By Ahizechukwu C. Eke, MD, PhD, MPH
Synopsis: In this randomized trial, the addition of warm compresses to perineal massage during the second stage of labor showed no significant difference in reducing perineal tears, obstetric anal sphincter injuries, or episiotomies compared to perineal massage alone.
Source: Shqara RA, Binenbaum A, Nahir Biderman S, et al. Does combining warm perineal compresses with perineal massage during the second stage of labor reduce perineal trauma? A randomized controlled trial. Am J Obstet Gynecol MFM. 2024;7(1):101547
Perineal trauma, particularly severe cases during the second stage of labor, is a major concern in modern obstetric care because of its significant implications for maternal health and postpartum recovery.1,2 Globally, the incidence of perineal trauma varies widely, with studies reporting rates between 20% and 85%, depending on the population and clinical practices.2,3
Perineal trauma, ranging from minor first-degree tears to severe third- and fourth-degree lacerations, often results in immediate pain, increased risk of infection, and long-term issues such as pelvic floor dysfunction and urinary or fecal incontinence.4 The burden of perineal trauma is compounded further in low-resource settings, where access to skilled birth attendants and effective preventive strategies is limited.5 Warm perineal compresses and perineal massage have emerged as noninvasive interventions aimed at reducing the likelihood and severity of perineal trauma.1,6 By improving tissue elasticity and promoting blood flow, these techniques hold promise as practical, low-cost solutions in labor management.
Evidence on the effectiveness of warm perineal compresses and perineal massage in reducing perineal trauma has been accumulating over the past two decades.7,8 Individual studies have shown that warm compresses applied to the perineum during the second stage of labor can reduce the incidence of severe lacerations and episiotomies by maintaining tissue warmth and flexibility.8 Similarly, antenatal perineal massage has been associated with a decreased risk of requiring suturing after childbirth, especially in primiparous women.9,10
Current research often focuses on each intervention in isolation, with limited data on their synergistic effects. Furthermore, variability in the training and implementation of these techniques across healthcare systems also poses challenges for standardization and broader adoption. Despite these findings, the combined use of these interventions, their efficacy, and the broader applicability of their combined use during the second stage of labor in diverse obstetric populations remain uncertain. Therefore, Shqara and colleagues designed this randomized trial to evaluate the combined effect of warm compresses and perineal massage on diverse populations, labor practices, and maternal and neonatal health outcomes.11
This was a single-center, randomized controlled trial conducted at a tertiary university-affiliated hospital in Israel between June 2023 and January 2024. Women were eligible for inclusion if they were at least 18 years of age with a term singleton pregnancy and a vertex presentation. Exclusion criteria included a history of third-degree perineal tear, nut allergy, intrauterine fetal death, Crohn’s disease with perineal involvement, more than five previous deliveries, or any contraindication to vaginal delivery.11
Eligible women were recruited and randomized in a 1:1 ratio to receive either warm compresses combined with perineal massage or perineal massage alone during the second stage of labor. Randomization was conducted using a web-based tool, and allocation was concealed until the second stage of labor. Participants in the warm compress group received compresses maintained at 45°C to 59°C for a minimum of 10 minutes and a maximum of 30 minutes, applied between contractions. Both groups received perineal massage with almond oil during active maternal pushing, performed by midwives trained in the study protocol.
The primary outcome was the rate of perineal tears requiring suturing, defined as greater than first-degree tears. Secondary outcomes included the rates of obstetric anal sphincter injuries (OASIs), episiotomies, and postpartum complications (such as retained placenta and urinary retention), as well as neonatal outcomes (such as birth weight and Apgar scores).
Midwives were surveyed on their preferences for future perineal protection methods (warm compresses vs. almond oil alone), their perception of the time required to prepare warm compresses, adherence to the study protocol regarding the application duration of compresses (10-30 minutes), and maintenance of the prescribed temperature range (45°C to 59°C).
Based on prior data, a sample size of 206 participants per group was calculated to detect a significant difference in the primary outcome with 80% power and a 5% significance level. Statistical analysis included intention-to-treat and per-protocol approaches, with continuous variables compared using t-tests or Mann-Whitney U tests and categorical variables analyzed with chi-squared or Fisher’s exact tests.
During the study period, 672 women were screened for eligibility, of whom 412 were randomized into two groups: 206 women receiving warm compresses plus perineal massage and 206 women receiving perineal massage alone during the second stage of labor. Baseline characteristics, including age, body mass index (BMI), gravidity, parity, and labor and delivery variables, were comparable between groups.
The primary outcome, the rate of perineal tears requiring suturing, was similar between the two groups (44.7% in the warm compress group vs. 45.6% in the massage-only group; P = 0.843). Subgroup analysis showed no significant differences in first-degree tears (22.8% vs. 21.4%; P = 0.722), second-degree tears (21.4% vs. 23.8%; P = 0.566), or third-degree tears (0.5% vs. 0.5%; P = 1.000). Rates of obstetric anal sphincter injuries also were identical in both groups (0.5% each; P = 1.000), and episiotomy rates were the same (19.4% in both groups; P = 1.000).
A sub-analysis by parity showed no significant differences in perineal lacerations, with rates of 51.8% vs. 56.6% in first deliveries (P = 0.480), and similarly nonsignificant differences for subsequent deliveries. Postpartum outcomes, including rates of retained placenta (1.5% vs. 2.4%; P = 0.723), manual uterine exploration (4.3% vs. 6.3%; P = 0.511), and urinary retention (0% vs. 1%; P = 0.244), were similar between the two groups. Neonatal outcomes, such as birth weight (3323.9 g vs. 3347.7 g; P = 0.570) and Apgar scores at five minutes (none < 7 in either group; P = 1.000), did not differ between the two groups.
In the midwives survey, 60% reported preferring warm compresses for perineal protection, despite 85% indicating that preparing warm compresses was time-consuming. All midwives adhered to the protocol, applying compresses at 45°C to 59°C for 10 to 30 minutes.
Commentary
The results of this trial demonstrate that the addition of warm compresses to perineal massage during the second stage of labor does not provide any significant benefit over perineal massage alone in reducing perineal trauma. Rates of perineal tears requiring suturing were comparable between the two groups, as were the rates of first-, second-, and third-degree tears, obstetric anal sphincter injuries, and episiotomies, with no notable differences across parity subgroups.
Postpartum outcomes, including retained placenta, manual uterine exploration, and urinary retention, also were similar between the two groups, as were neonatal outcomes such as birth weight and Apgar scores. Despite the lack of added clinical benefit, the majority of midwives expressed a preference for warm compresses, acknowledging their potential to improve maternal comfort, although many noted that their preparation was time-consuming.
These findings suggest that while warm compresses may offer some subjective benefits, perineal massage alone remains sufficient for perineal protection during labor, providing a simpler and equally effective option for obstetric care. The lack of significant differences in perineal trauma outcomes between the two groups aligns with previous studies, such as the randomized trial by Dahlen et al, which also found no added benefit of warm compresses during the second stage of labor in reducing the likelihood of perineal tears.12
Similarly, Cochrane meta-analyses have shown moderate evidence supporting the efficacy of warm compresses in preventing severe perineal trauma, but noted that this benefit is inconsistent across studies, particularly when warm compresses are not uniformly applied or combined with other interventions, such as perineal massage.1,8
The uniform use of perineal massage in both groups in this randomized trial could have enhanced overall outcomes, since previous research highlights its positive effects in reducing the risk of severe tears and promoting perineal elasticity. This consistency underscores the potential value of perineal massage as a standard of care.
However, the findings of this study differ from other research that has demonstrated clear benefits of warm compresses. For instance, a systematic review and meta-analysis by Magoga et al reported that warm compresses significantly increased the likelihood of an intact perineum and reduced the incidence of OASIs when compared to no perineal interventions.6 Additionally, the Terre-Rull et al trial observed a notable reduction in perineal tears requiring suturing when warm compresses were used.13
These discrepancies may stem from differences in study designs, populations, or implementation protocols, such as variations in compress temperature, duration of application, or timing relative to the second stage of labor. Unlike this trial, which employed a strict protocol for compress application, earlier studies may have allowed for more prolonged or frequent use of compresses, potentially enhancing their effectiveness.
Furthermore, cultural and healthcare practice differences between study populations may contribute to these variations, highlighting the need for further investigation into how specific settings and patient characteristics influence the effectiveness of warm compresses during labor.
In summary, this study demonstrated that the addition of warm compresses to perineal massage during the second stage of labor did not provide any significant benefit in reducing perineal trauma compared to perineal massage alone. Both interventions resulted in comparable rates of perineal tears, episiotomies, and OASIs, suggesting that perineal massage alone is sufficient as a protective measure during labor.
Warm compresses, while preferred by some midwives, were noted to be time-consuming to prepare without demonstrating additional clinical efficacy. This finding aligns with existing evidence supporting perineal massage as a key intervention for reducing severe perineal trauma but contrasts with studies that have shown benefits from warm compresses. The American College of Obstetricians and Gynecologists currently highlights the benefits of perineal protection techniques, including hands-on methods and massage, without specifically endorsing warm compresses, underscoring the need for further research to clarify the role of warm compresses in current-day obstetric practice.14,15
Ahizechukwu C. Eke, MD, PhD, MPH, is Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore.
References
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2. Opondo C, Harrison S, Sanders J, et al. The relationship between perineal trauma and postpartum psychological outcomes: A secondary analysis of a population-based survey. BMC Pregnancy Childbirth. 2023;23(1):639.
3. Frohlich J, Kettle C. Perineal care. BMJ Clin Evid. 2015;2015:1401.
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5. Aguiar M, Farley A, Hope L, et al. Birth-related perineal trauma in low- and middle-income countries: A systematic review and meta-analysis. Matern Child Health. 2019;23(8):1048-1070.
6. Magoga G, Saccone G, Al-Kouatly HB, et al. Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2019;240:93-98.
7. Maghalian M, Alikamali M, Nabighadim M, Mirghafourvand M. The effects of warm perineal compress on perineal trauma and postpartum pain: A systematic review with meta-analysis and trial sequential analysis. Arch Gynecol Obstet. 2024;309(3):843-869.
8. Dwan K, Fox T, Lutje V, et al. Perineal techniques during the second stage of labour for reducing perineal trauma and postpartum complications. Cochrane Database Syst Rev. 2024;10(10):CD016148.
9. Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2013;2013(4):CD005123.
10. Abdelhakim AM, Eldesouky E, Elmagd IA, et al. Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: A systematic review and meta-analysis of randomized controlled trials. Int Urogynecol J. 2020;31(9):1735-1745.
11. Shqara RA, Binenbaum A, Nahir Biderman S, et al. Does combining warm perineal compresses with perineal massage during the second stage of labor reduce perineal trauma? A randomized controlled trial. Am J Obstet Gynecol MFM. 2024;7(1):101547.
12. Dahlen HG, Homer CS, Cooke M, et al. Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: A randomized controlled trial. Birth. 2007;34(4):282-290.
13. Terré-Rull C, Beneit-Montesinos JV, Gol-Gómez R, et al. Application of perineum heat therapy during partum to reduce injuries that require post-partum stitches. [Article in Spanish]. Enferm Clin. 2014;24(4):241-247.
14. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2018;132(3):e87-e102.
15. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins — Obstetrics. Practice Bulletin No. 165: Prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2016;128(1):e1-e15.
In this randomized trial, the addition of warm compresses to perineal massage during the second stage of labor showed no significant difference in reducing perineal tears, obstetric anal sphincter injuries, or episiotomies compared to perineal massage alone.
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