Postnatal
Review of the literature Kettle & Frolich (2011) state that 85% of women giving birth vaginally sustain perineal injury, which can result in severe long-term physical problems such as dyspareunia, flatus and urinary and faecal incontinence. However, effects can also be psychological, such as a feeling of failure or post-traumatic stress disorder, particularly if the woman has had a straightforward labour without pain relief and then requires transfer to theatre for a spinal anaesthetic and complex suturing. Women may also feel too emotionally insecure and embarrassed to resume sexual relations because they are afraid of what their partner might think, which can negatively impact on self-esteem and confidence. In 2017, Aasheim et al undertook a Cochrane review examining various techniques that claim to reduce perineal trauma during the second stage of labour. Research studies were identified using a search strategy followed by three review authors independently evaluating them. Eight randomised control trials (involving 11,651 women from six countries) were selected and systematically reviewed, with the aim of assessing whether perineal massage or a warm compress applied to the perineum in the second stage of labour reduces perineal trauma. For the women to meet the selection criteria they had to be over 18 years old with no medical complications and planning to have a singleton cephalic vaginal birth after a gestation of 36 weeks. Using a computer software programme to reduce selection bias, participants were assigned perineal massage, a warm compress or no technique. It was revealed that the incidence of third and fourthdegree tears was significantly reduced in the women who received a warm compress or perineal massage, compared to women who had neither. Aasheim et al’s (2017) research is current, meaning midwives can use it to inform practice and enable them to provide evidence-based care. However, the methodological quality of the studies reviewed by Aasheim et al (2017) varied due to extraneous variables, for example, not being able to measure the pressure applied by the midwife holding the warm compress or massaging the perineum, the temperature of the warm compress and how far into the vagina the midwife went when massaging. The studies examined used different lubricants to carry out the massage and it could be argued that the lubricant plays a more important role in preventing tears than the massage action itself. Therefore, further investigation is necessary to investigate which lubricants are the most effective at reducing perineal trauma. It was also impossible to ensure that all groups were treated equally, as many different midwives were used to deliver the interventions. These midwives had their own thoughts and opinions, which could impact on the results if they carried out the technique incorrectly or half-heartedly because they did not believe it would work. A further weakness of this Cochrane review is that ethnicity of the participants was not controlled and because Dahlen et al (2013a) found that Asian 480
women are more likely to sustain perineal injury than non-Asian women; the results of the study could be impacted if there were a large number of Asian participants. Dahlen (2013a) also found that nulliparous women are at higher risk of tearing than multiparous women. The women in this Cochrane review were both nulliparous and multiparous, with no differentiation between the two in the results. Therefore it remains unknown whether massage or a compress is more or less effective for primigravid women or those who have had a previous vaginal birth. However, the research has high validity because all studies successfully measured what they were designed to and the data collection tool was accurate and consistent, thus increasing reliability. Furthermore, the large sample size was a huge strength as the results were more representative of the general population and the influence of extreme cases was limited. The findings are generalisable, although are potentially not relevant to populations where women do not routinely give birth in hospital settings or where there is no midwife present, for example in rural regions of Africa. This is because all the participants delivered in hospital and it was always the midwife who carried out the massage or applied the warm compress, meaning outcomes may be different if women or their partners do it. Nonetheless, if carried out exactly as in the studies, the results are transferable to other populations. The effect of perineal massage in labour was also explored in Geranmayeh et al’s (2012) study. Ninety women between 38–42 weeks’ gestation were randomly assigned to either a control or intervention group. In the latter, the midwife used sterile Vaseline to perform perineal massage during the second stage of labour. When the women were examined after delivery, the massage group were found to have a significantly higher number of intact perineums than the control group and it was also noted that they has shorter second stages. It was concluded that massaging the perineum increases integrity, therefore reducing perineal trauma. In this study all participants were primiparous, which is a strength because parity is known to affect perineal outcome. It was also advantageous that the participants were all similar in characteristics such as demographic area, weight gain in pregnancy, fetal weight and abortion history. Notwithstanding, too many variables being controlled can lead to the results being less generalisable to other populations. The methodological quality of this research is debateable due to not being able to control the length of time each participant’s perineum was massaged for. They were simply massaged for the length of their second stage — which may have been five minutes in some women or hours for others. Furthermore it was not stated whether the women were massaged immediately upon discovery of full dilation or once they commenced active pushing. Assessing perineal trauma can be subjective and Geranmayeh et al (2012) do not establish whether an ‘intact perineum’ MIDIRS Midwifery Digest 27:4 2017