Archives of Gynecology and Obstetrics

, Volume 285, Issue 1, pp 77–81

Reducing perineal trauma through perineal massage with vaseline in second stage of labor

Authors

  • Mehrnaz Geranmayeh
    • Nursing and Midwifery SchoolTehran University of Medical Sciences
  • Zahra Rezaei Habibabadi
    • Nursing and Midwifery SchoolTehran University of Medical Sciences
  • Bijan Fallahkish
  • Mahdi Azizabadi Farahani
    • Nursing and Midwifery SchoolTehran University of Medical Sciences
  • Abbas Mehran
    • Nursing and Midwifery SchoolTehran University of Medical Sciences
Materno-Fetal Medicine

DOI: 10.1007/s00404-011-1919-5

Cite this article as:
Geranmayeh, M., Rezaei Habibabadi, Z., Fallahkish, B. et al. Arch Gynecol Obstet (2012) 285: 77. doi:10.1007/s00404-011-1919-5

Abstract

Purpose

Maintaining an intact perineum is a highly regarded aim in delivery procedures today. Since perineal massage is a common practice during delivery, the present study aims to investigate the effect of perineal massage with Vaseline on perineal trauma (rate of episiotomy procedures and perineal tears).

Method

Ninety primiparous women (aged between 18 and 30 years with gestational age of 38–42 weeks) were selected sequentially in Tehran in 2009. Once participants’ characteristics were registered, they were randomly assigned to the intervention (perineal massage with Vaseline) or control groups. In the massage group, perineal massage was performed in the second stage of delivery once the genitalia were treated with sterilized Vaseline. The perineum was examined after the delivery in terms of episiotomy or tear and its severity degree.

Results

The two groups were homogeneous in terms of demographic data, weight gain during pregnancy, gestational age, abortion history and fetal weight. The second stage of delivery was significantly shorter in the massage group than the control group and the massage group had significantly more intact perineum (P = 0.004). In addition, lower episiotomy and higher first- and second-degree perineal tears were seen in the massage group in comparison with the control one (P < 0.001). Neither of the groups suffered from third- and fourth-degree tears.

Conclusion

The findings showed that the perineal massage with Vaseline in the second stage of labor increases perineal integrity and decreases perineal traumas (episiotomy and tears). So, it seems that the perineal massage could be an effective way to preserve an intact perineum in labor.

Keywords

EpisiotomyPerineal tearPerineal massageVaselineVaginal delivery

Introduction

Episiotomy, which is the most common surgical procedure in midwifery [1], involves an incision through the perineum made to enlarge the vaginal diameter. The prevalence of episiotomy varies in different countries, ranging from 8% in Holland to 14% in the UK, 50% in the US and up to 99% in East European countries [2]. Episiotomy is commonly performed in Asian countries because the shortness and tenacity of perineum in most Asian women makes them susceptible to extensive tears [3]. In case of Iran, although no official statistics are published, various scattered studies show a prevalence of 88–97% of episiotomy procedure in hospitals [4, 5].

Despite the widespread adoption of episiotomy, there is no unanimous agreement over its most often claimed advantage (preventing severe perineal tears) [6]. In numerous studies, episiotomy has been imputed with a risk factor for third- and fourth-degree tears [7]. Furthermore, it has been claimed that not only may episiotomy fail to protect the perineal body, but also it may increase anal sphincter incontinence due to the increased risk of incurring third- and fourth-degree tears [8]. As a matter of fact, fecal incontinence in women who have undergone episiotomy is higher than those with natural tears [9] by 4–6 times [10]. Therefore, some studies warn that traumas resulting from episiotomy may be severe than spontaneous perineal tears [5]. Hemorrhage, prolonged postpartum pain, risk of infection and intercourse impairment, among others, are associated with episiotomy [10]. Thus, it may seem that the common practice of episiotomy as one method of care is not efficient enough and should be regarded with suspicion [11].

Since more than half of women giving birth without episiotomy also suffer from tears requiring repair [12], and also because other studies on limited application of episiotomy indicate that 51–77% of traumas incurred in women require suture [13], appropriate interventions are needed in order to minimize the risks associated with episiotomy and also perineal tears. In addition, women delivering with intact perineum suffer less postpartum pain and experience less dyspareunia within 3 months of delivery [14]. Therefore, studies are warranted to examine different ways to minimize labor pain, prevent perineal traumas (episiotomy or tears) and promote delivery with intact perineum [15, 16]. One common practice performed during pregnancy or labor by midwifes is perineal massage [17]. Nevertheless, the results are mixed on the effect of perineal massage on reducing the need for episiotomy and on increasing the chance of maintaining a healthy and intact perineum. Some researchers believe that perineal massage is an effective way in increasing the chance of maintaining an intact perineum in primiparous mothers [1, 18, 19], while other researchers have not reported any difference in this regard [20, 21]. Motivated by these mixed results on the effectiveness of perineal massage in labor, the present study aims to examine the effect of perineal massage with Vaseline on perineal traumas.

Materials and methods

Sampling

The present randomized clinical trial (RCT) was conducted on 90 primiparous women in 2009 that referred to Imam Sajjad Hospital in Shahryar, Tehran. Entry requirements included an age of 18–30 years, gestational age of 38–42 weeks, meeting all vaginal delivery requirements with anterior cephalic presentation, nonexistence of any perineal injury (scar, inflammation, injury, etc.) which might interfere with massage and no sensitivity to Vaseline. Exclusion criteria included fetal distress during delivery and instrument assisted delivery or any reason requiring cesarean section. Meeting exclusion criteria, 17 participants dropped out of the study and replaced with other participants through random assignment. An ethical approval was earned from the ethical committee of the Research Department of Tehran University of Medical Sciences. Written consents were also secured from all participants and their husbands before the initiation of active phase of delivery and the entry to labor room.

Intervention

First, a checklist including demographic variables (age, education, weight, and height), abortion history, gestational age and weight gain during pregnancy was prepared on the basis of data obtained from all the participants. The participants were then randomly assigned to the intervention group (receiving perineal massage with Vaseline treatment) and the control group (receiving routine care). A midwife performed all deliveries in both groups. In the massage group, in the second stage of delivery (after crowning and transfer of mother onto delivery table), the clitoris, labia major and labia minor and the vestibule were treated with Vaseline. Another midwife performed sweeping and rotating perineal massage during uterine contractions and continued until the baby’s head was out. The process would be halted if the mother felt discomfort, and resumed when feeling at ease. Vaseline is a refined semi-solid compound of mineral hydrocarbons which is a semi-transparent, soft and odorless substance used as foundation in lotions and skin softeners. It is not absorbed by the skin immediately and rarely has any side effects, especially if applied locally [22]. A maximum of 40 g of sterilized Vaseline was applied. The control group only received routine labor care. In case of imminent tears in either group and at the discretion of the delivery agent, medio-lateral episiotomy was performed. After the delivery of head, the mucus on the head, in the mouth and nostrils were removed and after full delivery, the head and face were dried by sterilized gas and followed once again by the removal of mucus from the mouth and nose. Recorded outcomes were oxytocin consumption during labor, the length of the second stage of labor, nuchal cord, neonate’s weight, the condition of the perineum in terms of episiotomy or tears and degree thereof, 1–5 min neonate Apgar scores and neonatal complications. In addition, postpartum conditions or any likely side effects of Vaseline were followed-up and recorded within 10 days of delivery through telephone or in person.

Data analysis

Data were analyzed through SPSS v.16. The qualitative variables were described using frequency and percentage and the quantitative variables were described using mean and standard deviation. To compare the two groups, chi-square and Fisher’s exact tests were calculated. An independent t test was also performed for the quantitative variables. A P value less than 0.05 was considered as significant.

Results

The two groups were not significantly different in terms of demographic variables (age, post-secondary education and height) (P > 0.05). In terms of pre-pregnancy weight, the control group was significantly higher than the massage group (P = 0.014). However, the two groups were not different in terms of weight gain during pregnancy (P = 0.719). The two groups were also homogenous in terms of gestational age and abortion history (P > 0.05). Table 1 shows the demographic and pregnancy data of the participants.
Table 1

Demographic and delivery characteristics of participants

 

Massage group

Control group

P value

Demographic characteristics

 Age (years)

21 ± 3

22 ± 3

0.113a

 Education (Diploma or upper)

23 (51%)

18 (40%)

0.290b

 Pre-pregnancy weight (kg)

55 ± 8

60 ± 11

0.014a

 Height (cm)

158 ± 7

158 ± 6

0.884a

Delivery characteristics

 Gestational age (weeks)

39.3 ± 0.9

39.7 ± 0.9

0.154a

 Weight gain during pregnancy (kg)

13 ± 5

13 ± 6

0.719a

 Abortion history

1 (2%)

4 (9%)

0.361c

aIndependent sample t test

bChi-square test

cFisher’s exact test

Table 2 includes data on delivery and its outcomes for the two groups. The two groups were not significantly different in terms of oxytocin consumption at labor, nuchal cord and the neonate’s weight (P > 0.05). However, the length of the second stage of birth was significantly shorter in the massage group compared with the control one (37 ± 20 and 46 ± 19 min, respectively, P = 0.038). The massage group had a significantly higher frequency of intact perineum (P = 0.004). Neither of the groups suffered from third- and fourth-degree tears. In terms of perineal traumas, massage could cause a decrease in episiotomy rate and an increase in first- and second-degree tears (P < 0.001). The Apgar scores for all neonates in both the groups were over 7 on 1–5 min, and neonatal complications were detected. Furthermore, in the follow-up study within 10 days of delivery, the massage group showed no side effects associated with Vaseline and less than 10% of mothers in both the groups experienced effects such as burning, pain and inflammation at perineum, which was not significantly different, however, in the two groups (P = 0.528).
Table 2

Labor characteristics and perineal status

 

Massage group

Control group

P value

Oxytocin consumption during labor (%)

33 (73%)

30 (67%)

0.490b

Nuchal cord (%)

9 (20%)

5 (11%)

0.245b

Neonatal weight (g)

3.2 ± 0.4

3.3 ± 0.4

0.437a

Length of the second stage of labor (min)

37 ± 20

46 ± 19

0.038a

Perineal status

 Perineal trauma

33 (73%)

43 (96%)

0.004b

 Intact perineum

12 (27%)

2 (4%)

Perineal trauma type

 First-degree tear

15 (45%)

4 (9%)

<0.001b

 Second-degree tear

3 (10%)

1 (2%)

 Episiotomy

15 (45%)

38 (88%)

aIndependent sample t test

bChi-square test

Discussion

The findings in this study showed that the massage of perineum with Vaseline in the second stage of labor not only reduces the length of the second stage, but also increases the intact perineum, mainly by decreasing the frequency of episiotomy. In addition, despite an increase in the frequency of spontaneous perineal tears in perineal massage (compared with routine care), none of the tears were qualified as third or fourth degrees. Maternal and neonatal complications were also similar to those of a routine care.

Perineal stretching and massage in the second stage of delivery are commonly performed by midwifes [11]. The results are, however, mixed whether this method is effective on prevention of perineal traumas or not. The RCT studies conducted by Albers et al. [20] and Stamp et al. [21] showed no evidence of decrease in perineal traumas. However, a previous study in Iran [23] showed that the perineal massage reduces the need for episiotomy and increases the chance of an intact perineum, which is in line with our findings. Previous studies also showed that women in the massage group experienced less episiotomy and perineal tears [18, 24]. This difference could be explained through the exclusion of fetal macrosomia, instrumental birth and massage during pregnancy from the study and the lower rate of episiotomy in those societies and also the anthropometric differences of Iranian women. Therefore, the results of these two experiments in the Iranian context, where most vaginal deliveries involve episiotomy, have come to be similar. Although the results of RCT studies fail to show any effect of massage during delivery on reducing perineal traumas, it has been claimed that this method is harmless, suggesting that midwifes choose the appropriate delivery method at their discretion on the basis of their experience, labor condition and mother’s comfort [25].

Massage therapy is said to have several advantages, including reduction of stress and pressure, enhancement of blood circulation and relief of pain. Furthermore, since the perineal muscles surrounding the vaginal orifice are stretched they are less likely to incur damage [26]. In addition, it seems that through acceleration of blood circulation, elasticity and tenderness of tissue, perineal massage helps mothers become familiar with sensations such as burning, pins and needles, less pressure and strain during the delivery of neonatal head [27, 28]. Perineal massage has not only been studied at the delivery but also through the last weeks of pregnancy. Although some studies report its positive effects on the rate of episiotomy [13, 29], others fail to report such results [30]. Therefore, it seems that the perineal massage in late pregnancy period or during delivery is a challenging issue requiring further inquiry considering confounding factors such as the total cases of episiotomy and the anthropometric characteristics of women.

Although the findings in the present study show a decrease in perineal trauma through Vaseline massage, one should note that the most important limitation of this study (and many other similar ones) is the fact that the decision to perform episiotomy is made at the discretion of the midwife to prevent any likely perineal tear. Nevertheless, a decrease in the rate of episiotomy and an increase in the number of first- and second-degree tears in the massage group (in addition to other effects of massage) could be attributed to the decision of the midwife for delaying an episiotomy procedure. Therefore, one may assert that perineal massage could be an assuring method for the delivery agent, which could even nominally decrease the rate of episiotomy and its associated effects in areas with high prevalence of episiotomy (e.g., Iran). In addition, despite random assignment of participants, the pre-pregnancy weight in the massage group was higher than that of the control group in our study. However, since the weight gain and fetal weight were not significantly different in the two groups, it seems unlikely that the decrease in perineal trauma in the massage group could be a function of the pre-pregnancy weight. However, further studies with larger sample sizes are recommended.

Conclusion

The findings of the present study showed that the perineal massage with Vaseline in the second stage of birth increases the integrity of perineum and reduces the perineal traumas (episiotomy and tears). Therefore, this method is recommended to be considered as an effective way to maintain intact perineum during delivery and further research is strongly suggested taking into account variables such as anthropometric characteristics of participants.

Conflict of interest

None.

Copyright information

© Springer-Verlag 2011