Skip to main content

Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials


Introduction and hypothesis

Most vaginal births are associated with trauma to the perineum. The morbidity associated with perineal trauma can be significant, especially when it leads to third- and fourth-degree perineal tears. We hypothesized that antenatal perineal massage could decrease the incidence of perineal trauma, particularly severe perineal tears and other postpartum complications.


We searched four different databases from inception until August 2019 for the available trials. We included randomized controlled trials (RCTs) which assessed the effect of antenatal perineal massage (intervention group) versus control group (no antenatal perineal massage) in perineal trauma patients. Data were extracted from eligible studies and meta-analyzed using RevMan software. Primary outcomes were the risk of episiotomies and perineal tears. Secondary outcomes were perineal pain, second stage of labor duration, wound healing, anal incontinence, and Apgar scores at 1 and 5 min.


Eleven RCTs with 3467 patients were analyzed. Women who received antenatal perineal massage had significantly lower incidence of episiotomies (RR = 0.79, 95% CI [0.72, 0.87], p < 0.001) and perineal tears (RR = 0.79, 95% CI [0.67, 0.94], p = 0.007), particularly the risk of third- and fourth-degree perineal tears (p = 0.03). Better wound healing and less perineal pain were evident in the antenatal perineal massage group. Antenatal perineal massage reduced the second stage of labor duration (p = 0.005) and anal incontinence (p = 0.003) with significant improvement in Apgar scores at 1 and 5 min (p = 0.01 and p = 0.02).


Antenatal perineal massage is associated with a lower risk of severe perineal trauma and postpartum complications.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10


  1. 1.

    Kalichman L. Perineal massage to prevent perineal trauma in childbirth. The Israel Medical Association journal: IMAJ. 2008;10:531–3.

    PubMed  Google Scholar 

  2. 2.

    Kettle C, Tohill S (2008) Perineal care. BMJ Clin Evid 2008.

  3. 3.

    Berghella V, Baxter JK, Chauhan SP. Evidence-based labor and delivery management. Am J Obstet Gynecol. 2008;199:445–54.

    Article  Google Scholar 

  4. 4.

    Oberaigner W, Leitner H, Oberaigner K, et al. Migrants and obstetrics in Austria—applying a new questionnaire shows differences in obstetric care and outcome. Wien Klin Wochenschr. 2013;125:34–40.

    Article  Google Scholar 

  5. 5.

    Jiang H, Qian X, Carroli G, Garner P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017;2:CD000081.

    PubMed  Google Scholar 

  6. 6.

    Nodine PM, Roberts J. Factors associated with perineal outcome during childbirth. Journal of Nurse-Midwifery. 1987;32:123–30.

    CAS  Article  Google Scholar 

  7. 7.

    Mayerhofer K, Bodner-Adler B, Bodner K, et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. The Journal of reproductive medicine. 2002;47:477–82.

    PubMed  Google Scholar 

  8. 8.

    Belihu FB, Small R, Davey M-A. Episiotomy and severe perineal trauma among eastern African immigrant women giving birth in public maternity care: a population based study in Victoria, Australia. Women and Birth. 2017;30:282–90.

    Article  Google Scholar 

  9. 9.

    Bagade P, Mackenzie S. Outcomes from medium term follow-up of patients with third and fourth degree perineal tears. J Obstet Gynaecol. 2010;30:609–12.

    CAS  Article  Google Scholar 

  10. 10.

    DeBeche-Adams TH, Bohl JL. Rectovaginal Fistulas. Clin Colon Rectal Surg. 2010;23:99–103.

    Article  Google Scholar 

  11. 11.

    Priddis H, Dahlen H, Schmied V. Women’s experiences following severe perineal trauma: a meta-ethnographic synthesis. J Adv Nurs. 2013;69:748–59.

    Article  Google Scholar 

  12. 12.

    Abd El fttah Ali H. Effects of prenatal perineal massage and Kegel exercise on the episiotomy rate. IOSR Journal of Nursing and Health Science. 2015;4:61–70.

    Google Scholar 

  13. 13.

    Ibrahim Elsebeiy F. Comparison of the effects of prenatal perineal massage versus Kegel exercise on labor outcome. IOSR Journal of Nursing and Health Science. 2018;7:43–53.

    Google Scholar 

  14. 14.

    Beckmann MM, Stock OM (2013) Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews CD005123.

  15. 15.

    Albers L, Borders N. Minimizing genital tract trauma and related pain following spontaneous vaginal birth. Journal of Midwifery & Women’s Health. 2007;52:246–53.

    Article  Google Scholar 

  16. 16.

    Williams A, Herron-Marx S, Knibb R. The prevalence of enduring postnatal perineal morbidity and its relationship to type of birth and birth risk factors. J Clin Nurs. 2007;16:549–61.

    Article  Google Scholar 

  17. 17.

    Ugwu EO, Iferikigwe ES, Obi SN, et al. Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: a randomized controlled trial. J Obstet Gynaecol Res. 2018;44:1252–8.

    Article  Google Scholar 

  18. 18.

    Mei-dan E, Walfisch A, Raz I, et al. Perineal massage during pregnancy: a prospective controlled trial. The Israel Medical Association journal: IMAJ. 2008;10:499–502.

    PubMed  Google Scholar 

  19. 19.

    Julian PT Higgins and Sally Green (2011) Cochrane Handbook for Systematic Reviews of Interventions.

  20. 20.

    Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.

    Article  Google Scholar 

  21. 21.

    Green S, Higgins PTJ, Alderson P, Clarke M, Mulrow D C Oxman DA (2011) Cochrane Handbook: Cochrane Reviews: Ch 8: Assessing risk of bias in included studies. 2011. In: Cochrane Handbook for: Systematic Reviews of Interventions. pp 3–10.

  22. 22.

    Egger M, Smith GD, Schneider M, Minder C. Bias in meta­analysis detected by a simple , graphical test. Bmj. 2015;14:1–16.

    Google Scholar 

  23. 23.

    Terrin N, Schmid CH, Lau J, Olkin I. Adjusting for publication bias in the presence of heterogeneity. Statistics in Medicine Statist Med. 2003;22:2113–26.

    Article  Google Scholar 

  24. 24.

    Labrecque M, Eason E, Marcoux S, et al. Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. Am J Obstet Gynecol. 1999;180:593–600.

    CAS  Article  Google Scholar 

  25. 25.

    Shipman MK, Boniface DR, Tefft ME, McCloghry F. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. BJOG: An International Journal of Obstetrics and Gynaecology. 1997;104:787–91.

    CAS  Article  Google Scholar 

  26. 26.

    Labrecque M, Marcoux S, Pinault JJ, et al. Prevention of perineal trauma by perineal massage during pregnancy: a pilot study. Birth (Berkeley, Calif). 1994;21:20–5.

    CAS  Article  Google Scholar 

  27. 27.

    Shimada M. A randomized controlled trial on evaluating effectiveness of perineal massage during pregnancy in primiparous women. J Jpn Acad Nurs Sci. 2005;25:22–9.

    Article  Google Scholar 

  28. 28.

    Dönmez S, Kavlak O. Effects of prenatal perineal massage and Kegel exercises on the integrity of postnatal Perine. Health. 2015;7:495–505.

    Article  Google Scholar 

  29. 29.

    Shahoei R, Hashemi-Nasab L, Gaderkhani G, et al. The impact of perineal massage during pregnancy on perineal laceration during childbirth and postpartum: a randomized clinical trial study. Chronic Diseases Journal. 2016;4:13–20.

    Google Scholar 

  30. 30.

    Abed El-Azim Mohamed H, Saied Elngger N. Effect of regular perineal massage during last month of pregnancy on perineal outcomes. Zagazig Nursing Journal. 2011;7:33–48.

    Google Scholar 

  31. 31.

    Dieb AS, Shoab AY, Nabil H, et al (2019) Perineal massage and training reduce perineal trauma in pregnant women older than 35 years: a randomized controlled trial. Int Urogynecol J.

  32. 32.

    LaCross A, Groff M, Smaldone A. Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis. J Midwifery Womens Health. 2015;60:37–47.

    Article  Google Scholar 

  33. 33.

    Ehsanipoor RM, Saccone G, Seligman NS, et al. Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2017;96:804–11.

    Article  Google Scholar 

  34. 34.

    Saccone G, Ciardulli A, Baxter JK, et al. Discontinuing oxytocin infusion in the active phase of labor: a systematic review and meta-analysis. Obstet Gynecol. 2017;130:1090–6.

    CAS  Article  Google Scholar 

  35. 35.

    Ciardulli A, Saccone G, Anastasio H, Berghella V. Less-restrictive food intake during labor in low-risk singleton pregnancies: a systematic review and meta-analysis. Obstet Gynecol. 2017;129:473–80.

    Article  Google Scholar 

  36. 36.

    American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Practice bulletin no. 165: prevention and Management of Obstetric Lacerations at vaginal delivery. Obstet Gynecol. 2016;128:e1–e15.

    Article  Google Scholar 

  37. 37.

    Eogan M, Daly L, O’Herlihy C, et al. The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: a prospective observational study. J Matern Fetal Neonatal Med. 2006;19:225–9.

    Article  Google Scholar 

  38. 38.

    Takeuchi S, Horiuchi S. Randomised controlled trial using smartphone website vs leaflet to support antenatal perineal massage practice for pregnant women. Women Birth. 2016;29:430–5.

    Article  Google Scholar 

  39. 39.

    Ismail SIMF, Emery SJ. Patient awareness and acceptability of antenatal perineal massage. J Obstet Gynaecol. 2013;33:839–43.

    CAS  Article  Google Scholar 

Download references

Author information




Ahmed Mohamed Abdelhakim: Project development, Data Collection, and Manuscript writing.

Elsayed Eldesouky: Manuscript editing.

Ibrahim Abo Elmagd: Manuscript editing.

Attia Mohammed: Manuscript editing.

Elsayed Aly Farag: Manuscript editing.

Abd Elhalim Mohammed: Manuscript revision.

Khaled M. Hamam: Project development and Data collection.

Ahmed Salah hussien: Data analysis.

Ahmed Said Ali: Data analysis.

Nawal Hamdy Ahmed Keshta: Manuscript revision.

Mohamed Hamza: Manuscript revision.

Ahmed Samy: Manuscript writing.

Ali Abdelhafeez Abdel-Latif: Manuscript writing.

Corresponding author

Correspondence to Ahmed Mohamed Abdelhakim.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material


(DOCX 22 kb)


(PDF 345 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Abdelhakim, A.M., Eldesouky, E., Elmagd, I.A. et al. Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials. Int Urogynecol J 31, 1735–1745 (2020).

Download citation


  • Antenatal perineal massage
  • Perineal trauma
  • Episiotomy
  • Prenatal perineal massage