Antenatal perineal massage for reducing perineal trauma
Abstract
Background
Perineal trauma following vaginal birth can be associated with significant short‐term and long‐term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma.
Objectives
To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity.
Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012), EMBASE (1980 to October 2012) and reference lists of relevant articles.
Selection criteria
Randomised and quasi‐randomised controlled trials evaluating any described method of antenatal digital perineal massage undertaken for at least the last four weeks of pregnancy.
Data collection and analysis
Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information.
Main results
We included four trials (2497 women) comparing digital perineal massage with control. All were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)) and women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only. No differences were seen in the incidence of first‐ or second‐degree perineal tears or third‐/fourth‐degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage.
Authors' conclusions
Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.
PICOs
Plain language summary
Antenatal perineal massage for reducing perineal trauma
Antenatal perineal massage helps reduce both perineal trauma during birth and pain afterwards.
Most women are keen to give birth without perineal tears, cuts and stitches, as these often cause pain and discomfort afterwards, and this can impact negatively on sexual functioning. Perineal massage during the last month of pregnancy has been suggested as a possible way of enabling the perineal tissue to expand more easily during birth. The review of four trials (2497 women) showed that perineal massage, undertaken by the woman or her partner (for as little as once or twice a week from 35 weeks), reduced the likelihood of perineal trauma (mainly episiotomies) and ongoing perineal pain. The impact was clear for women who had not given birth vaginally before, but was less clear for women who had. Women should be informed about the benefits of digital antenatal perineal massage.
Authors' conclusions
Background
Genital tract trauma
Trauma to the genital tract commonly accompanies vaginal birth. Perineal trauma is classified as first degree (involving the fourchette, perineal skin and vaginal mucous membrane), second degree (involving the fascia and muscle of the perineal body), third degree (involving the anal sphincter) and fourth degree (involving the rectal mucosa) (Williams 1997). Genital tract trauma can result from episiotomies (incision to enlarge vaginal opening), spontaneous tears or both. Although in some countries the frequency of episiotomy has declined in recent years, overall rates of trauma remain high. There is considerable variation in the reported rates of perineal trauma because of inconsistency in definitions and reporting practices. In studies of restrictive use of episiotomy, 51% to 77% of women still sustained trauma that was considered to be sufficiently extensive to require suturing (Albers 1999; Mayerhofer 2002; McCandlish 1998). Even in a home birth setting, approximately 30% of women experience some degree of perineal trauma (Murphy 1998). Rates of trauma are especially high in women having their first baby (Albers 1999).
Morbidity associated with perineal trauma
Perineal trauma can be associated with significant short‐term and long‐term morbidity. Most women experience perineal pain or discomfort in the first few days after a vaginal birth. Of those women who sustain perineal trauma, 40% report pain in the first two weeks postpartum, up to 20% still have pain at eight weeks (Glazener 1995), and 7% to 9% report pain at three months (McCandlish 1998; Sleep 1987). Women giving birth with an intact perineum, however, report pain less frequently at one, two, 10 and 90 days postpartum (Albers 1999; Klein 1994).
Perineal pain or discomfort is common and may impair normal sexual functioning. Dyspareunia (painful sex) following vaginal delivery is reported by 60% of women at three months, 30% at six months (Barrett 2000) and 15% still experience painful sex up to three years later (Sleep 1987). Trauma to the perineum has been associated with dyspareunia during the first three months after birth (Barrett 2000). Women with an intact perineum (compared with those who have experienced perineal trauma) are more likely to resume intercourse earlier, report less pain with first sexual intercourse, report greater satisfaction with sexual experience (Klein 1994), and report greater sexual sensation and likelihood of orgasm at six months postpartum (Signorello 2001).
Women giving birth to their first baby with an intact perineum have stronger pelvic floors (measured by electromyogram) and make quicker muscle recovery than those women suffering spontaneous tears or episiotomies (Klein 1994). Perineal trauma has not, however, been clearly associated with urinary incontinence (Woolley 1995). Anal sphincter or mucosal injuries are identified following 3% to 4% of all vaginal births. This rate is not reduced by a policy of restrictive use of episiotomy (Carroli 1999). Alarmingly, one‐third of those women who are recognised will suffer some degree of incontinence of faeces (from mild to severe) following primary repair (Sultan 2002). An estimated 35% of primiparas have ultrasound scan evidence of third‐ or fourth‐degree trauma that is unrecognised at delivery and presumably associated with vaginal birth (Sultan 1993).
There is no evidence that birthing practices that aim to reduce perineal trauma are correlated with adverse maternal or neonatal outcomes. Restrictive use of episiotomy results in less posterior perineal trauma, less suturing and fewer healing complications (Carroli 1999). Episiotomy does not reduce the risk of intraventricular haemorrhage in low‐birthweight babies (Woolley 1995), and allowing a longer second stage (and potentially avoiding perineal trauma), has not been shown to be associated with adverse perinatal outcomes (Menticoglou 1995).
Factors associated with perineal trauma
Numerous factors related to the woman or the care she receives have been suggested as potentially affecting the occurrence of genital tract trauma. Perineal trauma is more likely in nulliparas, and is more likely with increasing fetal head diameter and weight, and with malposition (Mayerhofer 2002; Nodine 1987). As mentioned, restrictive use of episiotomy is associated with less perineal trauma (Carroli 1999), as is the use of vacuum extraction for instrumental deliveries as opposed to forceps (Johanson 1999). There is no clear consensus about the role of perineal guarding (Mayerhofer 2002; McCandlish 1998), active directed pushing (Parnell 1993), maternal position (Gupta 2003) or the use of perineal massage during second stage (Stamp 2001) in reducing the incidence of perineal trauma. There is a lack of evidence to associate induction of labour with perineal trauma and only retrospective studies which suggest an association between accoucheur type and perineal trauma (Bodner‐Adler 2004; Shorten 2002). In the event of a perineal injury which requires suturing, a continuous subcuticular technique compared with interrupted sutures has been associated with less pain postpartum (Kettle 1998).
Preventing perineal trauma
The potential morbidity associated with vaginal birth is concerning. It is possible that this is contributing to the increase in requests for caesarean section (Al‐Mufti 1997). Considering these factors, any method proven to reduce the likelihood of sustaining genital tract trauma (and therefore delivery‐associated morbidity) is to be commended. Preventing even some of this childbirth trauma is likely to benefit large numbers of women. It may also result in cost savings in terms of less suturing, drugs and analgesics. Some have advocated the use of perineal massage antenatally in decreasing the incidence of perineal trauma during vaginal birth. It is proposed that perineal massage may increase the flexibility of the perineal muscles and therefore, decrease muscular resistance, which would enable the perineum to stretch at delivery without tearing or needing episiotomy. Our aim is to investigate the role of antenatal digital perineal massage and its effect upon the incidence and morbidity associated with perineal trauma.
Objectives
To assess the effect of antenatal perineal massage on the incidence of perineal trauma at birth and subsequent morbidity.
Methods
Criteria for considering studies for this review
Types of studies
All published and unpublished randomised and quasi‐randomised controlled trials evaluating any described method of digital antenatal perineal massage were considered for inclusion in the review.
Types of participants
All pregnant women who are planning vaginal birth and have undertaken digital perineal massage for at least the last four weeks of pregnancy.
Types of interventions
Any described method of perineal massage undertaken by women and/or her partner.
Types of outcome measures
Primary outcomes
(a) Perineal trauma requiring suturing;
(b) first‐degree perineal tear;
(c) second‐degree perineal tear;
(d) third‐ or fourth‐degree perineal trauma;
(e) incidence of episiotomy.
Secondary outcomes
(f) Length of second stage;
(g) instrumental delivery;
(h) length of inpatient stay;
(i) admission to nursery;
(j) Apgar less than four at one minute and/or less than seven at five minutes;
(k) woman's satisfaction;
(l) perineal pain postpartum;
(m) ongoing perineal pain postpartum;
(n) painful sex postpartum;
(o) sexual satisfaction postpartum;
(p) uncontrolled loss of urine postpartum;
(q) uncontrolled loss of flatus or faeces postpartum.
Search methods for identification of studies
Electronic searches
We searched the Cochrane Pregnancy and Childbirth Group’s Trials Register by contacting the Trials Search Co‐ordinator (22 October 2012).
The Cochrane Pregnancy and Childbirth Group's Trials Register is maintained by the Trials Search Coordinator and contains trials identified from:
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monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL);
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weekly searches of MEDLINE;
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weekly searches of EMBASE;
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handsearches of 30 journals and the proceedings of major conferences;
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weekly current awareness alerts for a further 44 journals plus monthly BioMed Central email alerts.
Details of the search strategies for CENTRAL, MEDLINE and EMBASE, the list of handsearched journals and conference proceedings, and the list of journals reviewed via the current awareness service can be found in the ‘Specialized Register’ section within the editorial information about the Cochrane Pregnancy and Childbirth Group.
Trials identified through the searching activities described above were each assigned to a review topic (or topics). The Trials Search Coordinator searched the register for each review using the topic list rather than keywords.
In addition, we searched CENTRAL (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012) and EMBASE (1980 to October 2012) using the search strategy in Appendix 1.
Searching other resources
We contacted researchers to provide further information. We contacted experts in the field for additional and ongoing trials. We searched the reference lists of trials and review articles.
We did not apply any language restrictions.
Data collection and analysis
For the methods used when assessing the trials identified in the previous version of this review, seeAppendix 2.
For this update, two review authors independently assessed for inclusion the two reports that were identified as a result of the updated search. We did not include either. If we identify new trials for inclusion in future updates of this review, we will use the methods described in Appendix 3.
Results
Description of studies
Results of the search
Twelve study reports of seven trials (Avery 1986; Foroghipour 2012; Labrecque 1994; Labrecque 1999; Mei‐Dan 2008; Shimada 2005; Shipman 1997) were identified from electronic searches. Four trials are included in this review (Labrecque 1994; Labrecque 1999; Shimada 2005; Shipman 1997), two trials are excluded (Avery 1986; Mei‐Dan 2008) and one is an ongoing trial (Foroghipour 2012).
Included studies
Four trials (Labrecque 1994; Labrecque 1999; Shimada 2005; Shipman 1997) involving 2497 women assessing digital perineal massage performed by the woman or her partner were included in the review. Labrecque 1994 was a pilot paper involving just 46 women. Labrecque 1994, Shimada 2005 and Shipman 1997 studied only women without previous vaginal birth. Labrecque 1999 involved women with and without a previous vaginal birth and the randomisation of participants was stratified by parity. The trial participants were also followed up with a questionnaire that was subsequently reported in 2001 (Labrecque 2001).
Excluded studies
Two trials (three study reports) were excluded (Avery 1986; Mei‐Dan 2008).
Risk of bias in included studies
Details for each trial are in the table of Characteristics of included studies, Figure 1 and Figure 2.
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
All included trials of digital perineal massage were of good quality. Given the nature of the intervention, it was not possible for any of the studies to blind participants to the intervention. The trials all recommended a similar technique of digital perineal massage which was undertaken at a similar gestation. The authors all instructed participants not to inform their birth attendant of their allocation and some attempt was made by authors of three of the four included studies to ensure adequate blinding of outcome assessment was upheld. The three month follow‐up questionnaire was returned by 79% of trial participants (with similar response rates from women in the massage and control groups).
Effects of interventions
We included four trials of digital perineal massage (involving a total of 2497 women) in the review. All four trials (Labrecque 1994; Labrecque 1999; Shimada 2005; Shipman 1997) report findings for a total of 2004 women without previous vaginal birth. Labrecque 1999 is the single trial reporting findings for an additional 493 women with previous vaginal birth.
Digital perineal massage versus control
Primary outcomes
(A) Perineal trauma requiring suturing
Perineal massage was associated with an overall 9% reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91; 95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)), Analysis 1.1. This reduction was statistically significant for women without previous vaginal birth only (four trials, 1988 women, RR 0.90 (95% CI 0.84 to 0.96), NNTB 14 (9 to 32)). Subgroup analysis revealed that women who massaged up to an average of 1.5 times per week experienced a 16% reduction (two trials, 1500 women, RR 0.84 (95% CI 0.74 to 0.96), NNTB 9 (6 to 18)), women who massaged an average of 1.5 to 3.4 times per week experienced a 8% reduction (two trials, 1650 women, RR 0.92 (95% CI 0.85 to 1.00), NNTB 22 (10 to 208)), while women who massage more than 3.5 times per week did not experience a statistically significant reduction in the incidence of trauma requiring suturing (two trials, 1598 women, average RR 0.94 (95% CI 0.86 to 1.02); Tau² = 0.00; I² = 0%), Analysis 2.1. There were no differences between subgroups according to the test for subgroup differences, interaction test (Chi² = 1.91; P = 0.59; I² = 0%; Analysis 2.1).
(B) First‐degree perineal tear
There was no difference in the incidence of first‐degree perineal tear overall (four trials, 2480 women, average RR 0.96 (95% CI 0.78 to 1.19); Tau² = 0.04; I² = 40%), Analysis 1.2, or in any subgroup.
(C) Second‐degree perineal tear
There was no difference in the incidence of second‐degree perineal tear overall (four trials, 2480 women, RR 0.99 (95% CI 0.85 to 1.15)), Analysis 1.3, or in any subgroup.
(D) Third‐ or fourth‐degree perineal trauma
There was no difference in the incidence of third‐ or fourth‐degree perineal trauma overall (four trials, 2480 women, RR 0.81 (95% CI 0.56 to 1.18)), Analysis 1.4, or in any subgroup.
(E) Incidence of episiotomy
Women who practised perineal massage were 16% less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)), Analysis 1.5. Again, this reduction was statistically significant for women without previous vaginal birth only (four trials, 1988 women, RR 0.83 (95% CI 0.73 to 0.95), NNTB 18 (11 to 70)), Analysis 1.5.1. There were no differences between subgroups according to the test for subgroup differences, interaction test (Chi² = 0.02; P = 0.89; I² = 0%; Analysis 1.5). Only the subgroup of women who massaged up to an average of 1.5 times per week experienced a statistically significant reduction in the incidence of episiotomy (two trials, 1500 women, RR 0.72 (95% CI 0.57 to 0.91), NNTB 12 (7 to 31)), Analysis 2.5.1. No such effect was seen in women who massaged more frequently. Again, There were no differences between subgroups according to the test for subgroup differences, interaction test (Chi² = 2.72; P = 0.44; I² = 0%; Analysis 2.5).
Secondary outcomes
(F) Length of second stage
No difference in length of second stage was seen overall (two trials, 2211 women, mean difference (MD) 3.84 minutes (95% CI ‐0.26 to 7.95)), Analysis 1.6, or comparing women with and without previous vaginal births. The women who massaged on average more than 3.5 times per week (but not the subgroups of women who massaged less frequently) had a statistically significant longer second stage (two trials, 1509 women average MD 10.80 minutes (95% CI 4.03 to 17.58); Tau² = 0.00; I² =0%), Analysis 2.6. There were differences between subgroups according to the test for subgroup differences, interaction test (Chi² = 8.33; P = 0.04; I² = 64%; Analysis 2.6).
(G) Instrumental delivery
There was no difference in the proportion of instrumental deliveries performed overall (three trials, 2417 women, average RR 0.94 (95% CI 0.77 to 1.16); Tau² = 0.01; I² = 33%), Analysis 1.7, or in any subgroup.
(H) Length of inpatient stay
Length of inpatient stay was not recorded in any of the included studies.
(I) Admission to nursery
Admission to nursery was not recorded in any of the included studies.
(J) Apgar less than four at one minute and/or less than seven at five minutes
Apgar scores were not recorded in any of the included studies.
(K) Woman's satisfaction with perineal massage
Woman's satisfaction was not recorded in any of the included studies; however, a subsequent paper (Labrecque 2001) did report women's views on the practice of perineal massage (seeDiscussion).
(L) Perineal pain postpartum
Perineal pain in the days following birth was not recorded in any of the included studies.
(M) Ongoing perineal pain postpartum
One trial involving 931 women reported perineal pain at three months postpartum. Overall there was no difference in the reporting of perineal pain at three months postpartum (RR 0.64 (95% CI 0.39 to 1.06), Analysis 1.13. Women who had previously birthed vaginally (and not nulliparas) were statistically significantly less likely to report perineal pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60); Tau² = 0.07; I² = 51%), Analysis 1.13.2, as were the subgroup of women who most frequently massaged (one trial, 701 women, RR 0.51 (95% CI 0.33 to 0.79) NNTB 11 (7 to 24)), Analysis 2.13.3. There were no differences between subgroups according to the test for subgroup differences, interaction test, for either of the subgroup analyses: (Chi² = 2.02; P = 0.16; I² = 50.4%; Analysis 1.13) (Chi² = 4.70; P = 0.20; I² = 36.1%; Analysis 2.13).
(N) Painful sex postpartum
No differences in the reporting of painful sex at three months postpartum were detected overall (one trial, 831 women, RR 0.96 (95% CI 0.84 to 1.08)), Analysis 1.14, or in any subgroup.
(O) Sexual satisfaction postpartum
One trial involving 921 woman reported the woman's sexual satisfaction at three months postpartum. No difference was seen overall (RR 1.02 (95% CI 0.96 to 1.10)), Analysis 1.15, or in any subgroup. In one trial, 916 women responded to questions about their partner's sexual satisfaction at three months postpartum. Again, no difference was seen overall (RR 0.97 (95% CI 0.91 to 1.04)), Analysis 1.16, or in any subgroup.
(P) Uncontrolled loss of urine postpartum
No difference was seen in the proportion of women reporting incontinence of urine at three months postpartum overall (one trial, 949 women, RR 0.90 (95% CI 0.74 to 1.08)), Analysis 1.17, or in any subgroup.
(Q) Uncontrolled loss of flatus or faeces postpartum
No difference was seen in the overall proportion of women reporting incontinence of flatus at three months postpartum (one trial, 948 women, RR 1.09 (95% CI 0.88 to 1.36); ), Analysis 1.19, or comparing women with and without a previous vaginal birth. Only the subgroup of women who massaged an average of less than 1.5 times per week reported flatal incontinence more frequently than controls (one trial, 587 women, RR 1.40 (95% CI 1.03 to 1.90) NNTB 10 (5 to 1111)), Analysis 2.19.1. Within this subgroup, there was no difference in the reporting of infrequent flatal incontinence (RR 0.87 (95% CI 0.60 to 1.26)), Analysis 2.19.2, however, more women reported flatal incontinence occurring at least daily (RR 2.66 (95% CI 0.99 to 7.16)). This finding is based on very small numbers (6/108 versus 10/479) and hence the significance of this finding is unclear ‐ seeTable 1. No difference was seen in the proportion of women reporting incontinence of faeces at three months postpartum overall (one trial, 948 women, RR 0.70 (95% CI 0.27 to 1.80), Analysis 1.18, or in any subgroup.
| Treatment | Control | Risk ratio, M‐H, Fixed, 95% CI | |||
| Events | Total | Events | Total | ||
| Reporting of infrequent flatal incontinence | 21 | 108 | 107 | 479 | 0.87 (0.57,1.32) |
| Reporting of flatal incontinence at least daily | 6 | 108 | 10 | 479 | 2.66 (0.99,7.16) |
Discussion
Women who practise digital perineal massage from approximately 35 weeks' gestation are less likely to have perineal trauma which requires suturing in association with vaginal birth. For every 15 women who practise digital perineal massage antenatally, one fewer will receive perineal suturing following the birth. There is no difference in the proportion of women who incur first‐ or second‐degree perineal tears or third/fourth degree perineal trauma comparing those who massage with controls. There is, however, a statistically significant 16% reduction in the incidence of episiotomies in women who practise digital perineal massage. Thus the reduction in perineal trauma requiring suturing following vaginal birth is almost entirely due to the fact that she is less likely to have an episiotomy. These reductions are significant for the subgroup of women who have never previously had a vaginal birth. There is no statistical difference in these outcomes for women who have previously birthed vaginally; however, only one included trial studied this group of women.
For the subgroup of women who have previously had a vaginal birth, antenatal perineal massage reduces the likelihood of perineal pain at three months in the sole study that assessed this outcome. The women who massage the most frequently are the least likely to report ongoing perineal pain postpartum. We proposed that this reduction in perineal pain at three months was because women who practise perineal massage are less likely to have an episiotomy and that having had an episiotomy is the most likely reason for ongoing pain. However, when we analysed the data excluding women who had episiotomies, this effect remained. In other words, for women who have had a previous vaginal birth, antenatal perineal massage appears to result in less reporting of perineal pain at three months even for those women who do not have an episiotomy. Women who massage the most frequently may not be able to further reduce their chance of an episiotomy but may lessen their likelihood of perineal pain at three months.
No significant differences are observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practise perineal massage compared with those who do not massage in the study that reported these outcomes.
Surprisingly the reduction in the incidence of episiotomy and of perineal trauma requiring suturing is not more pronounced in the women who massage the most frequently. It is also an unexpected finding that the subgroup of women who massage the most frequently have the longest second stage. If the reason that perineal massage works is that it increases the flexibility and decreases the resistance of the perineal muscles and soft tissues, then it would be anticipated that the most diligent massager should have the least chance of needing suturing and have a relatively short second stage. As this effect was not seen, there may be other reasons that women who practise perineal massage are less likely to incur perineal trauma (mainly episiotomies) that requires suturing. The decision regarding if and when an episiotomy is cut is a subjective one. We therefore considered the adequacy of blinding. We also considered the possibility that women who were instructed in perineal massage became very motivated to achieve a vaginal birth with an intact perineum and consequently, may have been more likely to want to keep pushing longer and oppose an episiotomy unless it was clearly necessary.
We proceeded to exclude women who had an episiotomy and reassess length of second stage (seeTable 2). No significant differences were seen in the length of second stage after excluding women who had an episiotomy. If birth attendants were unblinded, we propose that after excluding episiotomies, the remaining women in the massage group would still have been encouraged to push longer while those in the control group would have had an overall shorter second stage (as the controls who avoided episiotomy likely delivered quickly). The net effect would therefore be an overall increase in the length of second stage when compared with controls. As this effect was not seen, we considered it less likely that unblinding occurred.
| Duration | All women | Excl episiotomy |
| Length of 2nd stage (mins) | +3.84 (95% CI ‐0.26 to +7.95) | +3.57 (95% CI ‐0.86 to +8.00) |
| Length of 2nd stage for women massaging more than 3.5 times/week (mins) | +10.80 (95% CI +4.03 to +17.58) | +5.21 (95% CI ‐1.45 to +11.86) |
mins: minutes
CI: confidence interval
If the motivation of the informed woman for an intact perineum explains the reduction in trauma, then those who massaged the most frequently would likely have had the longest second stage (as was seen). Further, women in the control group who were less informed and motivated about preventing perineal trauma, may have been less likely to push for as long and more receptive to an episiotomy if suggested. By excluding women who had episiotomies, the time spent pushing for women who practise perineal massage should be reduced (particularly for the subgroup of women who massaged the most frequently). When this analysis was performed we did see a reduction in the length of second stage in this subgroup. This weighs against the supposition that perineal massage reduces the incidence of episiotomy because of increased flexibility of the perineum. Nevertheless, it appears that women who are instructed in perineal massage (either because they become more informed about birthing, episiotomies and the advantages of an intact perineum, or because of the act of massaging itself) are less likely to have an episiotomy, require perineal suturing or report ongoing perineal pain postpartum.
Most women find the practice of perineal massage acceptable and believe it helps them prepare for birth (Labrecque 2001). (Details regarding the technique of perineal massage as described by Labrecque and Shipman are provided under Characteristics of included studies). Women comment that in the first few weeks massage can be uncomfortable, unpleasant and even produce a painful or burning sensation. Most women report that the pain and burning sensation has decreased or gone by the second or third week of massage. The majority (79%) report they would massage again and 87% would recommend it to another pregnant woman. Most women considered their partner's participation as positive.
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 1 Perineal trauma requiring suturing.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 2 1st degree perineal tear.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 3 2nd degree perineal tear.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 4 3rd or 4th degree perineal trauma.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 5 Incidence of episiotomy.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 6 Length of second stage.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 7 Instrumental delivery.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 13 Perineal pain at 3 months postpartum.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 14 Painful sex at 3 months postpartum.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 15 Woman's sexual satisfaction at 3 months postpartum.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 16 Partner's sexual satisfaction at 3 months postpartum.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 17 Uncontrolled loss of urine at 3 months postpartum.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 18 Uncontrolled loss of faeces at 3 months postpartum.
Comparison 1 Digital perineal massage versus control: results by parity, Outcome 19 Uncontrolled loss of flatus at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 1 Perineal trauma requiring suturing.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 2 1st degree perineal tear.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 3 2nd degree perineal tear.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 4 3rd or 4th degree perineal trauma.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 5 Incidence of episiotomy.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 6 Length of second stage.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 7 Instrumental delivery.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 13 Perineal pain at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 14 Painful sex at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 15 Woman's sexual satisfaction at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 16 Partner's sexual satisfaction at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 17 Uncontrolled loss of urine at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 18 Uncontrolled loss of faeces at 3 months postpartum.
Comparison 2 Digital perineal massage versus control: results by frequency of massage, Outcome 19 Uncontrolled loss of flatus at 3 months postpartum.
| Treatment | Control | Risk ratio, M‐H, Fixed, 95% CI | |||
| Events | Total | Events | Total | ||
| Reporting of infrequent flatal incontinence | 21 | 108 | 107 | 479 | 0.87 (0.57,1.32) |
| Reporting of flatal incontinence at least daily | 6 | 108 | 10 | 479 | 2.66 (0.99,7.16) |
| Duration | All women | Excl episiotomy |
| Length of 2nd stage (mins) | +3.84 (95% CI ‐0.26 to +7.95) | +3.57 (95% CI ‐0.86 to +8.00) |
| Length of 2nd stage for women massaging more than 3.5 times/week (mins) | +10.80 (95% CI +4.03 to +17.58) | +5.21 (95% CI ‐1.45 to +11.86) |
| mins: minutes | ||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Perineal trauma requiring suturing Show forest plot | 4 | 2480 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.91 [0.86, 0.96] |
| 1.1 Women without previous vaginal birth | 4 | 1988 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.90 [0.84, 0.96] |
| 1.2 Women with previous vaginal birth | 1 | 492 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.95 [0.83, 1.08] |
| 2 1st degree perineal tear Show forest plot | 4 | 2480 | Risk Ratio (M‐H, Random, 95% CI) | 0.96 [0.78, 1.19] |
| 2.1 Women without previous vaginal birth | 4 | 1988 | Risk Ratio (M‐H, Random, 95% CI) | 0.97 [0.69, 1.36] |
| 2.2 Women with previous vaginal birth | 1 | 492 | Risk Ratio (M‐H, Random, 95% CI) | 1.01 [0.72, 1.41] |
| 3 2nd degree perineal tear Show forest plot | 4 | 2480 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.99 [0.85, 1.15] |
| 3.1 Women without previous vaginal birth | 4 | 1988 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.00 [0.84, 1.19] |
| 3.2 Women with previous vaginal birth | 1 | 492 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.96 [0.72, 1.29] |
| 4 3rd or 4th degree perineal trauma Show forest plot | 4 | 2480 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.81 [0.56, 1.18] |
| 4.1 Women without previous vaginal birth | 4 | 1988 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.82 [0.56, 1.20] |
| 4.2 Women with previous vaginal birth | 1 | 492 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.50 [0.05, 5.52] |
| 5 Incidence of episiotomy Show forest plot | 4 | 2480 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.84 [0.74, 0.95] |
| 5.1 Women without previous vaginal birth | 4 | 1988 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.83 [0.73, 0.95] |
| 5.2 Women with previous vaginal birth | 1 | 492 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.86 [0.57, 1.30] |
| 6 Length of second stage Show forest plot | 2 | 2211 | Mean Difference (IV, Fixed, 95% CI) | 3.84 [‐0.26, 7.95] |
| 6.1 Women without previous vaginal birth | 2 | 1719 | Mean Difference (IV, Fixed, 95% CI) | 2.16 [‐3.58, 7.91] |
| 6.2 Women with previous vaginal birth | 1 | 492 | Mean Difference (IV, Fixed, 95% CI) | 5.60 [‐0.27, 11.47] |
| 7 Instrumental delivery Show forest plot | 3 | 2417 | Risk Ratio (M‐H, Random, 95% CI) | 0.94 [0.77, 1.16] |
| 7.1 Women without previous vaginal birth | 3 | 1925 | Risk Ratio (M‐H, Random, 95% CI) | 0.90 [0.78, 1.04] |
| 7.2 Women with previous vaginal birth | 1 | 492 | Risk Ratio (M‐H, Random, 95% CI) | 1.58 [0.83, 3.02] |
| 8 Length of inpatient stay | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.1 Women without previous vaginal birth | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.2 Women with previous vaginal birth | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Admission to nursery | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.1 Women without previous vaginal birth | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.2 Women with previous vaginal birth | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Apgar < 4 at 1 minute and/or Apgar < 7 at 5 minutes | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10.1 Women without previous vaginal birth | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10.2 Women with previous vaginal birth | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11 Woman's satisfaction with perineal massage | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.1 Women without previous vaginal birth | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.2 Women with previous vaginal birth | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12 Perineal pain postpartum | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12.1 Women without previous vaginal birth | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12.2 Women with previous vaginal birth | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13 Perineal pain at 3 months postpartum Show forest plot | 1 | 931 | Risk Ratio (M‐H, Random, 95% CI) | 0.64 [0.39, 1.06] |
| 13.1 Women without previous vaginal birth | 1 | 555 | Risk Ratio (M‐H, Random, 95% CI) | 0.77 [0.55, 1.09] |
| 13.2 Women with previous vaginal birth | 1 | 376 | Risk Ratio (M‐H, Random, 95% CI) | 0.45 [0.24, 0.87] |
| 14 Painful sex at 3 months postpartum Show forest plot | 1 | 831 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.96 [0.84, 1.08] |
| 14.1 Women without previous vaginal birth | 1 | 493 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.97 [0.85, 1.11] |
| 14.2 Women with previous vaginal birth | 1 | 338 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.92 [0.68, 1.24] |
| 15 Woman's sexual satisfaction at 3 months postpartum Show forest plot | 1 | 921 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.96, 1.10] |
| 15.1 Women without previous vaginal birth | 1 | 552 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.03 [0.93, 1.14] |
| 15.2 Women with previous vaginal birth | 1 | 369 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.93, 1.11] |
| 16 Partner's sexual satisfaction at 3 months postpartum Show forest plot | 1 | 916 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.97 [0.91, 1.04] |
| 16.1 Women without previous vaginal birth | 1 | 548 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.99 [0.90, 1.09] |
| 16.2 Women with previous vaginal birth | 1 | 368 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.94 [0.87, 1.03] |
| 17 Uncontrolled loss of urine at 3 months postpartum Show forest plot | 1 | 949 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.90 [0.74, 1.08] |
| 17.1 Women without previous vaginal birth | 1 | 572 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.92 [0.71, 1.20] |
| 17.2 Women with previous vaginal birth | 1 | 377 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.87 [0.66, 1.13] |
| 18 Uncontrolled loss of faeces at 3 months postpartum Show forest plot | 1 | 948 | Risk Ratio (M‐H, Random, 95% CI) | 0.70 [0.27, 1.80] |
| 18.1 Women without previous vaginal birth | 1 | 572 | Risk Ratio (M‐H, Random, 95% CI) | 1.02 [0.41, 2.54] |
| 18.2 Women with previous vaginal birth | 1 | 376 | Risk Ratio (M‐H, Random, 95% CI) | 0.38 [0.10, 1.41] |
| 19 Uncontrolled loss of flatus at 3 months postpartum Show forest plot | 1 | 948 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.09 [0.88, 1.36] |
| 19.1 Women without previous vaginal birth | 1 | 571 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.13 [0.85, 1.50] |
| 19.2 Women with previous vaginal birth | 1 | 377 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.04 [0.74, 1.45] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Perineal trauma requiring suturing Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 1.1 Average number of massages per week < 1.5 | 2 | 1500 | Risk Ratio (M‐H, Random, 95% CI) | 0.84 [0.74, 0.96] |
| 1.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1650 | Risk Ratio (M‐H, Random, 95% CI) | 0.92 [0.85, 1.00] |
| 1.3 Average number of massages per week > 3.5 | 2 | 1598 | Risk Ratio (M‐H, Random, 95% CI) | 0.94 [0.86, 1.02] |
| 1.4 Any frequency of massage | 3 | 2417 | Risk Ratio (M‐H, Random, 95% CI) | 0.91 [0.86, 0.96] |
| 2 1st degree perineal tear Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 2.1 Average number of massages per week < 1.5 | 2 | 1500 | Risk Ratio (M‐H, Random, 95% CI) | 1.04 [0.60, 1.83] |
| 2.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1650 | Risk Ratio (M‐H, Random, 95% CI) | 1.00 [0.75, 1.33] |
| 2.3 Average number of massages per week > 3.5 | 2 | 1598 | Risk Ratio (M‐H, Random, 95% CI) | 0.89 [0.67, 1.17] |
| 2.4 Any frequency of massage | 3 | 2417 | Risk Ratio (M‐H, Random, 95% CI) | 0.99 [0.71, 1.38] |
| 3 2nd degree perineal tear Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 3.1 Average number of massages per week < 1.5 | 2 | 1500 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.00 [0.78, 1.27] |
| 3.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1650 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.94 [0.75, 1.16] |
| 3.3 Average number of massages per week > 3.5 | 2 | 1598 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.82, 1.27] |
| 3.4 Any frequency of massage | 3 | 2417 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.98 [0.84, 1.14] |
| 4 3rd or 4th degree perineal trauma Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 4.1 Average number of massages per week < 1.5 | 2 | 1500 | Risk Ratio (M‐H, Random, 95% CI) | 0.82 [0.08, 8.48] |
| 4.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1650 | Risk Ratio (M‐H, Random, 95% CI) | 0.64 [0.33, 1.25] |
| 4.3 Average number of massages per week > 3.5 | 2 | 1598 | Risk Ratio (M‐H, Random, 95% CI) | 1.19 [0.78, 1.81] |
| 4.4 Any frequency of massage | 3 | 2417 | Risk Ratio (M‐H, Random, 95% CI) | 0.81 [0.56, 1.19] |
| 5 Incidence of episiotomy Show forest plot | 3 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 5.1 Average number of massages per week < 1.5 | 2 | 1500 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.72 [0.57, 0.91] |
| 5.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1650 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.91 [0.77, 1.08] |
| 5.3 Average number of massages per week > 3.5 | 2 | 1598 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.84 [0.67, 1.04] |
| 5.4 Any frequency of massage | 3 | 2417 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.85 [0.75, 0.97] |
| 6 Length of second stage Show forest plot | 2 | Mean Difference (IV, Random, 95% CI) | Subtotals only | |
| 6.1 Average number of massages per week < 1.5 | 2 | 1403 | Mean Difference (IV, Random, 95% CI) | 0.97 [‐6.45, 8.39] |
| 6.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1525 | Mean Difference (IV, Random, 95% CI) | ‐2.38 [‐8.55, 3.79] |
| 6.3 Average number of massages per week > 3.5 | 2 | 1509 | Mean Difference (IV, Random, 95% CI) | 10.80 [4.03, 17.58] |
| 6.4 Any frequency of massage | 2 | 2211 | Mean Difference (IV, Random, 95% CI) | 3.35 [‐1.29, 8.00] |
| 7 Instrumental delivery Show forest plot | 3 | Risk Ratio (M‐H, Random, 95% CI) | Subtotals only | |
| 7.1 Average number of massages per week < 1.5 | 2 | 1500 | Risk Ratio (M‐H, Random, 95% CI) | 0.89 [0.71, 1.13] |
| 7.2 Average number of massages per week = 1.5 to 3.4 | 2 | 1650 | Risk Ratio (M‐H, Random, 95% CI) | 0.88 [0.72, 1.07] |
| 7.3 Average number of massages per week > 3.5 | 2 | 1598 | Risk Ratio (M‐H, Random, 95% CI) | 1.07 [0.86, 1.33] |
| 7.4 Any frequency of massage | 3 | 2417 | Risk Ratio (M‐H, Random, 95% CI) | 0.93 [0.76, 1.13] |
| 8 Length of inpatient stay | 0 | Mean Difference (IV, Fixed, 95% CI) | Subtotals only | |
| 8.1 Average number of massages per week < 1.5 | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.2 Average number of massages per week = 1.5 to 3.4 | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.3 Average number of massages per week > 3.5 | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 8.4 Any frequency of massage | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9 Admission to nursery | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 9.1 Average number of massages per week < 1.5 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.2 Average number of massages per week = 1.5 to 3.4 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.3 Average number of massages per week > 3.5 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 9.4 Any frequency of massage | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10 Apgar < 4 at 1 minute and/or Apgar < 7 at 5 minutes | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 10.1 Average number of massages per week < 1.5 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10.2 Average number of massages per week = 1.5 to 3.4 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10.3 Average number of massages per week > 3.5 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 10.4 Any frequency of massage | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11 Woman's satisfaction with perineal massage | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 11.1 Average number of massages per week < 1.5 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.2 Average number of massages per week = 1.5 to 3.4 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.3 Average number of massages per week > 3.5 | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 11.4 Any frequency of massage | 0 | 0 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12 Perineal pain postpartum | 0 | Mean Difference (IV, Fixed, 95% CI) | Subtotals only | |
| 12.1 Average number of massages per week < 1.5 | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12.2 Average number of massages per week = 1.5 to 3.4 | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12.3 Average number of massages per week > 3.5 | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 12.4 Any frequency of massage | 0 | 0 | Mean Difference (IV, Fixed, 95% CI) | 0.0 [0.0, 0.0] |
| 13 Perineal pain at 3 months postpartum Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 13.1 Average number of massages per week < 1.5 | 1 | 577 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.01 [0.65, 1.56] |
| 13.2 Average number of massages per week = 1.5 to 3.4 | 1 | 595 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.69 [0.42, 1.13] |
| 13.3 Average number of massages per week > 3.5 | 1 | 701 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.51 [0.33, 0.79] |
| 13.4 Any frequency of massage | 1 | 931 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.67 [0.50, 0.92] |
| 14 Painful sex at 3 months postpartum Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 14.1 Average number of massages per week < 1.5 | 1 | 521 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.85 [0.67, 1.08] |
| 14.2 Average number of massages per week = 1.5 to 3.4 | 1 | 538 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.03 [0.85, 1.25] |
| 14.3 Average number of massages per week > 3.5 | 1 | 622 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.96 [0.81, 1.13] |
| 14.4 Any frequency of massage | 1 | 831 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.95 [0.83, 1.09] |
| 15 Woman's sexual satisfaction at 3 months postpartum Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 15.1 Average number of massages per week < 1.5 | 1 | 569 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.04 [0.93, 1.16] |
| 15.2 Average number of massages per week = 1.5 to 3.4 | 1 | 588 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.08 [0.98, 1.19] |
| 15.3 Average number of massages per week > 3.5 | 1 | 692 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.99 [0.90, 1.08] |
| 15.4 Any frequency of massage | 1 | 921 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.02 [0.96, 1.10] |
| 16 Partner's sexual satisfaction at 3 months postpartum Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 16.1 Average number of massages per week < 1.5 | 1 | 576 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.01 [0.91, 1.11] |
| 16.2 Average number of massages per week = 1.5 to 3.4 | 1 | 586 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.03 [0.95, 1.13] |
| 16.3 Average number of massages per week > 3.5 | 1 | 688 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.93 [0.86, 1.02] |
| 16.4 Any frequency of massage | 1 | 916 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.97 [0.91, 1.04] |
| 17 Uncontrolled loss of urine at 3 months postpartum Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 17.1 Average number of massages per week < 1.5 | 1 | 587 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.10 [0.83, 1.46] |
| 17.2 Average number of massages per week = 1.5 to 3.4 | 1 | 606 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.84 [0.62, 1.15] |
| 17.3 Average number of massages per week > 3.5 | 1 | 714 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.83 [0.65, 1.06] |
| 17.4 Any frequency of massage | 1 | 949 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.90 [0.74, 1.08] |
| 18 Uncontrolled loss of faeces at 3 months postpartum Show forest plot | 1 | Risk Ratio (M‐H, Fixed, 95% CI) | Subtotals only | |
| 18.1 Average number of massages per week < 1.5 | 1 | 586 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.04 [0.36, 3.03] |
| 18.2 Average number of massages per week = 1.5 to 3.4 | 1 | 605 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.44 [0.10, 1.89] |
| 18.3 Average number of massages per week > 3.5 | 1 | 713 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.72 [0.29, 1.80] |
| 18.4 Any frequency of massage | 1 | 948 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.72 [0.35, 1.49] |
| 19 Uncontrolled loss of flatus at 3 months postpartum Show forest plot | 1 | 2854 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.09 [0.95, 1.25] |
| 19.1 Average number of massages per week < 1.5 | 1 | 587 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.40 [1.03, 1.90] |
| 19.2 Average number of massages per week = 1.5 to 3.4 | 1 | 606 | Risk Ratio (M‐H, Fixed, 95% CI) | 0.87 [0.60, 1.26] |
| 19.3 Average number of massages per week > 3.5 | 1 | 713 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.07 [0.82, 1.39] |
| 19.4 Any frequency of massage | 1 | 948 | Risk Ratio (M‐H, Fixed, 95% CI) | 1.09 [0.88, 1.36] |
