Arch Gynecol Obstet (2012) 285:7781

DOI 10.1007/s00404-011-1919-5

M A T ER N O - F E T A L M E D I C I N E

Reducing perineal trauma through perineal massage with vaseline

in second stage of labor
Mehrnaz Geranmayeh Zahra Rezaei Habibabadi
Bijan Fallahkish Mahdi Azizabadi Farahani
Zohreh Khakbazan Abbas Mehran

Received: 4 November 2010 / Accepted: 28 April 2011 / Published online: 26 May 2011
Springer-Verlag 2011

Abstract
Purpose Maintaining an intact perineum is a highly
regarded aim in delivery procedures today. Since perineal
massage is a common practice during delivery, the present
study aims to investigate the eVect of perineal massage with
Vaseline on perineal trauma (rate of episiotomy procedures
and perineal tears).
Method Ninety primiparous women (aged between 18
and 30 years with gestational age of 3842 weeks) were
selected sequentially in Tehran in 2009. Once participants
characteristics were registered, they were randomly
assigned to the intervention (perineal massage with Vaseline) or control groups. In the massage group, perineal massage was performed in the second stage of delivery once the
genitalia were treated with sterilized Vaseline. The perineum was examined after the delivery in terms of episiotomy or tear and its severity degree.
Results The two groups were homogeneous in terms of
demographic data, weight gain during pregnancy, gestational age, abortion history and fetal weight. The second
stage of delivery was signiWcantly shorter in the massage
group than the control group and the massage group had
signiWcantly more intact perineum (P = 0.004). In addition,
lower episiotomy and higher Wrst- and second-degree perineal tears were seen in the massage group in comparison
with the control one (P < 0.001). Neither of the groups
suVered from third- and fourth-degree tears.
M. Geranmayeh Z. Rezaei Habibabadi Z. Khakbazan (&)
A. Mehran
Nursing and Midwifery School, Tehran University
of Medical Sciences, East Nosrat Ave., Touhid Sq., Tehran, Iran
e-mail: khakbaza@sina.tums.ac.ir
B. Fallahkish M. A. Farahani
Tehran, Iran

Conclusion The Wndings showed that the perineal massage with Vaseline in the second stage of labor increases
perineal integrity and decreases perineal traumas (episiotomy and tears). So, it seems that the perineal massage could
be an eVective way to preserve an intact perineum in labor.
Keywords Episiotomy Perineal tear
Perineal massage Vaseline Vaginal delivery

Introduction
Episiotomy, which is the most common surgical procedure
in midwifery [1], involves an incision through the perineum
made to enlarge the vaginal diameter. The prevalence of
episiotomy varies in diVerent countries, ranging from 8% in
Holland to 14% in the UK, 50% in the US and up to 99% in
East European countries [2]. Episiotomy is commonly performed in Asian countries because the shortness and tenacity of perineum in most Asian women makes them
susceptible to extensive tears [3]. In case of Iran, although
no oYcial statistics are published, various scattered studies
show a prevalence of 8897% of episiotomy procedure in
hospitals [4, 5].
Despite the widespread adoption of episiotomy, there is
no unanimous agreement over its most often claimed
advantage (preventing severe perineal tears) [6]. In numerous studies, episiotomy has been imputed with a risk factor
for third- and fourth-degree tears [7]. Furthermore, it has
been claimed that not only may episiotomy fail to protect
the perineal body, but also it may increase anal sphincter
incontinence due to the increased risk of incurring thirdand fourth-degree tears [8]. As a matter of fact, fecal incontinence in women who have undergone episiotomy is
higher than those with natural tears [9] by 46 times [10].

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Therefore, some studies warn that traumas resulting from

episiotomy may be severe than spontaneous perineal tears
[5]. Hemorrhage, prolonged postpartum pain, risk of infection and intercourse impairment, among others, are associated with episiotomy [10]. Thus, it may seem that the
common practice of episiotomy as one method of care is
not eYcient enough and should be regarded with suspicion
[11].
Since more than half of women giving birth without episiotomy also suVer from tears requiring repair [12], and
also because other studies on limited application of episiotomy indicate that 5177% of traumas incurred in women
require suture [13], appropriate interventions are needed in
order to minimize the risks associated with episiotomy and
also perineal tears. In addition, women delivering with
intact perineum suVer less postpartum pain and experience
less dyspareunia within 3 months of delivery [14]. Therefore, studies are warranted to examine diVerent ways to
minimize labor pain, prevent perineal traumas (episiotomy
or tears) and promote delivery with intact perineum [15,
16]. One common practice performed during pregnancy or
labor by midwifes is perineal massage [17]. Nevertheless,
the results are mixed on the eVect of perineal massage on
reducing the need for episiotomy and on increasing the
chance of maintaining a healthy and intact perineum. Some
researchers believe that perineal massage is an eVective
way in increasing the chance of maintaining an intact perineum in primiparous mothers [1, 18, 19], while other
researchers have not reported any diVerence in this regard
[20, 21]. Motivated by these mixed results on the eVectiveness of perineal massage in labor, the present study aims to
examine the eVect of perineal massage with Vaseline on
perineal traumas.

Materials and methods

Sampling
The present randomized clinical trial (RCT) was conducted
on 90 primiparous women in 2009 that referred to Imam
Sajjad Hospital in Shahryar, Tehran. Entry requirements
included an age of 1830 years, gestational age of 38
42 weeks, meeting all vaginal delivery requirements with
anterior cephalic presentation, nonexistence of any perineal
injury (scar, inXammation, injury, etc.) which might interfere with massage and no sensitivity to Vaseline. Exclusion
criteria included fetal distress during delivery and instrument assisted delivery or any reason requiring cesarean section. Meeting exclusion criteria, 17 participants dropped
out of the study and replaced with other participants
through random assignment. An ethical approval was
earned from the ethical committee of the Research Depart-

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Arch Gynecol Obstet (2012) 285:7781

ment of Tehran University of Medical Sciences. Written

consents were also secured from all participants and their
husbands before the initiation of active phase of delivery
and the entry to labor room.
Intervention
First, a checklist including demographic variables (age,
education, weight, and height), abortion history, gestational age and weight gain during pregnancy was prepared
on the basis of data obtained from all the participants. The
participants were then randomly assigned to the intervention group (receiving perineal massage with Vaseline
treatment) and the control group (receiving routine care).
A midwife performed all deliveries in both groups. In the
massage group, in the second stage of delivery (after
crowning and transfer of mother onto delivery table), the
clitoris, labia major and labia minor and the vestibule
were treated with Vaseline. Another midwife performed
sweeping and rotating perineal massage during uterine
contractions and continued until the babys head was out.
The process would be halted if the mother felt discomfort,
and resumed when feeling at ease. Vaseline is a reWned
semi-solid compound of mineral hydrocarbons which is a
semi-transparent, soft and odorless substance used as
foundation in lotions and skin softeners. It is not absorbed
by the skin immediately and rarely has any side eVects,
especially if applied locally [22]. A maximum of 40 g of
sterilized Vaseline was applied. The control group only
received routine labor care. In case of imminent tears in
either group and at the discretion of the delivery agent,
medio-lateral episiotomy was performed. After the delivery of head, the mucus on the head, in the mouth and nostrils were removed and after full delivery, the head and
face were dried by sterilized gas and followed once again
by the removal of mucus from the mouth and nose.
Recorded outcomes were oxytocin consumption during
labor, the length of the second stage of labor, nuchal cord,
neonates weight, the condition of the perineum in terms
of episiotomy or tears and degree thereof, 15 min neonate Apgar scores and neonatal complications. In addition, postpartum conditions or any likely side eVects of
Vaseline were followed-up and recorded within 10 days
of delivery through telephone or in person.
Data analysis
Data were analyzed through SPSS v.16. The qualitative
variables were described using frequency and percentage
and the quantitative variables were described using mean
and standard deviation. To compare the two groups, chisquare and Fishers exact tests were calculated. An
independent t test was also performed for the quantitative

Arch Gynecol Obstet (2012) 285:7781

79

Table 1 Demographic and delivery characteristics of participants

Massage
group

Control
group

Table 2 Labor characteristics and perineal status

P value

Demographic characteristics

Control
group

P value

33 (73%)

30 (67%)

0.490b

23 (51%)

22 3

0.113

Education (Diploma or upper)

21 3

Oxytocin consumption
during labor (%)

18 (40%)

0.290b

Nuchal cord (%)

9 (20%)

5 (11%)

0.245b

Pre-pregnancy weight (kg)

55 8

60 11

0.014a

Neonatal weight (g)

37 20

3.3 0.4

0.437a

Length of the second

stage of labor (min)

3.2 0.4

46 19

Perineal trauma

33 (73%)

43 (96%)

0.004b

Intact perineum

12 (27%)

2 (4%)

First-degree tear

15 (45%)

4 (9%)

Second-degree tear

3 (10%)

1 (2%)

Episiotomy

15 (45%)

38 (88%)

Age (years)

Height (cm)
Delivery characteristics
Gestational age (weeks)
Weight gain during
pregnancy (kg)
Abortion history
a

Independent sample t test

Chi-square test
Fishers exact test

Massage
group

158 7

158 6

0.884a

39.3 0.9

39.7 0.9

0.154a

13 5
1 (2%)

13 6

0.719a

4 (9%)

0.361

Perineal status

Perineal trauma type

a
b

variables. A P value less than 0.05 was considered as

signiWcant.

0.038a

<0.001b

Independent sample t test

Chi-square test

pain and inXammation at perineum, which was not signiWcantly diVerent, however, in the two groups (P = 0.528).

Results
Discussion
The two groups were not signiWcantly diVerent in terms of
demographic variables (age, post-secondary education and
height) (P > 0.05). In terms of pre-pregnancy weight, the
control group was signiWcantly higher than the massage
group (P = 0.014). However, the two groups were not
diVerent in terms of weight gain during pregnancy
(P = 0.719). The two groups were also homogenous in
terms of gestational age and abortion history (P > 0.05).
Table 1 shows the demographic and pregnancy data of the
participants.
Table 2 includes data on delivery and its outcomes for
the two groups. The two groups were not signiWcantly
diVerent in terms of oxytocin consumption at labor, nuchal
cord and the neonates weight (P > 0.05). However, the
length of the second stage of birth was signiWcantly shorter
in the massage group compared with the control one
(37 20 and 46 19 min, respectively, P = 0.038). The
massage group had a signiWcantly higher frequency of
intact perineum (P = 0.004). Neither of the groups suVered
from third- and fourth-degree tears. In terms of perineal
traumas, massage could cause a decrease in episiotomy rate
and an increase in Wrst- and second-degree tears
(P < 0.001). The Apgar scores for all neonates in both the
groups were over 7 on 15 min, and neonatal complications
were detected. Furthermore, in the follow-up study within
10 days of delivery, the massage group showed no side
eVects associated with Vaseline and less than 10% of mothers in both the groups experienced eVects such as burning,

The Wndings in this study showed that the massage of perineum with Vaseline in the second stage of labor not only
reduces the length of the second stage, but also increases
the intact perineum, mainly by decreasing the frequency of
episiotomy. In addition, despite an increase in the frequency of spontaneous perineal tears in perineal massage
(compared with routine care), none of the tears were qualiWed as third or fourth degrees. Maternal and neonatal complications were also similar to those of a routine care.
Perineal stretching and massage in the second stage of
delivery are commonly performed by midwifes [11]. The
results are, however, mixed whether this method is eVective
on prevention of perineal traumas or not. The RCT studies
conducted by Albers et al. [20] and Stamp et al. [21]
showed no evidence of decrease in perineal traumas. However, a previous study in Iran [23] showed that the perineal
massage reduces the need for episiotomy and increases the
chance of an intact perineum, which is in line with our Wndings. Previous studies also showed that women in the massage group experienced less episiotomy and perineal tears
[18, 24]. This diVerence could be explained through the
exclusion of fetal macrosomia, instrumental birth and massage during pregnancy from the study and the lower rate of
episiotomy in those societies and also the anthropometric
diVerences of Iranian women. Therefore, the results of
these two experiments in the Iranian context, where most
vaginal deliveries involve episiotomy, have come to be

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similar. Although the results of RCT studies fail to show

any eVect of massage during delivery on reducing perineal
traumas, it has been claimed that this method is harmless,
suggesting that midwifes choose the appropriate delivery
method at their discretion on the basis of their experience,
labor condition and mothers comfort [25].
Massage therapy is said to have several advantages,
including reduction of stress and pressure, enhancement of
blood circulation and relief of pain. Furthermore, since the
perineal muscles surrounding the vaginal oriWce are
stretched they are less likely to incur damage [26]. In addition, it seems that through acceleration of blood circulation,
elasticity and tenderness of tissue, perineal massage helps
mothers become familiar with sensations such as burning,
pins and needles, less pressure and strain during the delivery of neonatal head [27, 28]. Perineal massage has not
only been studied at the delivery but also through the last
weeks of pregnancy. Although some studies report its positive eVects on the rate of episiotomy [13, 29], others fail to
report such results [30]. Therefore, it seems that the perineal massage in late pregnancy period or during delivery is
a challenging issue requiring further inquiry considering
confounding factors such as the total cases of episiotomy
and the anthropometric characteristics of women.
Although the Wndings in the present study show a
decrease in perineal trauma through Vaseline massage, one
should note that the most important limitation of this study
(and many other similar ones) is the fact that the decision to
perform episiotomy is made at the discretion of the midwife
to prevent any likely perineal tear. Nevertheless, a decrease
in the rate of episiotomy and an increase in the number of
Wrst- and second-degree tears in the massage group (in
addition to other eVects of massage) could be attributed to
the decision of the midwife for delaying an episiotomy procedure. Therefore, one may assert that perineal massage
could be an assuring method for the delivery agent, which
could even nominally decrease the rate of episiotomy and
its associated eVects in areas with high prevalence of episiotomy (e.g., Iran). In addition, despite random assignment
of participants, the pre-pregnancy weight in the massage
group was higher than that of the control group in our
study. However, since the weight gain and fetal weight
were not signiWcantly diVerent in the two groups, it seems
unlikely that the decrease in perineal trauma in the massage
group could be a function of the pre-pregnancy weight.
However, further studies with larger sample sizes are
recommended.

Conclusion
The Wndings of the present study showed that the perineal
massage with Vaseline in the second stage of birth

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Arch Gynecol Obstet (2012) 285:7781

increases the integrity of perineum and reduces the perineal

traumas (episiotomy and tears). Therefore, this method is
recommended to be considered as an eVective way to maintain intact perineum during delivery and further research is
strongly suggested taking into account variables such as
anthropometric characteristics of participants.
ConXict of interest

None.

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