IJG-08412; No of Pages 4

International Journal of Gynecology and Obstetrics xxx (2015) xxxxxx

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

2Q2

Effect of perineal massage on the rate of episiotomy and perineal tearing

3Q1

Gulbahtiyar Demirel a,, Zehra Golbasi b

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a r t i c l e

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Article history:
Received 4 July 2014
Received in revised form 24 April 2015
Accepted 13 July 2015

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Keywords:
Duration of the second stage of labor
Episiotomy
Perineal laceration
Perineal massage

a b s t r a c t

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i n f o

Department of Midwifery, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkey

Department of Nursing, Faculty of Health Sciences, Cumhuriyet University, Sivas, Turkey

Objective: To examine the effects of perineal massage during active labor on the frequency of episiotomy and perineal tearing. Methods: A randomized controlled study was conducted at a center in Sivas, Turkey, between
January 1, 2010, and May 31, 2011. Healthy pregnant women presenting for their rst or second delivery at
3742 weeks of pregnancy were enrolled during the rst stage of labor. Participants were randomly assigned
(1:1) to the massage group (10-minute perineal massage with glycerol four times during the rst stage and
once during the second stage of labor) or control group (routine care). The frequency of episiotomy and perineal
tearing were compared between the groups. Participants and investigators were not masked to group assignment. Results: Both groups contained 142 participants. Episiotomy was performed among 44 (31.0%) women
in the massage group and 99 (69.7%) in the control group (P = 0.001). Lacerations were recorded among 13
(4.2%) women in the massage group and 6 (4.2%) in the control group (P = 0.096). Conclusion: Application of perineal massage during active labor decreased the frequency of episiotomy procedures.
ClinicalTrials.gov: NCT02201615
2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

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1. Introduction

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Perineal traumaspontaneous or episiotomy-induced damage to

the genital organs during delivery [1]affects the quality of active
labor, especially among primiparous women [2,3]. It is frequently observed during delivery and can have detrimental effects on a mothers
health and quality of life [3]. Women who experience perineal trauma
can subsequently be affected by conditions such as dyspareunia, urinary
and anal incontinence, perineal pain, and delayed motherneonate
interaction [46].
Perineal trauma can be caused by episiotomy [2,3]one of the most
frequently used obstetric interventions [7,8]. Although some studies
argue that performance of episiotomy should be limited owing to the
negative effects of perineal trauma on maternal and neonatal health
[8,9], this obstetric procedure continues to be widely applied in many
countries. For example, the prevalence of episiotomy is 8% in the
Netherlands, 14% in the UK, 50% in the USA, and as high as 99% in
many eastern European countries [10]. One study found that episiotomy
is performed in more than 65% of all deliveries and more than 90% of
those among primiparous women in Turkish hospitals [11]. Another
found that the rate of episiotomy among all deliveries was 74.2% [12].

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Corresponding author at: Department of Midwifery, Faculty of Health Sciences,

Cumhuriyet University, Sivas 58140, Turkey. Tel.: + 90 05052589929; fax: + 90
3462191261.
E-mail address: gulbahtiyar_doganer@hotmail.com (G. Demirel).

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Overall, episiotomy is still routinely used in Turkey among primiparous

women and women with two or more previous deliveries [13,14].
The accumulation of evidence that episiotomy does not ensure
perineum integrity and has overwhelming negative effects has led
to an increase in the number of studies on other protective variables
(e.g. prenatal perineal massage and hot treatment) [2,3]. Perinealprotective birth techniques are recommended to prevent perineal
lacerations and their associated morbidity [3,15]. Perineal massage can
prevent perineal lacerations, protect perineal integrity, and enable
women to rapidly regain function after delivery [2,3,5]. It can stimulate
both rehabilitation and the re-elasticization of tissues and muscles, and
is thought to have a positive effect on vaginal delivery owing to its impact on tissues and muscles in the perineal area [2,3].
However, previous studies have provided varied results regarding
the effectiveness of perineal massage for the prevention of perineal
trauma. Some studies indicated that prenatal perineal massage [2,3,
13] and perineal massage during the second stage of active labor [16,
17] reduce the rate of perineal trauma. By contrast, others have reported
that perineal massage provides neither an advantage nor a disadvantage in terms of the rate of perineal trauma [1,6]. Thus, further studies
are needed on whether perineal massage secures perineal integrity. In
addition, there are few studies on the application of perineal massage
during both the rst and second stages of labor.
As a result, the aim of the present study was to examine the effects of
perineal massage applied during labor on the frequency of episiotomy
procedures and perineal tearing. A secondary aim was to assess the effect of massage on the duration of the second stage of labor.

http://dx.doi.org/10.1016/j.ijgo.2015.04.048
0020-7292/ 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.

Please cite this article as: Demirel G, Golbasi Z, Effect of perineal massage on the rate of episiotomy and perineal tearing, Int J Gynecol Obstet
(2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.048

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During the study period, 284 women met the inclusion criteria and
agreed to participate (Fig. 1). Both groups contained 142 patients. All
participants completed the study and were included in analyses. The
control and massage groups both contained 71 multiparous pregnant
women. No signicant differences between groups were recorded for
age, length of pregnancy, or neonatal head circumference (Table 1).
No women delivered by cesarean.
Episiotomy was signicantly more common in the control group
than in the massage group (P = 0.001) (Table 2). Frequency of laceration did not differ signicantly between groups (P = 0.096) (Table 2).
The mean duration of the second stage of labor was signicantly
shorter in the massage group than in the control group among the
whole population, among primipara, and among multipara (P b 0.01
for all) (Table 3).

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3. Results

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The present randomized controlled study was conducted between

January 1, 2010, and May 31, 2011 among pregnant women presenting
for delivery at Sivas State Hospital, Sivas, Turkeya hospital with approximately 3200 normal vaginal births per year. Women were eligible
for inclusion when they had had no pregnancy-related complications
during pregnancy, they had no systemic condition, it was their rst or
second birth, the fetus was in cephalic presentation, they had no denitive indication for cesarean delivery, they were at 3742 weeks of pregnancy with verication of fetal dimensions, and they were in the latent
phase of the rst stage of labor with dilatation of less than 4 cm and
effacement of less than 50%.
Ethical approval (decision no. 2009-12/07) was obtained from
the Ethics Board for Clinical Research at Cumhuriyet University,
Sivas, Turkey, and written approval was obtained from the study institution. All women participated voluntarily and provided written
informed consent.
On arrival at the hospital, pregnant women were given a preevaluation form and assessed for compliance with the inclusion criteria.
Women who were eligible and agreed to participate were then divided
on the basis of parity (primiparous and multiparous). After the start column in a table of random numbers was designated by one researcher
(G.D.), the primiparous pregnant women were randomly assigned
(1:1) to the two groups by starting with the rst number for the control
group, the second number for the massage group, and so on. The multiparous pregnant women were randomly assigned to the two groups
in the same way. Participants and investigators were not masked to
group assignment.
Perineal massage was administered to all women in the massage
group in the rst stage of labor. The massage was performed in line
with a previous report [13]. Before massage was started, it was ensured that the bladder and bowel of the patient was empty. Each participant lay on her back in the lithotomic position, because in this
position, the abdominal muscles and hips are relaxed. The resting
phase, when the severity of contractions was reduced, was chosen
for the massage. In this phase, one researcher (G.D.) washed their
hands and put on gloves. Next, they poured a few drops of the lubricant (glycerol) onto their ngers and placed two thumbs 23 cm into
the vagina and applied pressure to the vaginal lateral walls with
their thumbs. Pressure was maintained at an intensity at which the
woman did not feel any pain. The pressurizing action was continued
for 2 minutes. Alongside the massage, the woman was asked to contract and relax the muscles in the perineal area and to become aware
of these muscles. The massage was paused at the onset of contractions and resumed when the contractions subdued. The massage
continued for 10 minutes in this manner. The participant was then
allowed to rest for a minimum of 30 minutes before the 10-minute
massage was repeated. The massage was performed four times during the rst stage of labor. When approaching the second stage of
labor, each patient was taken to an obstetric table and received another 10 minutes of perineal massage. Women in the control group
received routine care.
After delivery, the massage and control groups were evaluated in
terms of the rate of episiotomy and perineal tearing, and the duration
of the second stage of labor (Supplementary Material S1). In both
groups, women would be delivered by cesarean if necessary.
The necessary sample size was calculated by power analysis.
Previous studies indicate that the rate of intact perinea can be increased
by 10% by applying prenatal perineal massage [3,18]. In 2009, the frequency of episiotomy procedures at Sivas State Hospital was 63%
among all pregnant women and 99% among primiparous women. The
sample size needed to obtain a signicant difference with an value
of 0.05, a condence level of 1 of 0.95, a value of 0.20, and a
power of 1 of 0.80 was identied as 284 individuals. Equal numbers
of primiparous and multiparous women were approached.

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The study data were evaluated using SPSS version 14.0 (SPSS Inc,
Chicago, IL, USA). Women who received their assigned treatment
were included in analyses. The rates of episiotomy and spontaneous laceration were compared between the massage and control groups by 2
test, and the average duration of the second stage was compared by an
independent two-sample t test. P b 0.05 was considered signicant.

4. Discussion

2. Materials and methods

In the present study, the effects of glycerol-mediated perineal massage applied during the rst and second stages of labor were compared
against a control group of women who received no massage. The massage and control groups did not differ in maternal age, gestational age,
or neonatal head circumference, increasing the reliability of the present
ndings. Compared with the control group, signicantly fewer women
who had received perineal massage underwent episiotomy, indicating
a positive effect of perineal massaging applied during the rst and second stages of labor.
Previous studies have reported varied results on the effects of
perineal massage in the rst stage of labor on the rate of episiotomy procedures. For example, Mei-dan et al. [1] did not nd a signicant difference in the rate of episiotomy between women who received perineal
massage (20% of 23 women) and those who did not receive such massage (19% of 20 women). By contrast, Sayiner and Demirci [13] found
that the rate of episiotomy procedures among women who had undergone prenatal perineal massage (10% of 5) was signicantly lower than
that in the control group (92% of 46). Other studies have also suggested
that perineal massage initiated in the prenatal period decreases the
number of episiotomy procedures [3,18].
Whether perineal massage during the second stage of labor reduces
the rates of episiotomy has also been examined [6,16,17]. For example,
Karaam et al. [6] found that the frequency of episiotomy procedures
among women who had received perineal massage during the second
stage of labor (52.0% of 103 women) was lower than that in the control
group (60.6% of 120). In another study of the effect of perineal massage
during the second stage of labor, however, Geranmayeh et al. [17] did
not observe a difference in episiotomy rate between the massage (45%
of 15) and control (88% of 38) groups.
The present study differs from previous ones in that perineal massage was applied during both the rst and second stages of labor. The
varied results regarding the effect of perineal massage on the rate of episiotomy procedures among different studies are thought to stem from
variations in the timing of perineal massage (i.e. prenatal period, second
stage only, or rst and second stages).
Because the present sample included only healthy pregnant women
having their rst or second birth, the results cannot be generalized to
the whole population. However, the ndings still have implications for
perineal complications associated with labor.

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Please cite this article as: Demirel G, Golbasi Z, Effect of perineal massage on the rate of episiotomy and perineal tearing, Int J Gynecol Obstet
(2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.048

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G. Demirel, Z. Golbasi / International Journal of Gynecology and Obstetrics xxx (2015) xxxxxx

Assessed for eligibility (n=635)

Excluded (n=351)
Did not meet inclusion criteria (n=147)
Declined to participate (n=204)

Underwent perineal massage (n=142)

Received routine care (n=142)

Primiparous (n=71)

Primiparous (n=71)

Multiparous (n=71)

Multiparous (n=71)

t1:1
t1:2

Table 1
Individual and obstetric characteristics.a
Characteristic

Overall (n = 284)

Massage group (n = 142)

t1:4
t1:5
t1:6
t1:7
t1:8
t1:9

Age, y
Length of pregnancy, wk
Neonatal head circumference, cm
Parity
Primiparous
Multiparous

23.86 3.94
38.58 0.93
35.78 0.87

24.30 4.09
38.58 0.99
35.80 0.94

142 (50.0)
142 (50.0)

71 (50.0)
71 (50.0)

t1:10

Table 2
Frequency of laceration and episiotomy procedures.a

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N
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t statistic

P value

1.891
0.190
0.475

0.060
0.850
0.635

71 (50.0)
71 (50.0)

t2:1
t2:2

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Perineal massaging is recommended because it improves the elasticity of the perineal muscles, ensures perineal exibility during delivery,
and thereby reduces both the need for episiotomy and spontaneous lacerations [13,19]. In a study in Canada, Labreque et al. [18] determined
that perinatal perineal massaging increased the rate of intact perineum
from 15% to 24%. Other studies also reported a higher rate of intact perineum and fewer lacerations in perineal massage groups [2,16,17], but
some studies failed to identify such effects [1,20]. Sayiner and Demirci
[13] established a rate of spontaneous laceration of 12% (6 women) in
the prenatal perineal massage group and 2% (1 woman) in the control
group. In the present study, 9.2% of women in the massage group developed lacerations, as compared with 4.2% of women in the control group;
thus, the rate of spontaneous laceration in the massage group was lower
than that reported by Sayiner and Demirci [13]. This nding may suggest that massage applied during the rst and second stages of labor
more effectively avoids spontaneous laceration than does massage applied only during the prenatal period.
It is difcult to assess the present data on the duration of the second
stage objectively owing to the limited number of studies on the ideal

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Control group (n = 142)

23.42 3.74
38.59 0.87
35.76 0.79

Values are given as mean SD or number (percentage), unless indicated otherwise.

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t1:3

Fig. 1. Flow of patients through the study.

Allocated to control group (n=142)

R
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Allocated to massage group (n=142)

Randomly assigned (n=284)

duration of this stage of labor [21]. One study has specied the duration
of the second stage as lasting from 30 minutes to 2 hours for primiparous women and from 5 minutes to 30 minutes for multiparous
women [7]. The second stage of labor has been reported to be longer
for women undergoing episiotomy [22,23], and shorter for women
undergoing perineal massage [17]. For example, Geranmayeh et al.
[17] observed that the second stage of labor lasted 37 20 minutes in
their perineal massage group and 46 19 minutes in their control
group. In the present study, the average duration of the second stage
was signicantly shorter in the massage group than in the control
group. It was also signicantly shorter in the massage group among primiparous women and among multiparous women. These data indicate
that perineal massage applied during the rst and second stages of labor
shortened the duration of the second stage. These results should be conrmed in a larger and wider study sample.
In summary, the present study results indicate that application of
perineal massage during the rst and second stages of active labor
could decrease the rate of episiotomy procedures and shorten the duration of the second stage of labor.

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t2:3

Characteristic

t2:4
t2:5
t2:6
t2:7
t2:8
t2:9

Laceration
Yes
No
Episiotomy
Yes
No

t2:10

Overall
(n = 284)

Massage group
(n = 142)

Control group
(n = 142)

2
statistic
2.764

19 (6.7)
265 (93.3)

13 (9.2)
129 (90.8)

6 (4.2)
136 (95.8)

143 (50.4)
141 (49.6)

44 (31.0)
98 (69.0)

99 (69.7)
43 (30.3)

P value
0.096

Subgroup
b

42.608

Values are given as number (percentage) unless indicated otherwise.

0.001

t3:1
t3:2

Table 3
Duration of the second stage of labor.a

Primiparous
Multiparousb
Overallc
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b
c

Massage group

Control group

t statistic

P value

t3:3

29.63 3.58
21.04 3.42
25.33 5.50

33.96 3.78
22.38 2.19
28.18 6.58

7.032
2.770
3.935

0.001
0.006
0.001

t3:4
t3:5
t3:6

Values are given as mean SD and are in minutes.

n = 71 for both groups.
n = 142 for both groups.

Please cite this article as: Demirel G, Golbasi Z, Effect of perineal massage on the rate of episiotomy and perineal tearing, Int J Gynecol Obstet
(2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.048

t3:7
t3:8
t3:9

G. Demirel, Z. Golbasi / International Journal of Gynecology and Obstetrics xxx (2015) xxxxxx

The present study was supported by the Scientic Research

Project Fund of Cumhuriyet University, Sivas, Turkey (project number
SBF-005).

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References

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The authors have no conicts of interest.

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Conict of interest

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Supplementary data to this article can be found online at http://dx.

doi.org/10.1016/j.ijgo.2015.04.048.

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Please cite this article as: Demirel G, Golbasi Z, Effect of perineal massage on the rate of episiotomy and perineal tearing, Int J Gynecol Obstet
(2015), http://dx.doi.org/10.1016/j.ijgo.2015.04.048

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