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. 2001 Sep 29;323(7315):753.

Perineal massage in pregnancy

Such massage significantly decreases perineal trauma at birth

Michel Labrecque 1,2,3, Erica Eason 1,2,3, Sylvie Marcoux 1,2,3
PMCID: PMC1121301  PMID: 11675731

Editor—Stamp et al's trial of the effect that perineal massage during labour has on perineal trauma adds to our knowledge about care of the perineum during childbirth,1 but their report of the results of our trial is erroneous.2

We found an absolute increase of 9% in intact perineum in women who had not had a previous vaginal birth who were randomised to do antenatal perineal massage (24%, n=411) compared with the control group (15%, n=417). In the intention to treat analysis this difference was highly significant (95% confidence interval 4% to 15%; P=0.001).

The difference was also clinically important: one case of perineal trauma requiring suturing was avoided for every 11 women without a previous vaginal birth who were assigned to the massage group. When the results were analysed by actual practice, women randomised to do massage who practised perineal massage on less than one third, one third to two thirds, and more than two thirds of the assigned days had an intact perineum in 20%, 23%, and 28% of cases, respectively (χ2 for trend=13.2; P=0.0003).

Thus, in women approaching their first vaginal delivery, antenatal perineal massage significantly decreases the risk of perineal trauma.

References

  • 1.Stamp G, Kruzins G, Crowther C. Perineal massage in labour and prevention of perineal trauma: randomised controlled trial. BMJ. 2001;322:1277–1280. doi: 10.1136/bmj.322.7297.1277. . (26 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Labrecque M, Eason E, Marcoux S, Lemieux F, Pinault JJ, Feldman P, et al. Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. Am J Obstet Gynecol. 1999;180:593–600. doi: 10.1016/s0002-9378(99)70260-7. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Sep 29;323(7315):753.

True incidence of third degree tears should be ascertained

Steve Halligan 1

Editor—Stamp et al state that faecal incontinence after vaginal delivery is less likely in women whose perineum remains intact,1-1 but it is well recognised that clinical examination of the perineum by a midwife or doctor in no way reflects the true damage done to the sphincter complex.1-2 Anal endosonography, which images the sphincters in detail, shows a far higher incidence of sphincter disruption and laceration than does clinical examination.

A retrospective study of 8603 vaginal deliveries found that a third degree tear had been clinically diagnosed in only 50 women (0.6%),1-3 yet when the same authors used anal endosonography in a consecutive group of 202 deliveries there was evidence of third degree tears in 35% of primiparous and 44% of multiparous women—a startling incidence confirmed by other researchers.1-4 Furthermore, sonographically detected tears are strongly associated with physiological sphincter impairment and symptoms of anal incontinence, suggesting that they are functionally important.1-3

The message is clear: anal sphincter tears occur often during vaginal delivery, and clinical examination misses most of them. Inadequate training has a central role in this; a study of midwives and obstetricians found their anatomical knowledge to be generally inadequate—for example, only 7% of midwives and none of the doctors were aware that only the bulbospongiosus and superficial transverse perineal muscles were commonly divided during posterolateral episiotomy.1-5

The incidence of third degree tears in Stamp et al's study (1.7% in the massage group versus 3.8% in the control group) suggests that most tears went unrecognised. The authors state that their trial was underpowered to detect third degree tears and that further research with a larger sample is warranted to determine if their trend towards reduced risk with perineal massage is real. Instead, it may be more scientifically valid to determine the true incidence by using endosonography; this would certainly be easier given the much smaller sample size needed. Alternatively, as third degree tears are so common, research should be directed towards assessing primary repair, who should perform it, and the training needed.

References

  • 1-1.Stamp G, Kruzins G, Crowther C. Perineal massage and prevention of perineal trauma: randomised controlled trial. BMJ. 2001;322:1277–1280. doi: 10.1136/bmj.322.7297.1277. . (26 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Sultan A, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905–1911. doi: 10.1056/NEJM199312233292601. [DOI] [PubMed] [Google Scholar]
  • 1-3.Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994;308:887–891. doi: 10.1136/bmj.308.6933.887. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-4.Fines M, Donnelly V, Behan M, O'Connell PR, O'Herlihy C. Effect of second vaginal delivery on anorectal physiology and faecal continence: a prospective study. Lancet. 1999;354:983–986. doi: 10.1016/S0140-6736(98)11205-9. [DOI] [PubMed] [Google Scholar]
  • 1-5.Sultan AH, Hudson CN. Are junior doctors and midwives adequately prepared to repair the perineum? J Obstet Gynaecol. 1993;13:484–485. [Google Scholar]

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