Antenatal Perineal Massage

1. Antenatal Perineal Massage  Krystal Jenkins, Cynthia Maxwell, and Kristi Watts OU-Tulsa College of Nursing 2010

2. PICO Question Do women who deliver vaginally who do antenatal perineal massage, compared to women who have a routine episiotomy, have reduced perineal laceration and pain?

3. PICO Defined Population: Women in labor who deliver vaginally Intervention: Antenatal massage of perineum Comparison: Performing a routine episiotomy Outcomes: Reduce perineal laceration and pain

4. Problem and Prevalence Three million women give birth vaginally each year Episiotomy rates have steadily declined over past 25 years 35% of mothers with a vaginal birth had an episiotomy. Genital tract trauma can result from episiotomies, spontaneous tears or both (Beckmann, 2) Greater genital tract trauma results in greater postpartum morbidity (Albers, 3)

5. Definitions Perineum-Area between your vaginal opening and your rectum Routine Episiotomy-Incision to enlarge vaginal opening Antenatal Perineal Massage- Using two fingers to stretch your perineal tissues before birth Genital Tract Trauma-Trauma to the genitals during childbirth Perineum-This area stretches a lot during childbirth and sometimes tears. Episiotomy- The perineum is the area that is cut by the physician. You will need stitches if an episiotomy is performed. Genital tract trauma- Can impact the perineum, and vulva.Perineum-This area stretches a lot during childbirth and sometimes tears. Episiotomy- The perineum is the area that is cut by the physician. You will need stitches if an episiotomy is performed. Genital tract trauma- Can impact the perineum, and vulva.

6. Myths of Episiotomies Physicians concerned with perineal shatter Physicians felt they were protecting the perineum “by temporarily abolishing it” Physicians believed episiotomies reduced the risk of: Incontinence Drooping of bladder and rectum into vagina (Eason, 466) Doctors felt multiple jagged lacerations would be harder to repair (Eason, 466) Doctors felt multiple jagged lacerations would be harder to repair (Eason, 466)

7. Review of the Literature

8. Albers, (2007) Reviews research on the reduction of genital tract trauma and related post-delivery pain Evaluated two Randomized trials on the effects of perineal massage Findings: Shipman found a 6% reduction in trauma Labrecque found a 9% reduction in nulliparas Education handout was distributed to women. Labrecque found no significant difference in multiparous women. Labrecque found no significant difference in multiparous women.

9. Beckmann, (2006) Included four randomized and quasi-randomized controlled trials Findings: Antenatal perineal massage reduced overall incidence of perineal trauma Women were 16% less likely to have episiotomy Restrictive use of episiotomy: Less posterior perineal trauma Less suturing Fewer healing complications Benefits: Cost savings 2497 Women Cost savings: Less suturing, drugs, analgesics.2497 Women Cost savings: Less suturing, drugs, analgesics.

10. Eason, (2000) Randomized control trials of interventions affecting perineal trauma Findings: Avoiding episiotomy in 4.4 women prevents one case of trauma 46 of 47 women with anal sphincter tears had episiotomies Fewer sutures and less time overall with restrictive episiotomies

11. Labrecque, (1999) Randomized single blind study 1,034 multiparous 493 nulliparas At the 34th week of pregnancy women performed daily 10 minute massage Findings: Women with intact perineums In Nulliparas: 24% of massage group 15% of control group In Multiparas: 35% of massage group 32% of control group

12. Eogan, (2006) An observational study of: 100 massage group 79 control group Findings: Women with intact perineums 24% of women who massaged 15% of controls In nulliparous women an increase of 6.2% in intact perineum Significantly in women older than 30 years old

13. Pros of Restricted Use of Episiotomy “No benefits accompany the routine use of episiotomies” Should be avoided except in rare situations Restrictive use reduced healing time (Eason, 465) Use when infant is in extreme jeopardy. Example: Extensive vaginal tearing appears likely Your baby is in an abnormal position Your baby needs to be delivered quickly Use when infant is in extreme jeopardy. Example: Extensive vaginal tearing appears likely Your baby is in an abnormal position Your baby needs to be delivered quickly

14. Advantages of Antenatal Massage Practiced more by Certified Nurse Midwives (Eason, 467) Helps reduce perineal trauma and pain afterwards Performed the last 4-6 weeks of pregnancy More impact on nulliparas Very non-invasive Supported by many women May be performed by the woman or her partner. May be performed by the woman or her partner.

15. Research Summary Practicing antenatal perineal massage at 34 weeks protects perineal integrity (Beckmann, 7) Restrictive use of episiotomies has better outcomes than routine use (Eason, 464) By reducing perineal trauma, postpartum morbidity will improve

16. Recommendations Patients Perform or have partner perform massage beginning at 34 weeks before delivery Discuss restrictive use of episiotomy with physician prior to delivery Nurses Educate patients the positive outcomes associated with antenatal massage Educate patients the proper procedure and compliance

17. Rationale for Recommendations Reasons to perform: -Increases “stretchiness” -Smaller chance of tearing or needing episiotomy -Helps practice relaxing the muscles of the perineal area used during delivery Lubricants: Vitamin E, Almond oil, Vegetable oil, Olive oil, KY Jelly DO NOT USE: baby oil, mineral oil, or petroleum jelly You want to feel a slight burning stretching sensation This is a good time to practice slow, deep breathing techniques used in delivery. Lubricants: Vitamin E, Almond oil, Vegetable oil, Olive oil, KY Jelly DO NOT USE: baby oil, mineral oil, or petroleum jelly You want to feel a slight burning stretching sensation This is a good time to practice slow, deep breathing techniques used in delivery.

18. Techniques to perform perineal massage: Wash your hands well Lubricate your thumbs and perineal tissues Place thumbs 1 to 1.5 inches inside vagina Press down and to the sides Hold position for 1-2 minutes With thumbs massage using “U” shaped movement Perform for 10 minutes daily

19. Method for Evaluation Keep journals throughout pregnancy Evaluate compliance of massage Assessment at post-partum check ups Evaluate patient satisfaction

20. Suggestions for Further Research More evidence needed regarding whether stretching massage during labor is helpful or harmful (Eason, 470) Randomized trials of perineal massaging devices are needed (Beckmann, 8) Factors affecting delivery such as pelvic floor exercises, general exercise and body mass index need to be examined (Albers, 10)

21. New Research Questions Research on delivery techniques is needed: - Does flexion of the fetal head affect perineal integrity? -Does avoiding maternal pushing in the third stage of labor promote perineal integrity? -Does preventing rapid delivery promote perineal integrity? (Eason, 470)

22. References Albers, L., CNM, D., & Borders, N. C. (2007). Minimizing genital tract trauma and related pain following spontaneous vaginal birth. Journal of Midwifery & Women's Health , 52 (3), 246-253. Eogan, M., Daly, L., O'Herlihy, C., (2006). The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: A prospective observational study. Journal of Maternal - Fetal & Neonatal Medicine. Taylor & Francis Ltd. Retrieved March 24, 2010 from HighBeam Research: http://www.highbeam.com/doc/1P3-1071473651.html

23. References Labrecque, M, E. E.-J. (1999). Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. American Journal of Obstetrics and Gynecology , 180 (3), 593-600. Beckmann, M.M., Garrett A.J. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub2. Eason, E., Labrecque, M., (2000). Preventing perineal trauma during childbirth: a systematic review. The American College of Obstetricians and Gynecologists. 95 (3), 464-471.