Intrapartum injuries are a topic of concern for women during
childbirth especially those who are conceiving for the first time.
It occur as a result of inelastic perineum ,long second stage of labor
,inadequate perineal support and large size of baby. Perinatal injuries can
cause short term and long term complications .It includes bleeding, pain
,infections ,hematoma and discomfort in early post partum period .
It can also result in urinary and fecal incontinence in long
term .It also affects the quality of life and are known to
cause sexual dysfunction in women.
Antepartum perineal massage reduces the risk of
intrapartum tears, perineal pain and rate of episiotomies during labor. Many
international studies are already done which support this but there is scarcity
of Indian data.
HYPOTHESIS Antepartum
perineal massage is effective in decreasing the frequency of vaginal birth
related perineal injuries in primiparae as compared to women who do not receive
antepartum perineal massage .
AIM To study the effect of antepartum perineal
massage on vaginal birth related perineal trauma .
PRIMARY OBJECTIVE
To compare the frequency of perineal tears, in women who will
receive antepartum perineal message as compared to women who will not receive
antepartum perineal massage.
SECONDARY OBJECTIVE To compare the
duration of 2nd stage of labor(in minutes), rates of
episiotomy and perineal pain at 48 hours in
postpartum period in study and control group .
This study will be carried out after prior approval from the
Institutional Ethical and Research committee.
STUDY DESIGN- Randomised control trial
PLACE OF STUDY-ANC OPD of obstetrics and gynaecology
at Lady Hardinge medical college and SSK hospital, Delhi
INCLUSION CRITERIA All low risk
primigravida between 34-36 weeks of gestation with single
live fetus in cephalic presentation between the age of 18 and 35 years.
EXCLUSION CRITERIA
All high
risk primigravida .
All
primigravida with diagnosed pelvic floor dysfunction and preexisting genital
infections.
Previous
history of perineal trauma and Expected fetal weight more
than 95th centile for that gestation
SAMPLE SIZE ESTIMATION- 55 per group
METHODOLOGY
An informed
consent will be taken from all the eligible women fulfilling inclusion criteria
.The participants will be selected in both groups based on systematic random
sampling technique.
Participants
will be explained about benefits and technique of antepartum perineal message
using pictorial charts.
Randomization:
Using sequential computer-generated block randomization (block size of four)
study participants will be divided into two groups, study group (receiving
intervention of antepartum perineal massage) and control group (not receiving
antepartum perineal massage), with 1:1 allocation ratio. Allocation will be
concealed with the use of sequential numbered opaque envelopes. Allocation will
be done by candidate. Participants & investigator delivering intervention
as well as assessing outcome will be aware about the intervention being
received. Data Analyst will be blinded to the allocation.
Detailed history
will be taken and detailed examination including ,general physical
examination ,systemic examination ,obstetric examination will
be done.
They
will be given supervised session of antepartum massage at every OPD visit and
explained to perform the same at home .
They are asked to give
self massage at home once before next visit .Enrolled women will be followed up
weekly and then compliance will be checked.
Antepartum
perineal massage will be done twice a week for 10 mins till
delivery.
Control
group will not receive antepartum perineal massage.
Both the
groups will be managed as per standard protocol and followed up weekly
till delivery and 48hrs postpartum .
All women
who will have Preterm vaginal delivery and LSCS will be excluded from the
study.
Normal
vaginal delivery will be conducted by residents posted in labor room
and trained in conducting vaginal deliveries.
Delivery
details and duration of second stage of labor ( in minutes) will be recorded , it
lasts for 2 hours in nulliparas (median 50 minutes).
Assessment
of pain will be done at 48 hours postpartum using VAS Pain score of (1-10).The
mean pain score of two groups will be calculated .
The
visual analog scale(VAS) is a validated, subjective measure for pain. Scores
are recorded by making mark on a 10-cm line that represents a continuum between
“no pain†and “worst painâ€. The VAS takes < 1minute to complete.
The data
will be subjected to statistical analysis.
STEPS OF ANTEPARTUM PERINEAL MASSAGE
Women will be asked to
lie in comfortable and relaxed position .Propped up position with
back supported and wide apart legs flexed at knees and hip joint.
Researcher will do
antepartum massage under all aseptic precaution with gloved hands and using 2%
lignocaine jelly, thumbs of both hands will be inserted in the vagina to
a depth of 3 to 5 cms and pressed down towards the anus and to the sides of the
vaginal walls. The thumbs will be held in this position for about 1
minute until a slight burning ,tingling sensation is felt .
Gentle massage will be
done in the lower half of vagina using a U shaped movement for 2-3 minutes and
repeated 2-3 times.
Massage can be done in
one direction at a time i.e. from side to side or the thumbs can be swept in
opposite direction. The message will be done for 10 minutes
Simultaneously relaxed
breathing is advised to relax the pelvic floor muscles and allowing the tissues
to stretch.
Women will be advised to
repeat the massage once at home before coming to next OPD visit . They are
advised to wash hands and can use a lubricant like coconut oil .
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