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Perineal Massage During Pregnancy & How To Do It — OUR FIT FAMILY LIFE




The study examined the effect of perineal massage on perineal trauma among primigravidae in Federal medical centre (FMC) Yenagoa Bayelsa State. Six research questions and five hypotheses were developed to guide the study. Related Literature on the subject matter was reviewed. An experimental study design (Ramdomised Controlled Trial) was used for the study. The study population consists of all primigravidae attending antenatal Clinic at Federal Medical Centre (FMC) Yenagoa. A sample size of one hundred (100) was used for the study after estimation with the use of power analysis. However only eighty- one (81) participants were used in the study as nineteen of them were excluded from analysis for emergency caesarian section during labour. Instrument for data collection were daily massage compliant form and data collection form for attending doctors/midwives adapted from another study. Data was analysed using Statistical Package for Social Science (SPSS) version 17.0.

Findings from the study shows that perineal massage from the 37th week of pregnancy seems to have a beneficial effect of increasing intact perineum by 19%, although this did not reach statistical significance. Major findings show no significant difference between primigravidae who performed perineal massage and those who did not perform perineal massage in the occurrence of perineal trauma. There was no significant relationship between the risk factors of fetal birth weight, maternal age, gestational age and Body Mass Index (BMI) and the occurrence of perineal trauma. Although there were weak positive and negative relationship observed between risk factors and occurrence perineal trauma, these did not reach statistical significance. The study concluded that although there was no significant difference between primigravidae who performed perineal trauma in the last week of pregnancy, perineal massage increase the likelihood of delivering with an intact perineum. Based on this, recommendations were made to encourage women who wish to perform perineal massage to do so.

                                                        TABLE OF CONTENTS

Title page
Table of Contents
List of Tables
List of Figures

Background to the Study
Statement of Problem
Purpose of the Study
Research Questions
Significance of the Study
Scope of the Study
Operational Definition of Terms

Concept of Perineal Massage
Types of Perineal Massage
Procedure for Perineal Massage
Benefits of perineal massage
Concept of perineal trauma/episiotomy
Determinants of Perineal Trauma
Degrees of Perineal Trauma
Morbidity associated with Perineal Trauma
Theoretical Review
Application to the Study
Conceptual Model
Empirical Review
Summary of Literature Review

Research Design
Area of study
Population of the Study
Inclusion criteria
Sampling Procedure
Recruitment of study participants
Training Sessions
Study Protocol
Data Collection Instrument
Ethical Consideration and Consent
Procedure for Data Collection of Data
Method of Data Analysis

Presentation of Results
Test of Hypothesis
Summary of Major Findings

Discussion of Major Findings
Implications of the Study
Limitations of the Study
Suggestions for Further Studies
Summary of the Study

Background to the Study
Maternal and perinatal health have emerged as the most important issue that determines global and national wellbeing because every individual, family and community is at some point intimately involved in pregnancy and the success of child birth (World Health Organization, 2005). Pregnancy and child birth is still considered a perilous journey despite the honor bestowed on womanhood and the appreciation of the birth of a new born baby.

According to World Health Organization (WHO) report, recent estimates revealed that over 350,000 women worldwide die from complications of pregnancy and childbirth- a reduction from the previous estimates of 536,000 per year (Hogan, Foreman & Naghavi, 2010; WHO, 2010; Khan, Wojdyla & Say, 2006). Out of this figure, 99% occur in the developing countries and 1% in the industrialized ones. The maternal mortality rate is highest in Sub-Saharan African countries, as the risk of dying from pregnancy-related cause is 1:16 in Africa but only 1:4000 in some developed countries (Lucas & Gilles, 2003). However for the first time in 2010, data showed that there is significant progress made in reducing maternal death globally (Gahr, 2011).
In Nigeria, the Maternal Mortality rate is still high as 59,000 women still die every year during pregnancy and childbirth (Centre for Reproductive Rights, 2012). These deaths are largely preventable. Equally of concern is that yearly, about 1,080,000 – 1,620,000 Nigerian women and girls suffer disabilities caused by complications during pregnancy and childbirth (Utoo, Musa Karshima & Ifenne, 2012). For every one that dies, 20- 30 more women suffer long term and short term disabilities such as chronic anaemia, maternal exhaustion or physical weakness, vesico-vaginal or recto-vaginal fistulae, stress incontinence, episiotomy wound breakdown, perineal trauma, chronic pelvic pain, Pelvic Infammatory Disease (PID), Infertility, ectopic pregnancy, emotional depression (Adedokun,2013).

Perineal trauma is one of the morbidities that results from childbirth. It is defined as any damage that occurs to the genitalia during childbirth spontaneously or intentionally by surgical invasion termed episiotomy (Kettle &Tohill, 2011). Women frequently incur perineal trauma at delivery (Fahami, Shokoni & Kianpour, 2012). About 70% of women giving birth vaginally sustain some degree of perineal trauma and it is associated with postnatal morbidity (Kettle, 2011; Smith, Price, Simonite &Burns, 2013). Several studies have reported the incidence of perineal trauma in the developed countries among women and the increased morbidity associated with it (Kettle & Tohill, 2011; Marsh, Lynne, Christine & Alison, 2011; Roos, Thakar & Sultan, 2010).

Perineal trauma could be in the form of first to fourth degree tears or an unnatural straight-edge cut from an episiotomy (Chapman, 2006). Episiotomy is a common surgical procedure experienced by women (Marsh et al, 2011). It is frequently done among pregnant women in labour and its practice dates back to the 16th century (Lang, Wong & Pun, 2006). Studies have revealed that episiotomy accounts for a large proportion of perineal trauma and there is no evidence that it prevents severe lacerations (Kumar, Ooi & Nicoll, 2012; Kettle & Tohill 2011; Fahami et al. 2012).

Few studies carried out in Nigeria on episiotomy and perineal trauma also revealed high incidences of episiotomy rate and perineal trauma among women (Chigbu, Onwere, Alika&Adibe, 2008; Enyindah, Tiebai, Anya &Okpanu, 2007). Enyindah et al, (2007) in the study carried out in University of Port Harcourt Teaching Hospital revealed that perineal trauma is one of the most common occurrences in vaginal deliveries with 40% of primigravida and 20% of multiparous women affected. Chigbu, et al (2007) assert that episiotomy rate in Abia State University Teaching Hospital, which constitute 45% of 100 vaginal deliveries is associated with major perineal lacerations.

Possible deleterious effects of perineal trauma are dyspareunia (painful intercourse) urinary and faecal incontinence as well as perineal pain (Kalichman, 2008). Some women report continued perineal pain 8 weeks after birth (22%) and others for up to a year or longer. The likelihood of perineal pain and sexual problem in the post partum period is the least for women with intact perineum,while women with episiotomy tend to report more pain with intercourse 3 months after delivery (Klein et al, 1994 in Kalichman, 2008; Marsh et al, 2011). Studies have shown that perineal massage can reduce the likelihood of perineal trauma and ongoing perineal pain and is well accepted by women (Aasheim, Nilsen, Lukasse & Reinar, 2011; Beckmann & Stock, 2013).

Perineal massage is a procedure which involves the gentle stretching of the tissues surrounding the vagina and the perineum. It is thought to improve perineal outcomes by stretching out the vaginal tissues, promoting perineal relaxation and improving circulation to the tissues. It is advocated during pregnancy to increase elasticity of the perineal muscles and reduce the risk of perineal trauma from episiotomy and spontaneous tear (Begley, 2014).
There are two forms of massage commonly practiced to reduce perineal trauma. The antenatal perineal massage which involves the massage of the perineal body and lower portion of the vagina in the last month of pregnancy by the woman or her spouse and the intra-partum massage, which is performed by the midwife in the second stage of labour. The antenatal perineal massage is the type that is being proposed in this study.

Evidences about perineal trauma and its impact on women’s health require the use of specific techniques to reduce the rate and morbidities associated with it. Perineal massage has been found to reduce the likelihood of perineal trauma and poor perineal outcomes (Aasheim, Nilsen, Lukasse & Reinar, 2011 ; Beckmann & Stock, 2013; & Avery & Burket, 2012). The prevention of perineal trauma through the use of perineal massage may improve perineal outcome and reduce complications in the postpartum period. This will go a long way in reducing the morbidity and mortality associated with perineal trauma among women. This study is geared towards investigating the effect of perineal massage in reducing perineal trauma in women.

Statement of Problem
Perineal trauma is one of the morbidities that result from childbirth. Studies have shown that most women having vaginal deliveries sustain some form of perineal injury ( Fahami, Shokoni & Kianpour, 2012 ; Kettle & Tohill, 2011). Enyindah et al, (2007) in their study at University of Port-Harcourt Teaching Hospital also showed that perineal trauma is one of the most common occurrences in vaginal deliveries with 40% of primigravidae and 20% of multiparous women affected.

In the Federal Medical Centre, Yenagoa where this study is being proposed, the researcher observed that between January 2009 and January 2012, a total of four thousand and fifty one (4051) babies were delivered through spontaneous vaginal birth. Out of this, a total of one thousand, three hundred and sixty-six (1366) cases of perineal trauma (episiotomy, 1st , 2nd and 3rd degree tears) were recorded (Labor ward register of FMC, Yenagoa). The total number of women who had episiotomy was eight hundred and twenty-six (826), those with first and second degree tears were four hundred and fifty-nine (459), while eighty-one had third degree tears. Among the recorded cases eight hundred and eighty-nine (889) were primgravidae and the others were multiparas.

The average perineal trauma rate (episiotomy and lacerations) between the stated periods was estimated at 40.98% which is relatively high in comparison to the 10% recommended by the World Health Organization (Alayande, Amole & Akin, 2012). In addition monthly statistics between January 2009 and January 2012, in mothers who attended Postnatal clinic at six weeks showed that more than 67.1% of women had wound breakdown during assessment. (Postnatal clinic records FMC, Yenagoa). Since perineal massage has been implicated from studies as resulting in reduction of episiotomy rate, increase intact perineum and better perineal outcome, the present study investigated the effect of antenatal perineal massage on perineal trauma among primigravidae delivering in FMC, Yenagoa.

Purpose of the Study
The purpose of this study was to investigate the effect of antenatal perineal massage on reduction of the occurrence of perineal trauma among primigravidae in Federal Medical Centre Yenagoa, Bayelsa State.
Research Questions
1. What is the incidence of perineal trauma among primigravidaewho participated in the study at Federal Medical Centre, Yenagoa?
2. What is the difference in perineal outcome between primigravidae who perform perineal massage and primigravidae who did not?

3. What is the relationship between maternal age and perineal of primigravidae who performed perineal massage.
4. What is the relationship between fetal birthweight andperineal outcome of primigravidae who perform perineal massage
5. To what extent is gestational age of the pregnancy of primigravidae who performed perineal massage andperineal outcome related?
6. To what extent isbody mass index of primigravidae who performed perineal massage and perineal outcome related?
1. There is no significant difference in perineal outcome between primigravidae who performed perineal massage and primigravidae who did not.
2. There is no significant relationship in maternal ages of primigravidae who performed perineal massage and perineal outcome.
3. There is no significant relationship infetal birth weights of primigravidae who performed perineal massage and perineal outcome.
4. There is no significant relationship in gestational age of pregnancies of primigravidae who performed perineal massage and perineal outcome.
5. There is no significant relationship in body mass indexes of primigravidae who performed perineal massage and perineal outcome.

Significance of the Study
It will provide evidence-based knowledge to nurses, midwives and other healthcare professionals attending to women in labour on how to reduce the routine use of episiotomy and prevent various degrees of tears from occurring during labour.
The study will provide midwives and other health workers attending to mothers at birth, knowledge of the advantages of performing perineal massage and by explaining to them the various benefits, midwives will be providing women with options for optimal health that they may not have previously considered.
The study will add to the existing body of knowledge about perineal massage and provide women with information on how to prevent perineal tears from occurring during delivery.
It will also add to the body of knowledge about benefits derived from carrying out perineal massage and assist policymakers in the health sector to enforce and implement policies on the definitive use of episiotomy.

Scope of the Study
The study covered all primigravidae in the 34th–36th week of pregnancy with single gestation attending antenatal clinic in Federal Medical Centre, Yenagoa, who have not engaged inprior perineal massage. It also involved four times weekly perineal massage by the pregnant woman and/or her spouse in the last month of pregnancy.The studyinvolved primigravidae (experimental group) exposed to treatment (perineal massage), and primigravidae (control group) not exposed to treatment (no massage). It also involved determining the relationship between gestational age, body mass index, fetal birthweight and maternal age and the occurrence of perineal trauma.

Operational Definition of Terms
1. Effect of perineal massage; the difference in perineal outcome that occur as a result of the intervention (perineal massage) among the experimental and control group.
2. Perineal massage is operationally defined as the antenatal massage of the perineumand the lower part of the vagina by the pregnant woman and/her spouse, performed four times a week in the 37th, 38th, 39th and 40th weeks of pregnancy.
3. Perineal trauma refers 1st, 2nd, 3rd, 4th degree tears and episiotomy that occur among the control and the experimental groups of primigravidae in the process of all vaginal deliveries.
4. Maternal age refers to the age the respondents (primigravidae) attained on the day she delivers her baby in the maternity ward of Federal Medical Centre, Yenagoa.
5. Infant birth weight is operationally defined as weight of the newborn baby measured in kilogrammes immediately after delivery at the maternity.
6. Gestational age refers to the age pregnancy in weeks from conception to the time of delivery of the newborn baby.
7. Body mass refers to measurement of weight in kilogrammes divided by the square of height measured in meters of all the primigravidae in this study at the 37th week of pregnancy.
8. Perineal outcome refers to the condition of the perineum immediately after delivery at the maternity.