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The Effectiveness of Prenatal Perineal Massage at Reducing the Risk of Perineal Trauma During Vaginal Delivery: a Meta-Analysis

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The Effectiveness of Prenatal Perineal Massage at Reducing the Risk of Perineal Trauma During Vaginal Delivery: a Meta-Analysis ABSTRACT THE EFFECTIVENESS OF PRENATAL PERINEAL MASSAGE AT REDUCING THE RISK OF PERINEAL TRAUMA DURING VAGINAL DELIVERY: A META-ANALYSIS Background: Perineal injury occurs in 85% of all women who experience a vaginal delivery.1 Research has suggested that prenatal perineal massage can reduce the risk of perineal trauma. The purpose of this meta-analysis is to determine if perineal massage should be performed in pregnant women as preparation for their vaginal delivery. Methods: Electronic databases were searched and eligible articles involving prenatal perineal massage compared to standard routine care during pregnancy were gathered. The PEDro Scale was used to assess the quality of the studies included in this meta-analysis. Data including sample sizes were extracted to calculate the overall relative risk of an episiotomy or laceration occurring in the perineal massage group over the control group. Results: After screening, 7 controlled trials were included for analysis. Women were found to have a 30% risk reduction of experiencing a third- or fourth-degree tear after practicing perineal massage. Static massage decreased the risk of third- and fourth-degree tears by 73% and dynamic massage by 16%. Perineal massage 3-4 times per week decreased the risk of third- and fourth-degree tears by 73% compared to 22% for daily massage. Conclusion: Digital perineal massage reduced the severity of perineal injury. Future research should be conducted to determine the most effective parameters and techniques for perineal massage. Kari Anne Turner May 2020 THE EFFECTIVENESS OF PRENATAL PERINEAL MASSAGE AT REDUCING THE RISK OF PERINEAL TRAUMA DURING VAGINAL DELIVERY: A META-ANALYSIS by Kari Anne Turner A project submitted in partial fulfillment of the requirements for the degree of Doctor of Physical Therapy in the Department of Physical Therapy College of Health and Human Services California State University, Fresno May 2020 APPROVED For the Department of Physical Therapy: We, the undersigned, certify that the project of the following student meets the required standards of scholarship, format, and style of the university and the student's graduate degree program for the awarding of the doctoral degree. Kari Anne Turner Project Author Nupur Hajela (Chair) Physical Therapy Jennifer Roos Physical Therapy For the University Graduate Committee: Dean, Division of Graduate Studies AUTHORIZATION FOR REPRODUCTION OF DOCTORAL PROJECT X I grant permission for the reproduction of this project in part or in its entirety without further authorization from me, on the condition that the person or agency requesting reproduction absorbs the cost and provides proper acknowledgment of authorship. Permission to reproduce this project in part or in its entirety must be obtained from me. Signature of project author: ACKNOWLEDGMENTS I would like to thank the following special people for the love, support, and laughter during this strenuous, yet rewarding process: Nupur Hajela, PT, DPT, PhD Jennifer Roos, PT, DPT, GCS Kenneth Paul Turner Glenn & Linda Silveira Alex & Katie Cabatic Kim & Paul Turner Sam Mendoza Aly Huber Alyssa Cabri Nicole Cope and Mason Rivera TABLE OF CONTENTS Page LIST OF TABLES ................................................................................................. vii LIST OF FIGURES ............................................................................................... viii BACKGROUND ...................................................................................................... 1 Clinical Importance ........................................................................................... 1 Anatomy & Physiology ..................................................................................... 2 Degrees of Perineal Laceration ......................................................................... 4 Utilization of Episiotomy .................................................................................. 5 Current Research ............................................................................................... 7 METHODS ............................................................................................................... 9 Search Strategy.................................................................................................. 9 Quality Appraisal ............................................................................................ 10 Data Collection Process .................................................................................. 10 Operational Definitions ................................................................................... 11 Statistical Analysis .......................................................................................... 12 RESULTS ............................................................................................................... 13 Study Selection................................................................................................ 13 Study Characteristics ....................................................................................... 13 Primary Analysis: Effects of Perineal Massage on Episiotomy and OASIS .. 14 Primary Sub-Analysis: Static vs. Dynamic Perineal Massage ........................ 15 Secondary Sub-Analysis: Daily Vs. 3-4x Weekly .......................................... 15 DISCUSSION......................................................................................................... 17 Summary of Results ........................................................................................ 18 Threats to Validity........................................................................................... 19 vi vi Page Limitations ...................................................................................................... 21 Clinical Implications ....................................................................................... 22 Future Research ............................................................................................... 23 Conclusion ....................................................................................................... 23 REFERENCES ....................................................................................................... 24 TABLES ................................................................................................................. 30 FIGURES................................................................................................................ 36 APPENDIX: PEDRO SCALE ............................................................................... 39 LIST OF TABLES Page Table 1. PEDro Scale of Eligible Studies............................................................... 31 Table 2. Study Characteristics ................................................................................ 32 Table 3. Study Inclusion and Exclusion Criteria .................................................... 33 Table 4. Perineal Massage Characteristics ............................................................. 34 Table 5. Results: Perineal Trauma after Massage .................................................. 34 Table 6. Results: Perineal Trauma with Static vs. Dynamic Massage ................... 35 Table 7. Results: Perineal Trauma with Daily vs. 3-4x Week Massage ................ 35 LIST OF FIGURES Page Figure 1. Grades of OASIS .................................................................................... 37 Figure 2. Stress-strain curve ................................................................................... 37 Figure 3. Perineal massage technique .................................................................... 38 Figure 4. Consort map ............................................................................................ 38 BACKGROUND Perineal trauma commonly occurs to women during labor in a vaginal delivery. Trauma to the perineum results in injury, which can involve an episiotomy or a laceration. An episiotomy is an incision made by a medical doctor to enlarge the vaginal opening and a laceration is a spontaneous tear of soft tissue within the perineal region. Eighty-five percent of women sustain one or both of these types of perineal injuries during a vaginal delivery.1 Injury to the perineum leads to a variety of secondary morbidities during the postpartum period.2-4 The most common report from women following a perineal injury is pain.2 Perineal pain causes insomnia, anxiety, delay in or prevention of mother-neonate bonding, failure to find a tolerable position while breastfeeding, and dyspareunia.1,2 Another consequence of a perineal injury is urinary incontinence (UI). Urinary incontinence is the most frequently reported long-term morbidity following perineal trauma4,5 Up to 40% of women with post- partum UI, continue to experience UI for the duration of their lifetime.6 Urinary incontinence is highly associated with the development of subsequent psychological, physical, and social problems such as avoiding social interactions and physical activity due to fear of voiding in public.6 A longitudinal study conducted in 2006 determined that 42% of women continued to experience symptoms of UI 12 years following their vaginal delivery.7 Therefore, once a woman develops UI, she tends to experience symptoms for the duration of her lifetime. Clinical Importance Perineal injuries are a concern for health care providers due to their tendency to contribute to long-term secondary morbidities such
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