Low-tech, at-home preparation in the last month before childbirth could help pregnant mothers avoid one of the more common surgeries performed on women in the United States, a new review suggests.
The review looked at studies in which women used a massage technique in the last four or five weeks of pregnancy to train the lower genital tract for childbirth. During perineal massage a women kneads the tissue below the vagina to prepare the tissue to expand more easily during birth.

There was a 15 percent reduction in episiotomies among the women who practiced perineal massage the review found, based on results from three trials, including data from 2,434 women.

The findings appear in the most recent issue of The Cochrane Library, publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

Lead reviewer Dr. Michael Beckmann and his colleagues also discovered an added benefit: Three months after birth, women who had practiced massage were less likely to report perineal pain -- whether or not they had an episiotomy.

Those positive results were most clear for mothers having their first vaginal birth. But Beckmann said the statistical trend of the research suggests that the benefits would also hold true for the other, smaller sub-groups of women in the study -- given larger sample sizes, more time and research.

An episiotomy is performed in up to 35 percent of vaginal births in the United States each year, affecting as many as 1 million women. But Beckmann said the number of episiotomies performed around the world is dropping following a general shift toward reserving the surgical procedure for emergencies.

A May 2005 article in the Journal of the American Medical Association cast doubt on many of the rationales offered for routine episiotomy. That evidence review found episiotomy does not reduce pain or improve healing in the short term, or prevent incontinence or impaired sexual function in the long term -- when compared with natural tears.

Many expectant mothers have heard about Kegel exercises to strengthen the pelvic-floor muscles before birth, but perineal massage isn't as well-known or recommended as often.

"It's not standard in obstetrics, but there is interest in this area," said Beckmann, an obstetrician with the QE2 Jubilee Hospital in Queensland, Australia.

"It's amazing the number of women who are fearful about cuts and tears and afraid of an episiotomy," said Sally Avenson, a certified nurse midwife in western Washington state.

As more women demand greater control and involvement in their childbirth plan, Avenson said, preventing an episiotomy -- or the spontaneous tears that can occur at childbirth -- has gained mainstream attention, and become a goal for all providers who care for pregnant women.

Perineal massage is now common in some corners of maternal health care, Beckmann said, so "it's nice to see there's some evidence behind it." He now says expecting women should be provided information on perineal massage and its likely benefits.

In the three reviewed studies, women practiced perineal massage for as little a four minutes three to four times a week, and as much as 10 minutes daily, beginning in week 34 of their pregnancy.

Pregnant women may not hear about perineal massage from their obstetrician, but midwives have recommended the practice for years. Avenson, a lecturer with the University of Washington's department of Family and Child Nursing, said it is difficult to separate the effect of perineal massage alone. But she includes the technique in her discussions about "perineal management."

"It goes along with a plan for exercise and nutrition. You can't isolate the perineum from health," she said.

"It's not anything where I guarantee you won't tear, but it is something you have power to do," said Avenson, who's led her own midwifery practice for 25 years.PregnancyAndBaby.com

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