Keywords
perineal trauma - perineal massage - hemorrhage - episiotomy - pain
Introduction
Perineal trauma is a type of damage that is the result of a tear or laceration during
childbirth [1]
[2]
[3]. Trauma can cause an unwanted
physical and psychological health burden. Perineal pain, hemorrhage, prolapse,
urinary incontinence, sexual dysfunction, and anxiety in later periods are some of
the morbidities [2]
[4]. The problems that occur due to
perineal trauma can negatively affect the quality of life of women [2]
[5].
Maternal age, macrosomia, and the episiotomy method are stated as risk factors in
perineal traumas [2]
[6]. Studies show that 85.0% of women are
exposed to birth-related perineal trauma and 59.0–73.0% are exposed to some type of
laceration [7]
[8]. It is reported that most traumas are
related to the application of an episiotomy [5]
[9]
[10]. An episiotomy, which is used to
facilitate delivery and shorten the second stage of labor, can lead to perineal
trauma and complications. Studies have shown that an episiotomy is frequently
performed on primiparous women and that they are exposed to trauma [2]
[7]
[11].
Since perineal trauma is a condition with serious complications in early and later
stages, prevention is easier and more beneficial and economical than treatment. For
this reason, some methods are used to protect the perineum in order to reduce
perineal trauma, manage pain, and reduce hemorrhage [12]
[13]
[14].
It is stated that perineal massage and warm compresses increase vasodilation and
perineum flexibility and decrease the episiotomy rate and interventional vaginal
delivery [5]
[12]
[13]
[14]. Studies have shown that these
methods, which can be applied in the first and second stages of labor, are effective
in reducing perineal trauma, hemorrhage, and pain [5]
[12]
[15]
[16]. It is therefore recommended that
midwives and nurses use such methods that reduce pain and trauma and that can be
applied easily [17]
[18]. Although there are studies on this
subject, some of studies evaluated only these methods alone, and in some of them,
only parameters affected by pain, trauma, and episiotomy were evaluated alone [12]
[13]
[14]
[15]
[16]. In this study, methods were used
both individually and together, and it was aimed to provide evidence for the
literature by evaluating their effects on more than one parameter.
The aim of this randomized control study was to evaluate the impact that massage and
warm compresses applied by midwives and nurses during the first and second stages
of
delivery on trauma, pain around the perineum, hemorrhage during labor, and the
length of episiotomy in a sample of primiparous women.
Methods
Design
A single-blind, single-center randomized controlled trial (RCT) design was used
to compare four groups (massage, warm compress, massage and warm compress,
control) of participants. This study was conducted in a training and research
hospital in Ankara, Türkiye. CONSORT 2010 guidelines for reporting RCTs were
followed to describe the methods. The study was registered on ClinicalTrials.gov
(NCT06005077).
Participants
This study involved primiparous women in gestational week 38 and over, with a
singleton pregnancy and the fetus in the vertex position. The exclusion criteria
were previous uterine surgery, a chronic/hematological disease, or a fetal
abnormality. In addition, patients for whom vacuum or forceps were applied
during delivery were excluded.
Sample selection and randomization
The study’s sample population included 716 women who gave birth vaginally. The
sample size was determined using the G*Power program. While calculating sample
size, data of the study in which trauma was evaluated by applying perineal
massage and a warm compress during labor were taken into account. The effect
size was found to be 0.522 [15]. It
was planned to conduct the study with a total of 120 participants at a 95.0%
confidence interval and 95.0% power. Randomization was carried out by a
researcher using a program through RANDOM.ORG. This study was conducted as a
single-blind study in which women did not know whether they were in the
intervention or control group. To prevent bias, a second researcher did not
assign the groups and did not perform outcome assessments.
A total of 120 pregnant women were included in the study, with 30 assigned to the
massage (PM) group, 30 to the warm compress (PWC) group, 30 to the massage and
warm compress (PM+PWC) group, and 30 to the non-intervention group, which
received routine midwife/nurse care. Assessed for eligibility were 716
participants, and 574 participants were excluded because of multiparity,
gestational age, chronic illness, or unwillingness to participate. A total of
142 women were randomized. In each group, 30 participants were analyzed, and 22
of them were excluded because of cesarean delivery and vacuum
implementation.
Data collection and intervention
Data collection was performed between May 2018 and September 2019. All
participants provided informed consent before participation. The control group
was given routine care by nurses and midwives. The participants were
continuously monitored until their transfer to a postpartum clinic. A
face-to-face interview was conducted throughout the research.
Massage only: Massage was performed with the fingers with the woman in the
lithotomy position. U-shaped movements were applied to 3–4 cm of the inner part
of the vagina, from the sidewalls and towards the rectum. This procedure was
carried out for 10 minutes in three phases, based on the cervical dilation
process. It was implemented when the cervix was dilated to 3–4 cm, 5–7 cm, or
8–10 cm.
Warm compress only: A compress moistened with 40°C water was placed on the
perineal area. The compress was replaced with a new one when it became cold or
dirty. This procedure was performed for 30 minutes based on the progress of
cervical dilatation. It was performed when dilatation of the cervix was 3–4 cm,
5–7 cm or 8–10 cm.
Both massage and warm compress: When dilation of the cervix reached 3–4 cm, a
warm compress was first applied for 30 minutes. Massage was then performed for
10 minutes. Both techniques were repeated when cervical dilation was 5–7 cm or
8–10 cm.
Pilot study
Prior to the study, massage and warm compresses were applied to 12 pregnant women
to
test the procedure. The pilot study was performed via data collection forms and a
hemorrhage follow-up/collector bag. As a result of the preliminary application,
application steps and data collection forms were evaluated and then necessary
revisions made. The findings of the pilot assessment were not included in main study
findings.
Measurement tools
The sociodemographic and obstetric data collection form
These data were used to assess the sociodemographic and obstetric characteristics
of the participants. This form, prepared by researchers, includes 15 questions
about the participant’s age, educational status, week of gestation, and health
problems experienced during pregnancy [1]
[4]
[5]
[8]
[11]
[16]
[17]
[18].
The stage of labor and newborn data collection form
This form was used to assess procedures performed during the first and second
stages of labor. In addition, it was used to assess the newborn’s condition
after delivery. This form, created by researchers based on the literature,
consisted of three sections. The first section contained questions about
procedures such as dilation, effacement, amniotomy, etc. The second section
included questions about perineal protection, pushing techniques, etc. during
the second stage. The third section included questions about the height, weight,
and APGAR score of the newborn. In total, these forms contained 33 questions
[1]
[4]
[5]
[8]
[11]
[12]
[13]
[15]
[16]
[17]
[18].
Visual analog scale (VAS)
The VAS is a one-dimensional scale that can be used to assess the intensity of
perceived pain. A rating of “0” indicates “no pain” and “10” indicates “the most
severe pain.”
Trauma assessment and hemorrhage and length of episiotomy measurement form
This was used to collect data on trauma to the perineal area and hemorrhage
quantity. Created by the researchers, it includes 13 questions assessing factors
such as episiotomy, the type and degree of trauma, and hemorrhage volume. A
postpartum hemorrhage follow-up collector bag (PBFCB) was used to measure the
volume of the postpartum hemorrhage.
Ethical considerations
Ethical approval (Decision number: 90057706-514.10 - 2018/13) was given by a
Clinical Research Ethics Committee in Türkiye, on 18.04.2018. Written consent
was given, and the consent forms were securely stored.
Data analysis
The statistical analysis was done using SPSS version 23.0 (IBM Corp., Armonk, NY,
USA). The significance level was accepted as p<.05. Descriptive
statistics were demonstrated as numbers and percentages. For continuous
variables, standard deviation, median, min., and max. were presented. The
Kolmogorov–Smirnov test was used to assess whether data followed a normal
distribution. Based on results, a one-way ANOVA was used to compare mean scores
among more than two independent groups. Subsequently, Tukey’s test was used for
identifying which groups differed. The Kruskal–Wallis test was used to determine
differences among more than two independent groups. The Wilcoxon test was used
to compare two dependent groups. The Friedman test was used to assess
differences between more than two dependent groups and a chi-square test was
used to analyze the relationship between two independent variables. In addition,
Fisher’s exact test was used for n×m tables. The Pearson coefficient test was
used to measure the association between two continuous variables.
Results
Homogeneity test and distribution of socio-demographic and obstetric
characteristics in control and intervention groups
This assessment was conducted to present equivalence between four groups. There
is no significance in age (p=0.270), residence (p=0.901),
educational status (p=0.566), or obstetric history, including week of
gestation (p=0.104), miscarriage/abortion (p=0.465), and pregnancy
intention (p=0.191) ([Table
1]).
Table 1 Homogeneity and distribution of socio-demographic
characteristics in the control and intervention groups.
|
Variable
|
PM (n=30) Mean±SD
|
PWC (n=30) Mean±SD
|
PM+PWC (n=30) Mean±SD
|
Control (n=30) Mean±SD
|
Total (n=120) Mean±SD
|
Statistical Analysis
|
|
F
|
p
|
|
Age
|
26.43
|
±3.90
|
25.4
|
3±4.02
|
25.43
|
±4.02
|
24.57
|
±3.81
|
25.4
|
7±3.94
|
1.125
|
0.342
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
X
2
|
p
|
|
Education Level
|
|
Elementary School
|
4
|
13.3
|
2
|
6.7
|
6
|
20.0
|
4
|
13.3
|
16
|
13.3
|
|
|
|
High School
|
9
|
30.0
|
13
|
43.3
|
8
|
26.7
|
11
|
36.7
|
41
|
34.2
|
7.730
|
0.566
|
|
Associate Degree
|
3
|
10.0
|
4
|
13.3
|
8
|
26.7
|
4
|
13.3
|
19
|
15.8
|
|
|
|
Bachelor's Degree
|
14
|
46.7
|
11
|
36.7
|
8
|
26.7
|
11
|
36.7
|
44
|
36.7
|
|
|
|
Employment Status
|
|
Working
|
9
|
30.0
|
9
|
30.0
|
6
|
20.0
|
5
|
16.7
|
29
|
24.2
|
2.319
|
0.566
|
|
Not Working
|
21
|
70.0
|
21
|
70.0
|
24
|
80.0
|
25
|
83.3
|
91
|
75.8
|
|
|
|
Residence
|
|
City
|
28
|
93.3
|
29
|
96.7
|
30
|
100.0
|
29
|
96.7
|
26
|
96.7
|
2.062
|
0.901
|
|
District
|
2
|
6.7
|
1
|
3.3
|
–
|
–
|
1
|
3.3
|
4
|
3.3
|
|
|
|
Body Mass Index
|
|
Underweight
|
–
|
–
|
–
|
–
|
1
|
3.3
|
–
|
–
|
1
|
0.8
|
|
|
|
Normal
|
9
|
30.0
|
15
|
50.0
|
2
|
6.7
|
4
|
13.3
|
19
|
15.8
|
10.859
|
0.232
|
|
Overweight
|
12
|
40.0
|
11
|
36.7
|
19
|
63.3
|
19
|
63.3
|
65
|
54.2
|
|
|
|
Obese
|
9
|
30.0
|
30
|
100.0
|
8
|
26.7
|
7
|
23.3
|
35
|
29.2
|
|
|
|
Pregnancy Week
|
|
<40 weeks
|
14
|
46.7
|
21
|
70.0
|
12
|
40.0
|
17
|
56.7
|
64
|
53.3
|
6.161
|
0.104
|
|
40 weeks and>
|
16
|
53.3
|
9
|
30.0
|
18
|
60.0
|
13
|
43.3
|
56
|
46.7
|
|
|
|
Miscarriage/Abortion
|
|
Yes
|
5
|
16.7
|
1
|
3.3
|
3
|
10.0
|
4
|
13.3
|
13
|
10.8
|
3.112
|
0.465
|
|
No
|
25
|
83.3
|
29
|
96.7
|
27
|
90.0
|
26
|
86.7
|
107
|
89.2
|
|
|
|
Weight Gain During Pregnancy
|
|
8 kg and below
|
3
|
10.0
|
1
|
3.3
|
3
|
10.0
|
3
|
10.0
|
10
|
8.3
|
6.355
|
0.380
|
|
9–12
|
14
|
46.7
|
8
|
26.7
|
9
|
30.0
|
7
|
23.3
|
38
|
31.7
|
|
|
|
13 kg and above
|
13
|
43.3
|
21
|
70.0
|
18
|
60.0
|
20
|
66.7
|
72
|
60.0
|
|
|
|
Pregnancy Intention
|
|
Intentional
|
27
|
90.0
|
29
|
96.7
|
30
|
100.0
|
30
|
100.0
|
116
|
96.7
|
4.397
|
0.191
|
|
Unintentional
|
3
|
10.0
|
1
|
3.3
|
–
|
–
|
–
|
–
|
4
|
3.3
|
|
|
PM=perineal massage, PWC=perineal warm compress, PM+PWC=combined perineal
massage and warm compress F=one-way analysis of variance (ANOVA),
χ2=chi-square and Fisher’s exact test
Primary outcomes: perineal trauma and degree of trauma
The effectiveness of massage and warm compresses to decrease perineal trauma in
pregnant women was investigated across the groups ([Table 2]). The perineal trauma rate
was 6.7% in the PM group and 3.3% in the PWC group. This percentage was 10% in
the PM+PWC group and 60% for the control group. Trauma incidence in the control
group was significantly greater than the intervention groups. A statistically
significant difference was found (chi-square test=40.417, p<0.001).
Additionally, the degree of perineal trauma was assessed, and it was understood
there was no trauma to participants exceeding the second degree. There was no
first-degree trauma in the warm compress group. First-degree trauma was observed
at a rate of 3.3% in the massage and massage+warm compress groups and 26.7% in
the control group. When the difference between groups regarding first-degree
trauma was examined, it was determined that there was a statistical significance
(p<0.05).
Table 2 Distribution of perineal trauma incidence in the
control and intervention groups.
|
PM (n=30) Mean±SD
|
PWC (n=30) Mean±SD
|
PM+PWC (n=30) Mean±SD
|
Control (n=30) Mean±SD
|
Total (n=120) Mean±SD
|
Statistical Analysis
|
|
F
|
p
|
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
X2
|
p
|
|
Perineal Trauma
|
|
Yes
|
2b
|
6.7
|
1b
|
3.3
|
3b
|
10.0
|
18a
|
60.0
|
24
|
20.0
|
40.417
|
<0.001
*
|
|
No
|
28b
|
93.3
|
29b
|
96.7
|
27b
|
90.0
|
12b
|
40.0
|
96
|
80.0
|
|
|
|
Type of Perineal Trauma
|
|
Laceration
|
1
|
50.0
|
1
|
100.0
|
1
|
33.3
|
4
|
22.2
|
7
|
29.2
|
4.207
|
0.889
|
|
Perineal Tear
|
1
|
50.0
|
0
|
–
|
1
|
33.3
|
8
|
44.4
|
10
|
41.7
|
|
|
|
Hematoma
|
0
|
–
|
0
|
–
|
1
|
33.3
|
6
|
33.3
|
7
|
29.2
|
|
|
|
Degree of Perineal Trauma
|
|
No Perineal Tear
|
29a,b
|
96.7
|
30b
|
100.0
|
29a,b
|
96.7
|
22a
|
73.3
|
110
|
91.7
|
13.386
|
0.001
*
|
|
1st Degree
|
1a,b
|
3.3
|
–b
|
–
|
1a,b
|
3.3
|
8a
|
26.7
|
10
|
8.3
|
|
|
*p<0.001, x2=chi-square and Fisher’s exact test,
a-b=There is a difference between the two groups; a-a/b-b=There is no
difference between the two groups.
Secondary outcomes
The results of the measurement of postpartum hemorrhage were 221.66 ml (±85.78)
in the massage group, 213.33 ml (±109.01) in the warm compress group, and 240.0
ml (±103.72) in the massage+warm compress group ([Table 3]). In the control group,
the incidence of postpartum hemorrhage was 410.83 (±211.48). The volume of
postpartum hemorrhage in the control group was significantly greater than the
intervention groups. A statistically significant difference was found between
the groups (Kruskal-Wallis test: 25.158, p<0.001). Episiotomy lengths
were 3.1 cm (±0.96) in the massage group, 2.63 cm (±0.94) in the warm compress
group, and 2.98 cm (±0.88) in the massage+warm compress group. In the control
group, it was measured as 4.13 (±0.88). The episiotomy length in the control
group was greater than the intervention groups ([Table 3]). A statistically
significant difference was found between the groups in terms of episiotomy
length (Kruskal-Wallis test: 36.434, p<0.001).
Table 3 Distribution of postpartum bleeding amount and
episiotomy length in the control and intervention groups.
|
Postpartum Bleeding Amount (ml)
|
Episiotomy Length (cm)
|
|
Median (Min–Max)
|
Median (Min–Max)
|
|
PM (n=30)
|
221.66 (±85.78)
|
3.10 (±0.96)
|
|
PWC (n=30)
|
213.33 (±109.01)
|
2.63 (±0.94)
|
|
PM+PWC (n=30)
|
240.0 (±103.72)
|
2.98 (±0.88)
|
|
Control (n=30)
|
410.83 (±211.48)
|
4.13 (±0.88)
|
|
x
2
;
p
|
25.158;<0.001*
|
36.434;<0.001*
|
|
Difference
|
4–1,2,3
|
4–1,2,3
|
*p<0.001, x2=Kruskal-Wallis test, 1=PM, 2=PWC,
3=PM+PWC, 4=Control Group
In all groups, pain severity scores were evaluated when dilatation of the cervix
was 3–4 cm, 5–7 cm, or 8–10 cm. In addition, pain scores were compared before
and after application in the intervention groups. When dilatation of the cervix
was 5–7 cm and 8–10 cm, pain scores were greater in the control group than in
the PW and PWC groups (p<0.05). Furthermore, a significant correlation
was found between the pain score before intervention and after three
interventions in the PW group ([Table
4]). It has been determined that perineal trauma is reduced after each
application of a warm compress. A statistically significant difference was
detected (p<0.05).
Table 4 Distribution of pain scores in the control and
intervention groups.
|
Intervention 1 (Dilation 3–4 cm)
|
Statistical Analysis
|
Intervention 2 (Dilation 5–7 cm)
|
Statistical Analysis
|
Intervention 3 (Dilation 8–10 cm)
|
Statistical Analysis
|
|
Before Mean±SD
|
After Mean±SD
|
Before Mean±SD
|
After Mean±SD
|
Before Mean±SD
|
After Mean±SD
|
|
PM (n=30)
|
4.17±1.53
|
4.40±1.90
|
t=–1.126
|
7.0±1.48
|
6.93±1.89
|
t=–0.226
|
9.03±0.96
|
9.0±0.98
|
t=–1.00
|
|
p=0.269
|
p=0.823
|
p=0.326
|
|
PWC (n=30)
|
4.40±1.86
|
4.27±1.83
|
t=–2.112
|
6.70±1.57
|
6.37±1.65
|
t=3.808
|
8.80±1.03
|
8.50±1.16
|
t=–3.071
|
|
p
=0.043
*
|
p
=0.001
**
|
p=0.005
**
|
|
PM+PWC (n=30)
|
3.33±1.02
|
3.43±1.10
|
t=–0.722
|
6.33±0.95
|
6.13±1.25
|
t=1.439
|
8.97±0.99
|
8.93±1.04
|
t=0.571
|
|
|
p=0.476
|
p>0.999
|
p=0.573
|
|
Control (n=30)
|
–
|
4.37±2.26
|
–
|
–
|
7.70±1.80
|
–
|
–
|
9.73±0.82
|
–
|
|
Statistical Analysis (x
2
;
p
)
|
F=4.103
|
F=1.893
|
|
F=1.785
|
F=5.246
|
|
F=0.435
|
F=7.640
|
|
|
p=0.20
|
p=0.135
|
|
p=0.174
|
p
=0.002
*
|
|
p=0.649
|
p
<0.001
*
|
|
|
Difference Between Groups
|
|
|
|
|
4–2,3
|
|
|
4–2,3
|
|
*p<0.05, **p<0.01, 1=PM, 2=PWC, 3=PM+PWC, 4=control group,
t=paired-samples t test, F=one-way ANOVA
Discussion
Massage and warm compress methods are nonpharmacological methods recommended for a
better childbirth result and to reduce trauma to the perineum, pain around the
perineal area, hemorrhage and episiotomy rates, and to increase the flexibility of
perineum [4]
[5]
[19]. In this study, the effectiveness of
massage and warm compresses on reducing trauma and pain were investigated.
Additionally, the volume of postpartum hemorrhage and the length of the episiotomy
were measured.
Our study revealed that massage and warm compress applications reduced perineal
trauma. In a study that shows the result of massage on the perineum, trauma
incidence was 63.2% in the massage group and 60.5% in the control group [20]. Another study that investigated the
effects of Vaseline massage revealed that trauma incidence was 73.3% in the
intervention group and 96.0% in the control group [15]. In a study evaluating the
effectiveness of perineal warm compresses, the rate of perineal trauma was 73.0% in
the compress group and 93.3% in the control group [12].
Considering complications and unwanted effects of perineal trauma, the severity of
perineal trauma is as important as the degree of trauma. Some studies have shown
that massage and warm compresses reduce the severity of perineal trauma [4]
[5]
[16]. In contrast to the literature, the
absence of a second and higher degree of perineal trauma in our research may be
attributed to the effective management of labor and application of correct clinical
procedures. Our study further revealed that the combined use of massage and warm
compresses did not provide an advantage. For this reason, it is thought that any of
these methods alone will be sufficient when application time, workforce, and cost
of
the healthcare team are considered.
According to the literature, the volume of hemorrhage increases due to routine
episiotomy and perineal trauma, accounting for approximately 20.0% of cases of
postpartum hemorrhage. For this reason, it is important to follow up hemorrhage with
objective measurement tools in terms of early and effective intervention in
postpartum hemorrhage [9]
[21]. Preterm postpartum hemorrhage is
also associated with episiotomy. Since routine episiotomy is common, especially in
primiparous patients, perineum-preserving approaches are recommended to decrease the
risk of trauma to the perineum, hemorrhage, and episiotomy length [16]
[21]
[22]
[23]. In line with our research results,
perineal massage and a warm compress did not change the physicians’ preference for
episiotomy. However, evaluating the flexibility of the perineum was preferable for
a
shorter episiotomy. Thus, it is thought that there is a decrease in the volume of
postpartum hemorrhage due to the reduction in episiotomy length and trauma.
Perineal trauma is frequently experienced during the second stage of labor. In this
period, trauma occurs due to the tension created by the fetal head in the perineal
tissue. Perineal trauma is associated with the implementation of an episiotomy and
type of suturing [17]
[24]. It has been reported that
approaches such as warm compress application and massage are effective for
decreasing perineal trauma. Different studies reported that perineal massage is
effective in reducing perineal trauma [12]
[19]. Moreover, there are
studies that have shown that warm compresses are effective in decreasing perineal
trauma [2]
[14]
[16]
[25]. The findings in the literature and
our findings coincide. Perineal trauma seems to be reduced in relation to
relaxation, especially in the tissues, as a result of a warm compress.
Limitations
First, there is no field-specific scale for evaluating perineal pain and trauma.
Second, our findings cannot be generalized to different groups because this
study included a single center only, and the researcher who conducted the study
was not blinded.
Conclusion
The warm compress intervention and massage application methods are effective for
decreasing trauma to the perineum, pain, hemorrhage volume, and episiotomy length.
With these methods performed during labor, it is possible to obtain perineal
flexibility and to perform a shorter episiotomy. It is thought that there is a
decrease in the volume of postpartum hemorrhage due to the reduction in episiotomy
length and trauma. In addition, warm compresses are particularly effective in
reducing perineal pain, as there is a relaxation of tissues. However, the use of two
methods together does not offer an advantage. These techniques can be used
independently of each other and they are recommended to decrease the rate of
perineal trauma, hemorrhage, pain, and episiotomy length.
