Perineal tearing: the controversy of hands on vs hands off - Page 5

[SaveTheWild]

Originally Posted by pamamidwife

Prenatal perineal massage has been shown to never improve the outcome of tearing.

I was actually just looking into this about a week or so ago and found this on the Cochrane site (it is a 2006 article, but looks at a bunch of studies done over time):

http://www.cochrane.org/reviews/en/ab005123.html

"Plain language summary
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 trials 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. There were no randomised trials on the use of massage devices. Women should be informed about the benefits of antenatal perineal massage."

I am still not sure how I feel about it, and it is interesting that the study notes that episomoties were reduced, but not necessarily tearing by all that much. still food for thought.

note thought that this is only about prenatal perineal massage, nothing at all about "massage" during delivery.

[orangefoot]

I'm in discussion about this elsewhere and also read this research review.

My feeling is how reliable can evidence on perineal massage be in reality?

All our skins are different as can be seen in the way we age and that some of
us have stretch marks and others don't. Were all the perinea of the
same skin type and elasticity? Did all the women carry out exactly the
same massage - and is this possible as all our vulvas are different?
Were all the women well hydrated? What was their diet like? What was
the context of each labour(home/hospital/midwife unit)? What positions
did the women choose to birth in...........?

Surely there are too many variables to make this type of research valid
in terms of recommending that all women do perineal massage?

I agree with Tinyshoes in her assessment that this just encourages us to believe that our bodies are broken and need some training or 'breaking in' and that if I don't massage and I do tear then *I* am at fault.

I have been cut once and torn twice (not on the original scar) what does that say about me? That I tore - no more, no less. I would love to avoid a tear but maybe I am tearable? My first was an underwater totally hands off tear so whose 'fault' was it?

Sorry this tear vs no tear really bugs me and if I'm honest upsets me a bit because I feel that sometimes within the homebirthing community not tearing is seen as being at the top of some mythical hierarchy and tearing is close to the bottom or at least not far away from a failure in some way.

[barbara]

I agree, how reliable can evidence on perineal massage be in reality? I think so much has to do with a woman's nutrition and hydration. Water works wonders to keep skin elastic, and I can't stress enough how important drinking plenty of water throughout pregnancy and birth is.

An interesting note is that I had a huge episiotomie with my first birth and tore on that scar line (slightly, not even needing to be sticth) for the following births, EXCEPT my last birth, where I did not tear! Now you must understand that this last birth was my 7th child and I was 40 years old! I gave birth on hands and knees, as I had with several of my other births, but I did take the time to breathe through those ring of fire contractions, where in the past births I had just pushed to get the baby out!

I'm also pretty sure that emotional factors have more to do with strecthing and tearing than prenatal massage can.

Anyway, I think the perinium is a wonderful part of a woman's body and it can do amazing things when it is allowed to.

[QueenOfThePride]

That was a really great article. I'm trying to remember more details from giving birth, but I was in so much pain at the time, I wasn't really cognizant. My OB was doing some kind of 'massage' more like stretching. When I pushed, she was stretching my skin and it was painful. It hurt like I was tearing just a little straight down each time, so I would stop pushing. I told her to stop doing whatever she was doing, and she did. Now that I read that article and this thread, I see that 'helping' me to stretch was counterproductive to my labor. Naturally, my baby's head would have begun crowning, and I would have slowed down my own pushing to ease his head out, because it would have hurt. But the perineal stretching was hurting me before he was even crowning. I pushed for an hour, and it was exhausting. I also don't know if my OB applied counterpressure to my baby's head or not. I was pushing and pushing and pushing and I could not get him out. I wanted him out so BAD! I was very frustrated, I yelled out, "I feel like I'm not doing anything!" I have this sense that my OB was pushing on baby's head, not letting him come out 'too fast'. But I really don't know if she was or not.

I'm really glad I got to read that article. It helps me understand the birth I've already had, and plan better (hands-off!) for the next one.

[cottonwood]

As I always say, I'd like to see these studies... too lazy to look for them at the moment, though.

Here's from the abstract:

Three trials (2434 women) comparing digital perineal massage with control were included. All were of good quality. Antenatal perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (three trials, 2417 women, relative risk (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat (NNT) 16 (10 to 39)). This reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.90 (95% CI 0.84 to 0.96), NNT 14 (9 to 35)). Women who practised perineal massage were less likely to have an episiotomy (three trials, 2417 women, RR 0.85 (95% CI 0.75 to 0.97), NNT 23 (13 to 111)). Again this reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.85 (95% CI 0.74 to 0.97), NNT 20 (11 to 110)). No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th 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 0.68 (95% CI 0.50 to 0.91) NNT 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.

Can somebody who understands statistics decipher these numbers?

And what the heck does this mean: "No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma." Well, what are they defining as "trauma", then?

ETA: Oh, okay. "Women who practised perineal massage were less likely to have an episiotomy." Not a tear. Okay, so what can we deduce from this? That those who do antenatal perineal massage are not less likely tear, but something is different that makes the doctor less likely to cut the tissue. What do you think? Maybe women having perineal massage are more tuned into their bodies and more likely to plan natural births, and therefore less likely to employ doctors who cut often?

[SaveTheWild]

Originally Posted by fourlittlebirds

ETA: Oh, okay. "Women who practised perineal massage were less likely to have an episiotomy." Not a tear. Okay, so what can we deduce from this? That those who do antenatal perineal massage are not less likely tear, but something is different that makes the doctor less likely to cut the tissue. What do you think? Maybe women having perineal massage are more tuned into their bodies and more likely to plan natural births, and therefore less likely to employ doctors who cut often?

yeah, that is my question too (the first part re: lss likely to be cut but not necessarily less likely to tear).

as far as being more likely to plan natural births... I don't know. these were randomized studies with a control, so women were assigned to be in one group or another, it wasn't their choice. So unless the act of massage led them to alter their birth plans, this shouldn't have an impact.

[Arwyn]

Or more likely that their OBs new they practiced perineal massage, and through the power of their own beliefs decided that fewer of those women "needed" episiotomies.

There's also the power of the women's own belief that because of having practiced antenatal perineal massage they wouldn't tear and therefore requested no episiotomy (or otherwise believed that they didn't need episiotomy).

I wouldn't trust these studies to provide any relevence to a homebirth, especially one with a hands-off midwife. All they showed was that episiotomies were reduced, which when comparing OB-attended hospital births (who cut, what, 90% of first time moms?) and midwife-attended homebirths (variable, but usually less than 10%, ought to be less than 5%) would be like comparing the amount of sand in a desert and a rainforest.