the second stage. The midwife would insert two fingers and use a water-soluble lubricant to stretch the vagina with a sweeping motion. And they stopped if it was uncomfortable for the participant. Episiotomy rates in the study were fairly high. They were between 25 and 27%. And this was not different between groups. This study was rated by the Cochran reviewers as being at low risk for bias. And in reading this study myself, it seems like it’s a very good quality.
The main problem though, is that the episiotomy rates are high. And so these results might not transfer to places where episiotomy rates are low. The researchers found no differences in the rates of intact perineum, the episiotomy, first or second-degree tears, or pain scores at three days, 10 days and three months after the birth. Overall, the results for the participants were pretty good, regardless of which group they were in. And there was only one fourth-degree tear in the entire study.
There was a slight trend towards a lower risk for a third-degree tear. There was a 1.7% risk in massage group versus a 3.6% risk in the control group. But these results were not statistically significant. The authors said that in order to see a difference between groups on third and fourth-degree tears, you’d probably need a sample size of at least 2,500. And this study only had 1340.
The authors also found no difference between groups in urinary or fecal incontinence or sexual satisfaction. One of the things you look for in these studies is whether or not the assessments, like checking and rating the degree of tears, are performed by an independent practitioner who doesn’t know which group that the client was in.
So most of the assessments were performed by independent practitioners. And they did a sub-analysis of those results and found similar results. The researchers concluded that there was no benefit to perineal massage, but there was no harm either. And it’s important to note that the most common reason for declining to participate in the study was because people did not want the perineal massage or they were not interested in being in this study.
The next study was published in 2005 by Albers. This study was carried out between the years 2001 and 2005, at the University of New Mexico, with 12 experienced certified nurse-midwives. They described the perineal massage is a gentle massage with two fingers moving from side to side. And that mild downward pressure was applied with steady side-to-side strokes that lasted about one second in each direction.
The massage was carried out during and in between pushes. And the pressure was dictated by the participants’ response. Out of the 1,211 participants or only 10 episiotomies were cut in the entire study. And none of the episiotomies extended to a third or fourth-degree tear. So we had about 1,200 participants. They were randomly assigned to one of three groups. You could either begin a group where you got a warm compress, a group where you received perineal massage with a lubricant, or a hands-off group.
Interestingly, none of these interventions had superior outcomes to the others. And overall these midwives had excellent outcomes with their clients. 73% of the participants had no need for stitches. That’s an incredibly high intact perineum rate. And the severe tear rates were very low. 0.7 to 1.5%. The author suggested that they’re a midwifery culture of favoring slow, calm, delivery of the head and a slow expulsion of the infant non-Valsalva pushing, which means you don’t hold your breath and push you breathe while you push, as well as giving birth and upright positions in delivering the baby’s head in between contractions may have contributed to their overall excellent outcomes, regardless of whether people got warm compress massage with lubricant or hands-off.
In this setting where the midwives already had such high intact perineum rates, that it wouldn’t make a difference to use a warm compress or to massage with lubricant.
Now, it’s very difficult to find any research that looks at satisfaction or pain levels with this intervention. So I did want to point out that these researchers did report that 13% of the people assigned to massage ask the midwife to stop massage.
So now we’re going to move on to some of the more recent studies that are smaller and not as high quality. The study published by Attarha et al in 2009, included 204 first-time mothers in Iran, randomly assigned to gentle perineal massage versus what they called maneuvering only. Maneuvering is probably something called the Ritgen’s maneuver, which I’ll explain in a few minutes.
The author said that the OB decided if an episiotomy would be used or not. All of the patients were put in the let lithotomy position for the delivery, meaning they were laying back with their feet and strips. The researchers split up shifts so that they would each have equal numbers of delivery of the massage and control groups. So this study is limited by the fact that the researcher knew who was in each group, the researcher was present at the birth of the baby, and the researcher did the assessment to figure out how they would rate the findings.
This is what we call a lack of blinding. And although it’s not always possible to “blind” people to groups assignments, you really should not have the researcher who is responsible for the results and knows with group people are in doing the assessment. Because that could lead to a conscious or subconscious bias when you’re rating the severity of a tear, for example.
So for this study and the next one, I got to do something really cool, which was I printed off these studies in… And they’re written in Farsi. And in the past, it was really hard to find a translator to get these studies where I could read the results, but Google Translate just keeps getting better and better. So I was actually printed them off in Farsi. And then I was able to use Google Translate on my phone to look at the text and it would translate it into English that I could at least get a basic understanding. It’s not perfect, because it’s obviously done with artificial intelligence, but it does at least give me some basic information about the study that I wouldn’t be able to get otherwise.
The results found that the control group had an 80% episiotomy rate, and the massage group had a 16.5% episiotomy rate. The control group had a 12% first or second-degree tear rate. The massage group had a 40% first or second-degree tear rate. The control group had a very high rate of third-degree tears. The text differed. So it was hard to tell exactly what the number was, but it was between nine or 10, around 10%. And there were zero third-degree tears in the massage group. There were no fourth-degree tears in the entire study.
Now the authors said that massage works because it may increase blood flow, elasticity, relaxation, and softness of the perineum. But it’s clear to me that it’s the fact that the providers, doing the massage gives them something to do with their hands so that they feel like they don’t have to grab the scissors and cut an episiotomy because no population needs an 80% episiotomy rate. That is all bias on the part of the obstetrician. So to me, it makes perfect sense. Psychologically, you give the OB something to do, to do the massage or the midwife. And the control group, they don’t have anything to do with their hands. So they use the scissors.
This Sohrabi et al study was also published in the Farsi written language and it was done in 2012. And this one included 120 first-time birthing participants who were enrolled in one of three arms. They could either receive perineal massage, a warm compress, or Ritgen’s maneuver, which is routine care.
I mentioned Ritgen’s maneuver in the last study. So I’m going to explain that now. So Rick’s maneuver dates back to the year 1855 when it was described by a doctor by the name of Von Ritgen in a German magazine. The original Ritgen maneuver was performed between contractions, but today something called the modified Ritgen is performed during a contraction, but without the patient pushing.
The modified version was first described in an obstetrics textbook in 1971. It’s a procedure that’s used to control a delivery of the baby’s head. Basically, the provider puts two fingers on your perineum, just behind the anus, and they put forward pressure on the baby’s chin through the perineal tissue. So the provider is pushing on the baby’s chin from outside the perineum. And they’re trying to keep the head flex like this. And then the other hand is used to put pressure against the top of the head.
And sadly, the original maneuver had the provider putting their fingers into the rectum. The modified version is on top of the perineum tissue. It’s estimated that millions of obstetricians around the world have been taught this technique since it was introduced 150 years ago. And it’s typically performed when the patient giving birth is in what they call the supine position or laying on their back or semi-sitting.
Although Ritgen maneuver is very common, extremely common in most hospitals around the world, a large randomized trial published in 2008 found that it did not lead to any improvement in the rate of third or fourth-degree tears. So although this study had a control group, it was really the Ritgen maneuver group.
So this study was interesting when I read the background and introduction. The author had a strict emphasis on not cutting episiotomies. And the researchers were adamant that episiotomies are extremely harmful. And researcher was the one attending the birth. So it makes sense that they ended up having a 0% episiotomy rate in the study.
Now all of the births in the study were performed or attended by the researcher. So the same person enrolled the patients in the study, randomly assigned them, then provided the clinical care into the assessments. And as I mentioned earlier, this creates a situation that’s at very high risk for bias because the researcher can consciously or subconsciously alter the results depending on the result that they hope to find. The researchers also did not provide a flow chart to understand who was included, who was excluded, who dropped out of the study, and why.
And then finally, all the participants gave birth in lithotomy position. So as I said earlier, there were zero episiotomy in the study. There were also zero third or fourth-degree tears. There was no significant difference in the rate of first or second-degree tears between the three groups. And there was no difference in the rate of people who needed repair or stitches. About 55 to 60% of the study participants required stitches, regardless of which group they were in. The authors concluded, “In this study, the use of physiotherapy techniques. And the second stage of labor probably had no effect on perineal health.”
And that brings us to the last study, this one by Geranmayeh et al. It was also published in Farsi. And included 91st-time mothers in Iran. At the time that this study was being published, the authors said that rates of episiotomy in their country were 88 to 97%. And this study took place in near 2009. The authors were looking for substitutes for episiotomies because of the known harm. So they wanted to see if perineal massage could be used in place of doing an episiotomy on everyone.
So when people are randomly assigned to the massage group, once the person was crowning, they were placed on a delivery table. The researcher put Vaseline on the vaginal area. And then they massaged the perineum in a sweeping motion until the baby was out. It was stopped if the birthing person was uncomfortable. And then resumed once they fell at ease again.
The control group received routine care, which they did not really describe. It is possible that the control group could have received the Ritgen maneuver. We don’t know. And episiotomies were cut at the discretion of the obstetrician or “tearing was imminent.”
Again, they did not provide a participant flow chart, which is needed in order to really assess the quality of the study. They didn’t talk about how my immunization was carried out. They didn’t describe why people dropped out of the stud, they had 17 people drop out, and how they were replaced with other people. So those are the limitations of the study.
They found no third or fourth-degree tears in the entire study. And the episiotomy rates were really high in the control group, 88% episiotomy rate in the control group, 45% in the massage group. They also found that the control group had fewer first and second-degree tears because they were being cut instead. And the massage group had more first and second-degree tears because that’s what you trade for, for a lower rate of episiotomy.
The length of the second stage was slightly shorter by 11 minutes in the massage group. And overall, 96% of women in the control group had perineal trauma of some kind compared with 73% of the massage group. Not really good results for either group. And it’s probably because episiotomies were being cut at such high rates. So I think we need to just take a step back and looking at the evidence as a whole. Some of these studies took place in really high episiotomy rates.
And most of the studies, specifically the last three, did not use blinded assessment. Some of the studies, the researcher was also the birth attendant, which introduces bias. And the control group was using the Ritgen maneuver and at least one study possibly, two or three.
So why did the meta-analysis authors, why did Aquino et al find a difference in severe perineal trauma rates? Well, if you do the math, I went through and looked at the numbers, the actual numbers of how often third or fourth-degree tears were happening in each study. You can see them in this PowerPoint slide I’m showing on YouTube. It seems like the results were swayed by the Stamp study and the Attarha study.
Overall, there were 17 severe tears in the massage group out of 1,296 participants for a rate of 1.3%. And 38 severe tears in the control group out of 1,129 participants for severe tear rate of 3.2% in the control group. However, the Attarha study found severe tear rates at almost twice the rate of the study with the next highest rates. And this seems highly implausible to have just the control group have a 10% severe tear rate, which is horribly high. They also had extremely high rates of episiotomy in the control group, which would explain the high rates of severe tears in that group.
So because those results seem really implausible and suggest bias, plus when we evaluated the study, we found that it was at high risk for bias. I would recommend excluding that study from any analysis. And if you exclude that study, that really only leaves you with the Stamp study since all of the others found either zero severe tears or identical numbers of severe tears between groups.
And the stamp study by itself, that was the first one that we looked at that, was really large and a good quality, but it took place in Australia with a high episiotomy rate. The authors did not find a significant difference between in groups. So there was a trend toward slightly better results with the massage group, but it was not statistically significant. And it could have been due to random chance.
And then we also need to take a step back and look at the Albert study that show that when midwives use methods such as the birthing position of choice, slow delivery, and non-Valsalva pushing or pushing while you’re breathing, you can have extremely low rates of severe tears without using perineal massage. So perineal massage does not seem necessary in order to avoid tears if you have a really great provider who is skilled at preventing tears.
So we’ve gone over this research in detail, we’ve looked, did the meta-analysis and then we dove down and looked at each of the individual studies that made up that supposed result that perineal massage during labor decreases the severe perineal trauma rate.
So what are my overall thoughts about this research? Well, first of all, much of this research does not apply to birth settings where episiotomy rates are lower than 20 to 80%. And I really have some questions and doubts about the Aquino et al 2020 meta-analysis in particular. For example, they specifically, I said they excluded trials that used the Ritgen’s maneuver, but at least one of the studies that they evaluated clearly said they used the Ritgen´s maneuver, and the Aquino et al team didn’t catch that. Which leads me to question, did they really thoroughly read the original studies?
They also didn’t discuss the limitation to the studies that they included in their meta-analysis, some of them were at very high risk for bias, or the fact that these study results might not be applicable to many clinical settings today. Also when I was printing off their results and comparing the numbers in their table to the original studies, some of the numbers didn’t match up. So overall, I just have some real quality questions about that meta-analysis.
I also want to point out that the Aquino et al meta-analysis had a racist statement in their discussion section. They said, “Asian race, for example, has been showed to be an independent risk factor for severe perineal lacerations in the U.S.” There is no scientific reason that there would be a difference in the ability of your perineal to stretch, depending on your ancestry or ethnicity. We are all of the same species, homo sapiens, and saying that Asian women are more likely to have a severe tear is a very common self-fulfill racist prophecy. Because if you believe that they’re more likely to have a severe tear, you’re more likely to cut an episiotomy on them, which is more likely to extend into a severe tear that you were predicting.
That’s a whole nother rabbit hole we could go down about how people think that ethnicity increases your risk of severe tears when it doesn’t have any to do with the ethnicity, but it’s more the biases of the care provider caring for you and whether or not they’re more likely to do something that causes a severe tear.
Also, the Aquino et al group used the results of their meta-analysis to make a broad-sweeping claim. They say that perineal massage during the second stage, “could become routine.” They’re basically saying this evidence justifies widespread use of this intervention. But I’ve already said, with all of these flaws in the research and the difficulty with transferring this research to low episiotomy settings, they really are making conclusions that are not by the actual data.
In my opinion, obstetricians should not be using the results from this meta-analysis as a basis for practice. But unfortunately, probably many do. And we haven’t even really talked about some of the more disturbing aspects of perineal massage. In the research studies, perineal massage during labor is typically done gently with water-soluble lubricant by a trained midwife. But we hear disturbing reports from doulas and nurses that perineal massage during Lee is often done, A without consent, and B, aggressively.
I’ve heard case reports of it being done more aggressively in retaliation because the doctor doesn’t like the patient’s birth plan, for example, or because they’re mad that the patient was trying to plan a home birth. This is obstetric violence. And perineal massage may be extremely painful, especially if you are unmedicated and you do not have an epidural to numb those sensations.
On the other hand, if you do have an epidural, you might not even realize that the perineal massage is happening. For example, in my first birth, I had an epidural. I couldn’t see what was going on down there because I was laying on my back, the OB is sitting between my knees and I can’t see what they’re doing. So I have no idea if they’re doing an aggressive perineal massage or gentle one or no massage at all.
And if you go back a few episodes, we talked about hands-on versus hands-off. Now, hands-off care seems to be more protective of the perineum. About a month ago, we were talking about hands-on versus hands-off care on our Instagram page, @ebbirth. And there were a lot of comments from doulas who wanted to talk about the trauma they’ve seen from aggressive perineal massage. One quote from a doula said, “Especially not the assault being sold as perineal massage during expulsion.”
Another mother said, “Yes, I wasn’t asked. And I didn’t have the energy or wherewithal to refuse. It’s definitely part of my trauma memory.” In response, a doula replied, “I absolutely hate that for you. That is never okay. As a doula, if this happens, I typically vocalize something like, looks like your doctor is starting perineal massage and pressure. Are you okay with that? So both heart parties hear it and are aware. No one’s body, especially down there, should ever be touched without full informed consent.”
Other doulas nurses in mid wise, affirmed that it’s about the informed consent piece. Are you asking the birthing person beforehand before you start doing this massage and stretching at their perineum? One doula said, “I have witnessed more intact perineums with hands-off care.” I will say that it’s depending on the provider. Some providers are so rough to a point I would call abuse.
Another nurse said, “I’m so excited to listen to this podcast and bring the evidence to our labor and delivery department. We have a few providers that feel the need to help stretch the perineum during second stage. And it’s been driving me crazy, especially with unmedicated or unblocked patients.”
So what’s the bottom line. Well, after looking at all of this research, it seems there is no reliable evidence that perineal massage with the water-soluble lubricant during labor reduces the risk of severe tears. The only supportive evidence we have on this comes from studies that took place in settings with very high episiotomy rates.
In general, perineal massage during the second stage probably has little to no benefit if it has any benefit at all, especially if providers already have a very low severe tear rate. Pain and satisfaction has not been well studied, but perineal massage makes the clinician feel like they’re “doing something”, which might distract them from doing something like cutting an episiotomy. So it may be helpful in high episiotomy settings.
Three of the five studies that make up the results of the Aquino at all, meta-analysis are of lower quality and unclear or high risk of bias. And most of these studies were done in settings with extremely high rates of episiotomy. And basically what the researchers are finding that if you give the provider something to do with their hands, the perineal massage, they’re less likely to cut the episiotomy.
But what if we just had people keep their hands off and not do the massage or the episiotomy? Well, the study from the University of New Mexico found that experienced nurse-midwives can have incredible outcomes without the use of perineal massage. And we’re going to talk more about the time-tested midwifery techniques next month when we wrap up the series.
So I think the overall conclusion is that perineal massage is not necessary. But if your OB has restless hands and wants to cut an episiotomy, proposing that they use perineal massage instead may lower that risk of experiencing or receiving an episiotomy.
So that wraps up this episode about perineal massage during labor. I hope it was eye-opening and illuminating for you. Next time we come back to this topic in a month, we’ll cover the research evidence on birthing positions for preventing tears, and researchers that have been documenting the wisdom from midwives who have passed down their knowledge through countless generations and who have really low tear rates with their clients. And that will likely be the wrap up episode for the series.
So if you enjoyed this episode, make sure you go back and listen to episodes 206, 210, and 216 to learn even more about protecting the perineum. And let your friends know that this protecting the perineum series is available. Finally, if you’ve enjoyed learning from this podcast about the evidence, please go leave us an honest review on whatever podcasting app you use.
We’ve had some semi-coordinated attacks on our reviews from people who are angry at us for using inclusive language. So if you’re interested in helping counteract that, please leave a review and tell your friends about our podcast. Word of mouth is one of the top ways that people find out about EBB.
Also, in about three weeks, we’ll be hosting our big spring webinar that is open to the public. If you want to get an invitation to attend that free webinar, make sure you go to our homepage at evidencebasedbirth.com. And sign up for our newsletter, using the form on that page. And that way you’ll be sure to get an invitation email to you with the link and invitation to join our free live webinar. These live webinars for the public happen only twice per year. Once in the spring and once in the fall. So don’t miss your chance to attend. Thanks, everyone. And I’ll see you next week. Bye.
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Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, and exclusive library of printer-friendly PDFs to share with your clients and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color.
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