JURNAL KEPERAWATAN SOEDIRMAN

journal homepage : www.jks.fikes.unsoed.ac.id

THE EFFECT OF PERINEAL MASSAGE ON PERINEAL STATUS AND

DURATION OF LABOR
Priyani Haryanti

Lecturer at STIKES Bethesda Yakkum Yogyakarta

ABSTRACT
Perineal rupture in postpartum mothers causes bleeding, pain, and high dependency on others after the
birth. The preliminary study results showed that 68.81% of postpartum mothers experienced perineal
rupture. The aim of this study was to determine the effect of perineal massage on perineal status and
length of labor. It was quasi-experimental research with control group post-test only design. The
population were all expectant mothers in the Yogyakarta Community Health Center. A sample of 60
respondents were divided into control and intervention groups using a random sampling method. The
inclusion criteria were 20-35 years old, singleton pregnancy, spontaneous labor, and gestational age of
34-36 weeks. The study instrument used was an observation sheet. Data were analyzed using
descriptive, t-test independent, Mann-Whitney‟s, and linear regression test. Results. The results showed
that perineal massage affects perineal status (p < 0.001) and the duration of stage I and stage II of
labor (p < 0.001). Perineal massage affects perineal status and the duration of labor in the Yogyakarta
City Community Health Center.

Keywords: Duration of the stage I and stage II of labour, Perineal massage, Perineal status

ABSTRAK
Ruptur perineum pada ibu post partum dapat menyebabkan perdarahan, nyeri dan ketergantungan
pada orang lain. Hasil studi di Puskesmas Tegalrejo dan Jetis menunjukkan jumlah persalinan
sebanyak ±25 per bulan dan 68,81% ibu mengalami ruptur perineum. Untuk mengetahui pengaruh pijat
perineum terhadap status perineum dan lama persalinan di Puskesmas Kota Yogyakarta. Metode
penelitian ini menggunakan quasi eksperimen dengan desain control group post test only design.
Populasi penelitian adalah seluruh ibu hamil di Puskesmas Yogyakarta. Sampel pada penelitian ini
berjumlah 60 responden yang dibagi menjadi kelompok kontrol dan intervensi secara random.
Instrumen penelitian menggunakan lembar observasi. Analisis data secara deskriptif, independent
sample t-test, uji Mann-Whitney, dan uji regresi linear. Hasil penelitian menunjukkan terdapat pengaruh
pijat perineum terhadap status perineum p=0,00, dan lama kala I dan kala II menunjukkan p=0,00. Pijat
perineum dapat mempengaruhi status perineum dan lama persalinan.

Kata kunci: Lama kala I dan II, Pijat perineum, Status perineum

Corresponding Author : Priyani Haryanti ISSN : 1907-6637

Email : [email protected] e-ISSN : 2579-9320

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BACKGROUND Priddis, Schmied, Kettle, Sneddon, &

The Indonesian government has Dahlen, 2014).
sought to improve mother and child health Previous study results have
by increasing the number of visits of shown that patients who performed
expectant mothers to health care centres perineal massage using a digital tool in the
(Kemenkes, 2016). Health workers who third trimester rarely have to go through an
are competent to conduct examinations episiotomy (Beckmann & Stock, 2013).
are obstetricians, doctors, midwives and Perineal massage is a massage
nurses (Kemenkes RI, 2015). The visit of performed on the perineum which is
K1 (first visitation of expectant mothers to carried out 5-7 times a week during the
health centres) and K4 (the minimum of last five to six months into the pregnancy
four times of expectant mother visitation to (Bulchandani, Watts, Sucharitha, Yates, &
health centres) Indonesia's Health Profile Ismail, 2015). The research conducted by
on 2014 in Indonesia had not reached Geranmayeh et al (2012) shows that
95% of the target (Kemenkes, 2016). perineal massage performed during stage
Expectant mother‟s visit for antenatal care II of labor using Vaseline is statistically
aims to monitor maternal and fetal health, proven to ensure a more intact perineum
recognise pregnancy complications early and thus lower episiotomy degree. Nursing
on, perform counseling, carry out interventions during labor can have a
laboratory tests, and administer iron and direct impact on the need for an
tetanus toxoid tablets (which should be episiotomy (Cuningham et al., 2013).
done at least four times during pregnancy Proposed steps to increase perineal
until delivery) (Kemenkes, 2016). stretching and reduce perineal trauma
Childbirth, also known as delivery include applying warm compresses,
and labor, is the process of delivering the gentle perineal massage, pelvic floor
fetus and placenta which is old enough or training and by using warm oil during the
can live outside the womb through the stage II of labor (Hastings-Tolsma, 2014;
birth canal or other passage, with or Leon-Larios, Corrales-Gutierrez, Casado-
without assistance (Reeder & Koniak- Mejía, & Suarez-Serrano, 2017; Wang,
Griffin, 2012). Most spontaneous labor is Jayasekara, & Warland, 2015). The
always followed by a perineal rupture research done by Aasheim, Abv, Lm, &
(Cuningham, Houth, & Rouse, 2013). Lukasse (2017) compared the
Research in the UK showed that perineal effectiveness of perineal massage, warm
rupture due to spontaneous labor was compresses, and perineal management
9.6% (125/1302) in nullipara and 31.2% proved that in the perineal massage group
(453/1452) in multiparous (Smith, Price, there was a decrease of three and four
Simonite, & Burns, 2013a). Other studies degrees of perineal rupture.
in USA showed the percentage of intact Some literature has shown the
perineal at delivery was 9,6%(125/1302) in benefits of perineal massage. With said
nullipara, and 31,2% (453/1452) benefits, perineal massage can be applied
(Hastings-Tolsma, 2014; Smith et al., to the Yogyakarta community, because it
2013a). To prevent extensive rupture, an is proven to be safe. From the preliminary
episiotomy is sometimes performed studies at the Tegalrejo and Jetis
(Cuningham et al., 2013). An episiotomy is Community Health Centers, the average
an incision made in the vagina and number of deliveries in 2017 was 25 per
perineum to widen the soft part of the birth month and 68.81% of those women
canal and shorten it (Reeder & Koniak- experienced perineal rupture. In the
Griffin, 2012). This intervention often interview with health workers who assisted
draws complaints from postpartum the labor, they said rupture occurred when
mothers who feel uncomfortable due to the perineal was rigid and thick, which
pain, psychological disorders and some made the stage I last longer. Postpartum
respondents even said they experience mothers stated that perineal rupture
discomfort during intercourse (Dahlen, caused bleeding and pain, which made
Mid, Priddis, Mid, & Thornton, 2015;

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them uncomfortable while taking care of outside and inside towards the rectal area.
their babies. Patients are guided to focus on the
The research aimed to identify relaxation of muscles when they feel any
the effect of perineal massage on perineal pressure and stretch.
status and the duration of labor in This research used percent
Yogyakarta‟s Community Health Center. agreement with ten assistants with
Diploma and Bachelor Degrees of
METHODS Midwifery. The assistants observed the
This research used a quasi- perineal wound, and the duration of stage I
experimental method with a non- and stage II. The observation resulted in
equivalent control group post test only. 80% agreement. Perineal status was
The population were all pregnant women measured based on the rupture using the
who received antenatal care at the theory by Cuningham et al (2013), which
Community Health Center in Yogyakarta. divides the degree of perineal rupture into
There were 60 respondents which were four stages. Laceration is categorized as
randomly divided into control groups and stage I if it reached the fourchette, perineal
interventions group. Inclusion criteria were skin and vaginal mucous membrane but
-women between 20-35 years old, with a not the fascia and the muscles below. It is
singleton pregnancy, spontaneous labor, included in the second degree of
were willing to be a respondent, with no laceration if it reached the fascia and
pregnancy complications and gestational perineal muscles, on the side of the skin
age of 34-36 weeks. The assistants were and mucous membrane, but not sphincter
provided with a perineal massage training ani. The rupture is usually expanded
and booklet and then they would do a upward on one or both sides of the vagina
home visit to give perineal massage for 15 causing a triangular shaped wound. The
minutes a day (Geranmayeh et al., 2012). laceration is categorized as third degree if
Expectant mothers in the intervention it expanded through the skin, mucous
group were given a perineal massage membrane, perineal corpus and sphincter
training and booklet. The booklet was ani. While the fourth degree laceration is if
about perineal massage with a compliance it expanded through rectal mucous that
check-list which must be filled out by the meant the rectal lumen was exposed. The
assistants. The pregnant women were rupture in the urethral area which causes
expected to do the massage by heavy bleeding most likely happens in this
themselves at home for 15 minutes a day, type of laceration. The duration of labor
6 times a week. Later, assistants would was measured using an observation
do a home visit to remind and guide the checklist and the clock in the delivery
expectant mothers in doing the massage. room. Stage I is the duration of 1-10cm
To do the perineal massage, first you must opening until complete opening, which
wash your hands and apply Virgin would be observed after the mother enters
Coconut Oil (VCO). Research shows that the delivery room. Stage II is the duration
VCO is beneficial as an anti-inflamatory from complete opening until delivery. The
and protects the skin (Varma et al., 2019). measurement of perineal status and
If the expectant mothers do the massage duration of delivery was done after the
by themselves, they should use the thumb, delivery was completed/stage II (Reeder &
but if the assistants are the one who do it, Koniak-Griffin, 2012).
they should use the pointing finger. Insert The data were analysed using
thumb or pointing finger in the vagina until independent sample t-test and the Mann-
the second finger bone segment. After Whitney test. Then, the data were
that, the expectant mother should do kegel analysed using simple linear regression.
(pelvic floor contraction) so that thumb or This study passed the ethical clearance at
pointing finger can feel the tensed Ethics Committee of Medical Faculty of
muscles. Relax the pelvic floor and move Universitas Kristen Duta Wacana (Duta
the thumb or pointing finger on the vagina Wacana Christian University) Yogyakarta
by making a U movement while pushing

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with registration number:459/C.16/FK/ 2017.

RESULTS
1. Univariate Analysis
Characteristics of respondents

Table 1. Characteristics of Frequency Distribution of Delivering Mothers and Babies in

Yogyakarta’s Community Health Center
Group
Characteristics of respondent P value
Intervention (n=30) Control (n=30)
Age
20-35 years old 17 (28.33%) 23 (38.33%) 0.85
<20 and >35 years old 13 (21.67%) 7 (11.66%)
Level of education
Elementary stage 8 (13.33%) 7 (11.66%)
Secondary stage 19 (31.66%) 22 (36.66%) 0.81
Higher stage 3 (5%) 1 (1.6%)
Parity
Primipara 14 (23.33%) 11 (18.33%) 0.3
Multipara 16 (26.66%) 19 (31.66%)
Baby’s Weight
2500-4000gr 28 (46.67%) 28 (46.67%) 0.69
<2500gr and >4000gr 2 (3.33%) 2 (3.33%)
Baby’s Sex
Male 12 (20%) 19 (31.66%) 0.06
Female 18 (30%) 11 (18.33%)

Table 1 shows the majority of Table 1. shows that most

mothers in the control group were aged newborn weight ranged between 2500gr-
between 20-35 years old (23 respondents 4000gr (28 respondents (46.67%)). In the
(38.33%)), 22 respondents had completed intervention group, the baby‟s sex was
secondary education level, and 19 mostly female (18 respondents (30%)). P
(31.66%) respondents were multiparous. P value >0.05 shows that there is no
value of > 0.05 shows no difference difference between intervention and
between the intervention and control control groups. This result shows that the
groups. These results showed respondent‟s characteristics are
homogeneous maternal characteristics. homogenous.

2. The Effect of Perineal Massage on the Perineal Status and the Duration of Delivery
a. The effect of perineal massage on perineal status

Table 2. The Effect of Perineal Massage on Perineal Status of Delivering Mothers in the
Yogyakarta Community Health Center
Perineal status Intervention Control p value
Intact 7 0 0.00
Degree 1 15 1
Degree 2 8 20
Degree 3 0 9

Table 2 shows p value of which means that perineal massage has

0.00<0.05 using Mann-Whitney analysis, an impact on perineal status.

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b. The effect of perineal massage on the duration of stage I and stage II of delivery

Table 3. The Effect of Perineal Massage on the Duration of Stage I of Delivering

Mother in Yogyakarta’s Community Health Center
Variable With perineal Without perineal Average P CI 95%
massage massage difference
n Average ±SD N Average ±SD
Duration of 30 470 123- 30 617 157 -147 0.00 -219.9 - -220
stage I
Duration of 30 53.3 25.9 30 70.7 31 -17 0.02 -32.12- - 32.14
stage II

Table 3 shows the effect of the independent sample t test, shows p

perineal massage on the duration stage I value of 0.00<0.05, which means that
and stage II of labor in Yogyakarta‟s perineal massage has an impact on the
Community Health Center. Analyzed using duration of the stage I and stage II labour.

3. The Effect of Perineal Massage on Perineal Status and Duration of Delivery by

Controlling External Variables
a. The effect of perineal massage on perineal status by controlling outside variables

Table 4. Effect of Perineal Massage on Perineal Status by Controlling Outside Variables

Model.1 Model.2 Model.3 Model.4 Model.5 Model.6
Coefficient Coefficient Coefficient Coefficient Coefficient Coefficient
Variable
CI CI CI CI CI CI
P value P value P value P value P value P value
Perineal 1.2 1.2 1.2 1.2 1.2 1.3
massage 0.9-1.5 0.95-1.6 0.9-1.6 1-1.5 0.9-1.5 1.0-1.6
0.00 0.00 0.00 0.00 0.00 0.00
Age
0.2 0.16
20-35 years
-0.14-0.56 -0.15-0.48
<20 and> 35
0.23 0.3
years
Level of -0.14 -0.03
education -0.32-0.29 -0.32-0.25
0.93 0.81
Parity -0.59 -0.56
Primipara -0.89 - -0.30 -0.86- -0.25
Multipara 0.00 0.01
Baby‟s weight
0.64 0.42
2500-4000 gr
0.0 – 1.2 -0.19-0.99
<2500 gr and
0.047 0.18
>4000gr
2
Adjustable R 0.49 0.49 0.48 0.59 0.51 0.60
Constants 0.8 0.45 0.82 1.66 0.11 0.96
N 60 60 60 60 60 60

Based on table 4, the analysis 0.00 (<0.05). This model has an adjusted
shows that perineal massage has a value of R2 of 0.60.
regression coefficient of 1.3 with p value of

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b. The effect of perineal massage on the duration of the stage I by controlling the
external variables

Table 5. Linear Regression Analysis: The Effect of Perineal Massage on the Duration of
the Stage I Delivery by Controlling the External Variables
Model.1 Model.2 Model.3 Model.4 Model.5 Model.6
Coefficient Coefficient Coefficient Coefficient Coefficient Coefficient
Variable
CI CI CI CI CI CI
P value P value P value P value P value P value
Perineal 147 136 149 164 147 154
massage 74-219 62-211 77-220 105-223 73-220 96-214
0.00 0.00 0.00 0.00 0.00 0.00
Age
-50 -48
20-35 years
-129-27 -113-16
<20 and >35
0.2 0.14
years
Level of 61 26,69
education -5.9-128 -31.3-84.7
0.073 0.36
Parity
-171 -167
Primipara
-231- -111 -229- -106
Multipara
0.00 0.00
Baby‟s weight
44 2.33
2500-4000gr
-102-191 -118.6-123
<2500gr and
0.55 0.96
>4000gr
Adjustable R2 0.20 0.21 0.24 0.49 0.19 0.49
Constants 323 406 208 568 275 590
N 60 60 60 60 60 60

Based on the 5th table of the coefficient of 159 with a p value of 0.00
model, the results of the analysis show (<0.05). This model has an adjusted value
that perineal massage has a regression of R2 of 0.49.

c. The effect of Perineal massage on the duration of the stage II by controlling the
external variables

Table 6. The Effect of Perineal Massage on the Duration of the Stage II by Controlling
the External Variables
Model.1 Model.2 Model.3 Model.4 Model.5 Model.6
Coefficient Coefficient Coefficient Coefficient Coefficient Coefficient
Variable
CI CI CI CI CI CI
P value P value P value P value P value P value
Perineal 17.33 18.93 17.5 20.2 17.33 22
massage 2.54-32.1 3.79-34.07 2.6-32.4 7.3-33.1 2.41-32.3 8.67-35.36
0.00 0.01 0.02 0.03 0.02 0.002
Age
8 8.2
20-35 years
-8-24 -6.3-22
<20 and> 35
0.32 0.26
years
Level of 5 1.2
education -8.92-19 -11.7-14
0.47 0.85
Parity
-29.17 -30.04
Primipara
7.3-33.2 -43.7- -16.3
Multipara
0.00 0.00

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Model.1 Model.2 Model.3 Model.4 Model.5 Model.6

Coefficient Coefficient Coefficient Coefficient Coefficient Coefficient
Variable
CI CI CI CI CI CI
P value P value P value P value P value P value
Baby weight
-2.1 -13.9
2500-4000 gr
-32-27 -40.9 – 13
<2500 gr
0.89 0.3
and> 4000gr
2
Adjustable R 0.071 0.071 0.06 0.29 0.55 0.29
Constants 36 406 26.57 77.80 32.28 78.3
N 60 60 60 60 60 60

Based on the 6th table, the perineal status (Beckmann & Stock, 2013).
analysis shows that perineal massage It is supported by meta-analysis research
has a regression coefficient of 22 with a p which says that perineal massage does
value of 0.002 (<0.05). This model has an not pose a harmful risk to the mother and
adjusted value of R2 of 0.29. fetus, as evidenced by many women who
voluntarily receive perineal massage
DISCUSSION (Bulchandani et al., 2015; Ismail & Emery,
1. The Effect of Perineal Massage on 2013).
the Perineal Status
2. The Effect of Perineal Massage on
The results of the analysis in the Duration of the Stage I of Delivery
table 2 showed the p=0.00 which means
that perineal massage has an impact on The results of the analysis in
the perineal status. This means that H Table 3 shows p=0.00, which means that
alpha is accepted and H zero is rejected, perineal massage has an impact on the
thus meaning that perineal massage does duration of the stage I of the delivery. The
affect perineal status. The anterior, stage I is the opening of 1-10cm of the
posterior, and lateral borders of the birth canal, which is divided into latent,
perineum are namely the anterior active, and transitional phases (Reeder &
symphysis pubis, the ischiopubic ramus, Koniak-Griffin, 2012). Each phase has a
and the anterolateral ischiadicum different duration for the progress of labor
tuberosity, the posterolateral sacrotuberale (Cuningham et al., 2013). Duration of the
ligament, and the posterior coccyx latent phase in nulliparous is 8.6 hours
(Cuningham et al., 2013). Perineal while multipara is 5.3 hours (Cuningham et
massage, which is taught once and carried al., 2013). The duration of the active
out routinely by pregnant women during phase in nulliparous is 4.6 hours while
the third trimester by moving the finger multipara is 2.4 hours (Cuningham et al.,
inside the vagina forming the U letter for 2013). The duration of the transitional
15 minutes, aims to flex the perineal phase is during the opening of 8-10cm
muscle (Bulchandani et al., 2015). The (Reeder & Koniak-Griffin, 2012). The
gradual massage aims to flex the mean difference in the intervention and
superficial perineal transverse muscles control groups was 147, meaning that
and ischioanal fossa in the posterior perineal massage accelerates stage I by
trigeminal (Cuningham et al., 2013). 147 minutes.
Ischioanal fossa serves to provide space
for rectal distension and stretch during 3. The Effect of Perineal Massage to the
childbirth (Cuningham et al., 2013). The Duration of Stage II of Delivery
anterior and posterior trigeminal are
connected by imaginary lines that connect Table 3 shows the results of
the two ischiatic tuberosity (Cuningham et p=0.00, which means that perineal
al., 2013). massage has an impact on the duration of
This is in line with the theory the stage II of the delivery. The mean of
which stated that perineal massage affects intervention group was 53.3 minutes and
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the control group was 70.7 minutes. This while in the previous study mentioned it
was supported by a theory which stated was only carried out during labor.
that the duration of stage II in nulliparous Multivariate analysis shows that perineal
is 1 hour and in multiparas is ¼ - ½ hours massage only affects the perineal status
(Reeder & Koniak-Griffin, 2012). Average by 60% and this is supported by a
difference is -17 which means perineal previous study, which stated that perineal
massage accelerates stage II by 17 rupture is caused by the duration of stage
minutes. The stage II is called pelvic stage II, the weight of the baby, difficulties in the
from the opening until the labor (Reeder & stage II, delivery with occipito posterior,
Koniak-Griffin, 2012). The duration of the and delivery by a diabetic mother (Hauck,
stage II of labor - Cuningham et al (2013). Lewis, Nathan, White, & Doherty, 2015;
says the median of stage II is 50 minutes Priddis et al., 2014; Smith, Price, Simonite,
for nulliparous and 20 minutes for & Burns, 2013b). This research is
multiparous. supported by previous research which
stated that perineal massage during the
4. The Effect of Perineal Massage on third trimester of pregnancy and during the
Perineal Status and Duration of stage II reduces the risk of episiotomy and
Delivery by Controlling External reduces the degree of perineal injury
Variables (Aquino et al., 2018; Demirel & Golbasi,
2015).
Table 4 shows the linear Table 5 shows the linear
regression analysis of the impact of regression analysis of the effect of
perineal massage on the perineal status perineal massage on the duration of the
by controlling external variables. The stage I of delivery by controlling external
analysis shows that perineal massage has variables (age, education level, parity of
a coefficient regression of 1.3 with p=0.00 the mother, and the weight of baby). The
which means there is a correlation results of the analysis shows perineal
between perineal massage and perineal massage has a regression coefficient of
status by controlling the age, the level of 159 with p value as much as 0.00, which
education, parity of the mother and the means there is a correlation between
weight of the baby. This means that perineal massage and the duration of the
perineal massage which was taught once stage I. It means that perineal massage
and carried out by the mother once a day which was taught once and performed at
for 15 minutes could prevent them from home once a day by expectant mothers
experiencing a rupture, or in other words, could accelerate the stage I by 159
having a more intact perineal status by minutes (2 hours 39 minutes). This model
1.3 points. This model has adjusted R2 of has an adjusted R2 value of 0.49 which
0.60 which means perineal massage means perineal massage during
treatment for pregnant women could affect pregnancy can affect the stage I by 49%
perineal status by 60% or 40% depending and the other 61% are influenced by other
on other factors which have not been factors, which have not been examined in
examined in this study. this study. Stage I is the 1-10cm opening
The results of this study are of the birth canal. The duration of one
different from the results of Zare, Pasha, & latent phase is 8.5 hours for nullipara and
Faramarzi (2014) study which stated that 5.3 hours for multipara. The duration of
perineal massage does not provide any one active phase to transition phase is 4.5
benefit to the perineal status. This study hours for nullipara and 2.4 hours for
follows the same weaknesses of previous multipara (Reeder & Koniak-Griffin, 2012).
research. In this study, the perineal Delivery often causes injury to the birth
massage intervention is carried out during canal. Injuries in the birth canal occur on:
the period of the third trimester of the pelvic floor/perineal, vulva and vagina,
pregnancy. Respondents regularly perform uterine cervix, uterus. While for
the massage slowly to relax and flex the spontaneous labor, perineal rupture is
superficial transverse perineal muscle and caused by: stiff perineal, fetal head‟s
ischioanal fossa in the posterior trigeminus passing too quickly through the pelvic
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floor, the baby's size, perineal width, parity massage to others (Beckmann & Stock,
(Reeder & Koniak-Griffin, 2012). When 2013). This adaptation makes the perineal
stimulation is done from the third trimester become flexible so that labor becomes
it will flex and relax the maternal perineal easier (Cuningham et al., 2013).
so that delivery becomes more
comfortable. Mothers who feel relaxed CONCLUSION
during stage II will make the descent of Perineal massage has an impact
the fetal head easier and accelerate the on perineal status and the duration of the
delivery. stage I and stage II of delivery. Perineal
Table 6 shows the linear massage prevents perineal rupture and
regression analysis of the effect of accelerates the duration of stage I and
perineal massage toward the duration of stage II of delivery.
stage II by controlling the external
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