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Letter to ‘Effectiveness of antenatal perineal massage in reducing perineal trauma and post‐partum morbidities: A randomized controlled trial’

We have read with interest the article by Ugwu et al. The authors evaluated the effectiveness of antenatal perineal massage (APM) in reducing perineal trauma. There are some questions regarding the study that need to be further clarified. First, participants were contacted at an interval of 1 week to reinforce compliance. Yet, neither the compliance rate nor whether the compliance itself was examined in the study group is described. Moreover, sample size calculation does not mention for which outcome it was performed. As some of the measured outcomes may not be frequently encountered, the study may have been underpowered to assess their occurrence. Second, patients were followed-up at 3 months using a questionnaire. The anal incontinence (AI) was evaluated using a questionnaire which has not been previously validated. Moreover, the proposed definition of AI used was relatively broad and not objectively measured – thus exposing the measured outcome to a substantial bias. Furthermore, the follow-up period up to 3 months might be too short to assess patient outcomes, since it was previously shown that physiological changes occur following delivery and thus evaluation for urinary and AI should be performed remotely from delivery. Third, the main outcome measured – episiotomy has an inherent bias since it is performed at the discretion of the treating obstetrician. An additional potential bias is the lack of evaluation of the indication for episiotomy as it may performed for indications which may not affect perineal function (e.g. expedite delivery in the setting of fetal heart rate abnormalities or for relief of shoulder dystocia). Moreover, it is surprising that the occurrence third degree or forth degree perineal tear was not reported, as these subset of perineal tears are the ones mostly associated with maternal morbidity. Moreover, as the rate of first and second degree perineal tears was comparable in both study groups, it may seem that episiotomy is the only factor affecting the rate of intact perineum, which as mentioned is a major limitation as its indication was not investigated. Finally, the author state that APM performed in the last weeks of gestation reduced the likelihood of episiotomy and the risk of flatus incontinence. This is in strike contrast to a previously published Cochrane review. Due to the various limitations stated above, we believe the authors should be more cautious in their conclusions, and claim for association rather than causation.